Tension Headache: Botulinum Toxin Paralysis of Temporal Muscles

SYNOPSIS
The pathogenetic mechanism of tension headache (TH) is still unknown. The role of pericranial muscle tension in TH is also enigmatic. To evaluate this factor in chronic TH, pericranial muscles were paralysed in 6 chronic TH patients, using botulinum toxin. All patients fulfilled the IHS criteria of chronic TH associated with involvement of the pericranial muscles, but not the current criteria for cervicogenic headache. The patients were followed-up regularly with evaluation of the paralysis, changes in pain intensity, and pressure pain threshold measurements. We primarily only injected the temporal muscle on the one side, using the other side as a control. Contralateral muscles were in some cases injected at a later stage. In our study, we did not find any significant reduction in pain intensity, as measured by the visual analogue scale, nor any changes in pressure pain threshold, as measured by an algometer. On the basis of our observations, we conclude that muscle tension in these muscles possibly plays a minor role in the genesis of chronic TH. In our study, however, we have only treated a limited number of patients, and only one pericranial muscle has been injected systematically. Further studies of various neck/posterior head muscles ought to be performed in order to further evaluate a possible effect of tension in the pericranial musculature in producing this type of pain.     

Botulinum Toxin Injection for Cervicogenic Headache

We report a 28-year-old woman with a 5-year history of cervicogenic headache following a whiplash injury, Her unilateral neck pain, if aggravated by exertion, would create a predictable sequence of events leading to a hemicephalgia. She proved medically refractory to usual therapies, but had a striking response to a single botulinum toxin injection in her symptomatic rapezius muscle. Repeated injections every 3 months have been required to maintain this benefit. The implications of this observation are discussed.     

Subcutaneous Botulinum Toxin for Chronic Post‐Thoracotomy Pain

Objective: Botulinum toxin is a neurotoxin that has been widely used in chronic pain for the treatment of multiple conditions with a component of localized muscle spasm. Recent studies suggest that botulinum toxin is effective in the treatment of neuropathic pain syndromes such as post‐herpetic neuralgia. Case Report: We report the case of a 67‐year‐old man who underwent atypical segmentectomy of a right lower lobe lung nodule. The patient was referred to our pain management department with a of 2‐year history persistent pain along the thoracotomy scar having a predominantly neuropathic component, refractory to standard treatments. He was successfully treated with subcutaneous botulinum toxin type A. Discussion: On the basics of our own experience and on the analysis of the reports published in the literature, fractioned subcutaneous injections of botulinum toxin may be useful for the treatment of various chronic localized pain conditions including chronic post‐thoracotomy pain.     

Botulinum Toxin A in the Treatment of Chronic Tension-Type Headache With Cervical Myofascial Trigger Points: A Randomized, Double-Blind, Placebo-Controlled Pilot Study

Objective.— To evaluate the efficacy of botulinum toxin A (BT-A) as a prophylactic treatment for chronic tension-type headache (CTTH) with myofascial trigger points (MTPs) producing referred head pain. Background.— Although BT-A has received mixed support for the treatment of TTH, deliberate injection directly into the cervical MTPs very often found in this population has not been formally evaluated. Methods.— Patients with CTTH and specific MTPs producing referred head pain were assigned randomly to receive intramuscular injections of BT-A or isotonic saline (placebo) in a double-blind design. Daily headache diaries, pill counts, trigger point pressure algometry, range of motion assessment, and responses to standardized pain and psychological questionnaires were used as outcome measures; patients returned for follow-up assessment at 2 weeks, 1 month, 2 months, and 3 months post injection. After 3 months, all patients were offered participation in an open-label extension of the study. Effect sizes were calculated to index treatment effects among the intent-to-treat population; individual time series models were computed for average pain intensity. Results.— The 23 participants reported experiencing headache on a near-daily basis (average of 27 days/month). Compared with placebo, patients in the BT-A group reported greater reductions in headache frequency during the first part of the study (P = .013), but these effects dissipated by week 12. Reductions in headache intensity over time did not differ significantly between groups (P = .80; maximum d = 0.13), although a larger proportion of BT-A patients showed evidence of statistically significant improvements in headache intensity in the time series analyses (62.5% for BT-A vs 30% for placebo). There were no differences between the groups on any of the secondary outcome measures. Conclusions.— The evidence for BT-A in headache is mixed, and even more so in CTTH. However, the putative technique of injecting BT-A directly into the ubiquitous MTPs in CTTH is partially supported in this pilot study. Definitive trials with larger samples are needed to test this hypothesis further.     

