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Both calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) and OnabotulinumtoxinA (botox) are used in the prevention of chronic migraines. However, it is not clear which is more effective overall. This review will compare the efficacy, side effects, cost-effectiveness, and other factors between CGRP mAbs and botox. We searched Pubmed and Google Scholar using the keywords migraines, CGRP mAbs, botox, efficacy, side effects, aura. All articles, including case-control/cohort studies, case series, case reports, randomized control trials, traditional/systematic reviews, were analyzed. CGRP mAbs and botox both reduce the frequency of migraines in patients. Patients have reported they decreased migraines' frequency and intensity in several studies after being given each medication. While CGRP mAbs are more recent medications, botox has been studied for more than a decade as a migraine preventative. Both drugs have minor short-term side effects, but some CGRP mAbs may cause persistent constipation too. CGRP mAbs are self-injected every month, and botox is physician-injected every three months, making it easier to stay compliant. While both medications are expensive, botox has a lower cost over time. Botox is more effective prophylaxis of migraines based on the articles that were reviewed. While both CGRP mAbs and botox are efficacious and tolerable, botox has been studied longer, has fewer side effects, is more cost-effective, and is easier to comply with.

Background Sialorrhea is a common comorbidity among children with neurologic disorders. Botulinum toxin injections and surgical procedures are recommended for the management of pathological sialorrhea in patients who fail conservative management or with concerns for salivary aspiration. The following review evaluates outcomes following botulinum toxin injections and surgical interventions for sialorrhea over a 10-year period with a focus on treatment options and outcomes for patients with anterior and posterior drooling. Methods The study included all patients less than 25 years of age who underwent a procedure for drooling (Current Procedural Terminology (CPT) codes 42440, 42450, 42509, 42510, 64611 matched with the International Classification of Diseases (ICD)-9 and ICD-10 codes 527.7 and K11.7) from January 1, 2006 to December 31, 2015. A chart review collected demographics, drooling medication use, and type of drooling (anterior, posterior, both). Outcome variables included pre- and post-procedure number of bibs, parent-reported outcomes, post-intervention drooling medication requirement, post-procedure length of stay, and complications. Results Seventy-one patients were included in our analysis, with 88 total procedures performed. The average age at first intervention was 8.9 years; 43 patients were male and 40 patients had cerebral palsy. Thirty-one patients experienced posterior drooling or anterior/posterior drooling. These patients were more likely to undergo surgery as the first invasive intervention. The most commonly performed interventions were botulinum toxin injections (28 patients, 39%) and sublingual gland excision (SLGE) with submandibular duct ligation (SMDL) (36 patients, 51%). Improvement following injections was noted in 56% of patients versus 73% of patients following any surgical intervention. Conclusion Management of drooling is complex with 18 different procedures performed over 10 years. Surgical interventions, specifically SLGE with SMDL and submandibular gland excision (SMGE), result in substantial improvement; these are commonly performed as the first intervention in patients with posterior drooling. By reviewing our experience, we hope to guide management decisions and help manage patient and caregiver expectations.