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Amelioration of trichotillomania with onabotulinumtoxinA for chronic migraine
  1. Emily Rubenstein Engel1 and
  2. Jeremy-Ann Ham2
  1. 1Department of Neurology, Scripps Clinic, La Jolla, California, USA
  2. 2Department of Medicine, Scripps Green Hospital, La Jolla, California, USA
  1. Correspondence to Dr Emily Rubenstein Engel; engel.emily{at}


We report a case of a woman in her 30s who struggled with a life-long history of trichotillomania (TTM; hair-pulling disorder), which was unsuccessfully treated with behavioural therapy and selective serotonin reuptake inhibitors. In addition to TTM, our patient had a history of chronic migraine which brought her to our clinic, and treatment with onabotulinumtoxinA (OBTA) was initiated per the Phase III REsearch Evaluating Migraine Prophylaxis Therapy protocol. After experiencing improvement with migraine symptoms, she began off-label treatment with OBTA for her TTM with 45 units being injected, 5 units per site, in diffuse regions of her scalp, primarily on the affected areas of TTM-induced alopecia. The patient reported marked improvement in her TTM signs and symptoms, which resulted in hair regrowth as early as the first follow-up visit 12 weeks post-treatment initiation. Treatment effects were maintained, and additional hair regrowth was observed at the 1-year post-treatment visit, which equated to four cycles of treatment.

  • Botulinum toxin
  • Neurology (drugs and medicines)
  • Psychiatry (drugs and medicines)
  • Headache (including migraines)
  • Anxiety disorders (including OCD and PTSD)

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  • Contributors The patient was under the care of ERE. Report was written by ERE and J-AH.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests ERE has received payment or honoraria on speaker bureaus for AbbVie and Biohaven/Pfizer. J-AH has no competing interests to declare.

  • Provenance and peer review Not commissioned; externally peer reviewed.