Botulinum Toxin A, Adjunctive Therapy for Refractory Headaches Associated With Pericranial Muscle Tension

Pericranial muscle tension may contribute to the development of facial discomfort, chronic daily headache, and migraine-type headache. Elimination of pericranial muscle tension may reduce associated myalgia and counteract influences that can trigger secondary headaches which fall within the migraine continuum. Four patients with chronic, predominantly tension-type headaches and associated pericranial muscles tension failed prolonged conventional treatment and, therefore, symptomatic areas were treated with botulinum toxin A. This alleviated myalgia and reduced the severity and frequency of migraine-type headaches with a concomitant reduction in subsequent medical and physical therapy interventions. Judicious use of botulinum toxin A into defined areas of pericranial muscle tension may be useful for reducing primary myalgia and secondary headache.     

Exertional Headache as Unusual Presentation of the Syndrome of an Elongated Styloid Process

We present the case of a 34-year-old man with a 2-year history of pain related to efforts in heavy lifting, beginning in the right ear and radiating to the neck and to the vertex. He underwent multiple negative neuroimaging examinations, until a 3-dimensional computerized tomography scan of the pharyngeal region evidenced an elongated styloid process. A diagnosis of Eagle's syndrome was made. The excision of the elongated styloid process was performed, resulting in complete and lasting pain relief. We focus on Eagle's syndrome and in particular on this atypical presentation.     

Evidence for the Use of Botulinum Toxin in the Chronic Pain Setting—A Review of the Literature

▪ Abstract:   A significant proportion of chronic pain is of musculoskeletal origin. Botulinum toxin (BTX) has been successfully used in the treatment of spasmodic torticollis, limb dystonia, and spasticity. Investigators have, thus, become interested in its potential use in treating many chronic pain conditions. Practitioners have used BTX, outside the product license, in the treatment of refractory myofascial pain syndrome and neck and low back pain (LBP). This article reviews the current evidence relating to chronic pain practice. There is evidence supporting the use of both BTX type A and type B in the treatment of cervical dystonias. The weight of evidence is in favor of BTX type A as a treatment in: pelvic pain, plantar fasciitis, temporomandibular joint dysfunction associated facial pain, chronic LBP, carpal tunnel syndrome, joint pain, and in complex regional pain syndrome and selected neuropathic pain syndromes. The weight of evidence is also in favor of BTX type A and type B in piriformis syndrome. There is conflicting evidence relating to the use of BTX in the treatment whiplash, myofascial pain, and myogenous jaw pain. It does appear that BTX is useful in selected patients, and its duration of action may exceed that of conventional treatments. This seems a promising treatment that must be further evaluated. ▪     

Trigeminal Neuralgic-Type Pain and Vascular-Type Headache Due to Gustatory Stimulus

We present a case of facial pain associated with sweet stimulus. An immediate, electriclike, short, unilateral pain was evoked by strong sweet gustatory stimulation. This was followed 6 to 8 hours later by a bilateral severe headache associated with bilateral tearing, rhinorrhea, periorbital swelling, flushing, and photophobia that lasted up to 2 days. The immediate pain that was experimentally induced with 2.5 grams of sucrose placed on the tongue could be abolished with carbamazepine. However, carbamazepine did not prevent the headache complex that appeared 6 to 8 hours later. Conversely, a trial with indomethacin abolished the late-onset headache, but not the immediate neuralgic-type pain. The independent nature of these pains suggests different pathophysiological mechanisms which are discussed.     

强脉冲光联合A型肉毒毒素面部年轻化的效果观察

目的 探讨强脉冲光联合A型肉毒毒素在面部年轻化中的效果.方法 选取2018年4月至2019年4月我院就诊的面部皮肤老化典型病例96例,按随机分组数字表分为对照组(48例)与研究组(48例),对照组予强脉冲光治疗,每4周治疗1次,连续治疗3次,研究组联合A型肉毒毒素进行微滴注射,注射点间隔1cm,每点注射0.05ml,比...     

Botulinum Neurotoxin for the Treatment of Migraine and Other Primary Headache Disorders: From Bench to Bedside

Botulinum toxin type A, a neurotoxin, is effective for treating a variety of disorders of involuntary muscle contraction including cervical dystonia, blepharospasm, and hemifacial spasm. It inhibits neuromuscular signaling by blocking the release of acetylcholine at the neuromuscular junction. The biological effects of the toxin are transient, with normal neuronal signaling returning within approximately 3 to 6 months postinjection.
Recent clinical findings suggest that botulinum toxin type A may inhibit pain associated with migraine and other types of headache. However, the mechanism by which this toxin inhibits pain is not fully understood and is under investigation. Research findings suggest that botulinum toxin type A inhibits the release of neurotransmitters from nociceptive nerve terminals and, in this way, may possess an analgesic effect. A number of retrospective open-label chart reviews and 3 double-blind, placebo-controlled trials have demonstrated that localized injections of botulinum toxin type A significantly reduce the frequency, severity, and disability associated with migraine headaches. Although the majority of patients in these studies experienced no botulinum toxin type A-mediated side effects, a small percentage of patients did report transient minor side effects including blepharoptosis, diplopia, and injection-site weakness. Currently, 4 randomized, placebo-controlled, clinical trials are being conducted to evaluate the efficacy, optimal dosing, and side-effect profile of botulinum toxin type A as a novel treatment for migraine and other types of headache. These studies may provide further evidence that botulinum toxin type A is an effective option for the preventive treatment of migraine.     

彩超水囊引导下A型肉毒毒素注射治疗面肌痉挛的临床疗效

目的:探讨彩超水囊引导下肉毒毒素注射治疗面肌痉挛的疗效。方法:面肌痉挛患者96例,随机分为A、B组各48例,A组给予口服药物6个月,B组给予彩超水囊引导下局部注射A型肉毒毒素(BTX-A)。治疗前后分别采用Cohen、Acbert痉挛强度分级评估疗效,观察2组疗效、持续时间、显效率和治疗前后肌痉挛强度及变化情况。结果:A组治疗后肌痉挛强度变化无统计学差异,B组治疗后肌痉挛强度变化有显著性差异(P<0.01),且显效率高于A组(P<0.01)。结论:彩超水囊引导下BTX-A注射治疗能显著降低面肌痉挛的肌张力,且安全、简单易行。     

Analgesic Effect of Botulinum Toxin A in Myofascial Pain Syndrome Patients Previously Treated with Local Infiltration of Anesthetic and Steroids

The purpose of this study was to evaluate the analgesic effect of botulinum toxin A (BoNTA) injections in patients with myofascial pain syndrome (MPS) who were previously treated with the local infiltration of anesthetic and steroids (LIAS). The study included a retrospective phase and a longitudinal open-label prospective phase, which were conducted on consecutive patients with MPS previously treated with the local infiltration of anesthetic (levobupivacaíne 0.25%) and steroids (triamcinolone 40 mg). Eligible patients were treated with a single intramuscular injection of BoNTA (Botox; Allergan, Inc., Irvine, CA). The treatment efficacy was determined according to the degree of pain relief obtained. Eighty-two patients met the inclusion/exclusion criteria and were included in the study. Successful results were obtained for 32 (39.0%) and 30 (36.6%) patients, during treatment with BoNTA and LIAS, respectively. The mean (standard deviation) length of the analgesic effect was significantly longer with BoNTA (29.6 [SD = 17.7] weeks) than with LIAS (8.5 [SD = 6.4] weeks), P <.0001. As regards the side effects, 19 (23.2%) patients reported transient soreness at the injection site for 2 to 3 days with BoNTA. The MPS patients previously treated with a local infiltration of anesthetic and steroids who then received a single injection of BoNTA experienced significantly reduced pain for a relatively long time.     

Efficacy of Meclofenamate Sodium versus Placebo in Headache and Craniofacial Pain

SYNOPSIS
Twenty patients were enrolled in a double-blind, placebo- controlled crossover study of meclofenomate sodium in headache and craniofacial pain. There were four observation periods of 15 days each: Period I was a wash-out period. In period 2, subjects were randomly assigned to a 15-day regimen of taking two capsules a day of 100mg meclofenamate sodium (group 1) or placebo (group 2). In period 3, group I was switched to placebo and group 2 to meclofenamate sodium for the next 15 days. Lastly, the patients took no medication for a further 15 days (period 4). A thermographic record of the craniofacial and neck areas was taken at the end of periods 1 and 4. A record of the pressure threshold and tissue compliance at different sites of the craniofacial, neck and shoulder areas was taken at the end of each period. During the trial, number and duration of painful events were recorded daily by the patients, and the level of pain evaluated on a visual analog scale. Mean data were analyzed for significant difference by ANOVA and paired t-test. During the meclofenamate sodium period, there was a significant decrease of days with painful events compared to the wash-out period in group I and compared to the placebo period in group 2. In the majority of patients, the meclofenamate sodium period scored lowest or second-lowest after the follow-up period in mean pain intensity. Data for pressure threshold, although not significant, were indicative of a possible increase during and after intake of meclofenamate sodium. An improvement of thermal symmetry was recorded at the second thermogram in a majority of patients. It is concluded that meclofenamate sodium showed a consistent analgesic effect in our patients, compared to the placebo.     

Evidence for Antinociceptive Activity of Botulinum Toxin Type A in Pain Management

The neurotoxin, botulinum toxin type A, has been used successfully, in some patients, as an analgesic for myofascial pain syndromes, migraine, and other headache types. The toxin inhibits the release of the neurotransmitter, acetylcholine, at the neuromuscular junction thereby inhibiting striated muscle contractions. In the majority of pain syndromes where botulinum toxin type A is effective, inhibiting muscle spasms is an important component of its activity. Even so, the reduction of pain often occurs before the decrease in muscle contractions suggesting that botulinum toxin type A has a more complex mechanism of action than initially hypothesized. Current data points to an antinociceptive effect of botulinum toxin type A that is separate from its neuromuscular activity. The common biochemical mechanism, however, remains the same between botulinum toxin type A's effect on the motor nerve or the sensory nerve: enzymatic blockade of neurotransmitter release. The antinociceptive effect of the toxin was reported to block substance P release using in vitro culture systems. ¹
The current investigation evaluated the in vivo mechanism of action for the antinociceptive action of botulinum toxin type A. In these studies, botulinum toxin type A was found to block the release of glutamate. Furthermore, Fos, a product of the immediate early gene, c- fos , expressed with neuronal stimuli was prevented upon peripheral exposure to the toxin.
These findings suggest that botulinum toxin type A blocks peripheral sensitization and, indirectly, reduces central sensitization. The recent hypothesis that migraine involves both peripheral and central sensitization may help explain how botulinum toxin type A inhibits migraine pain by acting on these two pathways. Further research is needed to determine whether the antinociceptive mechanism mediated by botulinum toxin type A affects the neuronal signaling pathways that are activated during migraine.     

Botulinum Toxin Type‐A (BOTOX®) in the Treatment of Occipital Neuralgia: A Pilot Study

Objective.— To determine the efficacy of occipital nerve blocks using reconstituted botulinum toxin type‐A (BTX‐A) in providing significant and prolonged pain relief in chronic occipital neuralgia. Background.— Occipital neuralgia is a unilateral or bilateral radiating pain with paresthesias commonly manifesting as paroxysmal episodes and involving the occipital and parietal regions. Common causes of occipital neuralgia include irritation or injury to the divisions of the occipital nerve, myofascial spasm, and focal entrapment of the occipital nerve. Treatment options include medication therapy, occipital nerve blocks, and surgical techniques. BTX‐A, which has shown promise in relief of other headache types, may prove a viable therapeutic option for occipital neuralgia pain. Methods.— Botulinum toxin type‐A (reconstituted in 3 cc of saline) was injected into regions traversed by the greater and lesser occipital nerve in 6 subjects diagnosed with occipital neuralgia. Subjects were instructed to report their daily pain level (on a visual analog pain scale), their ability to perform daily activities (on several quality of life instruments) and their daily pain medication usage (based on a self‐reported log), 2 weeks prior to the injection therapy and 12 weeks following injection therapy. Data were analyzed for significant variation from baseline values. Results.— The dull/aching and pin/needles types of pain reported by the subjects did not show a statistically significant improvement during the trial period. The sharp/shooting type of pain, however, showed improvement during most of the trial period except weeks 3‐4 and 5‐6. The quality of life measures exhibited some improvement. The headache‐specific quality of life measure showed significant improvement by 6 weeks which continued through week 12. The general health‐ and depression‐related measures showed no statistical improvement. No significant reduction in pain medication usage was demonstrated. Conclusions.— Our results indicate that BTX‐A improved the sharp/shooting type of pain most commonly known to be associated with occipital neuralgia. Additionally, the quality of life measures assessing burden and long‐term impact of the headaches, further corroborated improvement seen in daily head pain.     

Botulinum Toxin Occipital Nerve Block for the Treatment of Severe Occipital Neuralgia: A Case Series

▪ Abstract:   Persistent occipital neuralgia can produce severe headaches that are difficult to control by conservative or surgical approaches. We retrospectively describe a series of six patients with severe occipital neuralgia who received conservative and interventional therapies, including oral antidepressants, membrane stabilizers, opioids, and traditional occipital nerve blocks without significant relief. This group then underwent occipital nerve blocks using the botulinum toxin type A (BoNT-A) BOTOX® Type A (Allergan, Inc., Irvine, CA, U.S.A.) 50 U for each block (100 U if bilateral). Significant decreases in pain Visual Analog Scale (VAS) scores and improvement in Pain Disability Index (PDI) were observed at four weeks follow-up in five out of six patients following BoNT-A occipital nerve block. The mean VAS score changed from 8 ± 1.8 (median score of 8.5) to 2 ± 2.7 (median score of 1), while PDI improved from 51.5 ± 17.6 (median 56) to 19.5 ± 21 (median 17.5) and the duration of the pain relief increased to an average of 16.3 ± 3.2 weeks (median 16) from an average of 1.9 ± 0.5 weeks (median 2) compared to diagnostic 0.5% bupivacaine block. Following block resolution, the average pain scores and PDI returned to similar levels as before BoNT-A block. In conclusion, BoNT-A occipital nerve blocks provided a much longer duration of analgesia than diagnostic local anesthetics. The functional capacity improvement measured by PDI was profound enough in the majority of the patients to allow patients to resume their regular daily activities for a period of time. ▪