A Proposal to Prevent the "Mephisto Sign" Side Effect of Botulinum Toxin Type A Injection in Chronic Migraine

Abstract

Botulinum toxin type A (BoNT-A) has been reported as an effective treatment for chronic migraine. When BoNT-A is injected on the frontalis muscle for chronic migraine, an unexpected clinical side effect called the "Mephisto sign" may occur. The aim of this article is to propose a method to eliminate or prevent the Mephisto sign side effect. A 25-year-old female patient visited the hospital and was diagnosed with chronic migraine. A total of 155 U of BoNT-A was injected into 31 sites. 2-weeks later, and the patient developed the Mephisto sign. An additional 2-U dose was administered bilaterally to the lateral-most point of the frontalis muscles, and the eyebrow morphology returned to normal within 2-3 weeks. We propose that the development of the Mephisto sign may be prevented with an additional BoNT-A injection of 2-4 U bilaterally to the lateral most point of the frontalis muscles during the primary injection process.

The “Ram's Horns Sign”: A Case Report of an Unusual Side Effect of OnabotulinumtoxinA in a Chronic Migraine Patient

“…For example, the OM predominance on FM can induce the eyebrow ptosis, the most reported side effect due to an excessive BoNT‐A dose. Contrarily, the “Mephisto sign” has been associated with the prevalence of FM outer fibers on the OM, weakened by the BoNT‐A injection . Similarly, we suggest that the “ram horns” phenomenon observed in our patient can be the consequence of the predominance of the FM inner fibers on the weakened OM, resulting in two symmetrical bumps on the upper part of the forehead.…”

“…Although reversible, the phenomenon appears to be annoying for the patients, since it may last for several weeks. More recently, this condition has been described in a woman suffering from CM and named “Mephisto sign.” Interestingly, the authors proposed a simple method to prevent the “Mephisto sign” by means of additional BoNT‐A units into the distal end of the FM either prophylactically or at the follow‐up, if necessary.…”

Relationship between forehead motion and the shape of forehead lines—A 3D skin displacement vector analysis

“…Incomplete treatment of the frontalis muscle can result in an increased movement of the skin in the areas where the muscle was not affected by the neuromodulator injection . If the skin in the lateral aspect of the eyebrow is hyper‐elevated during forehead movement following neuromodulator application, the clinical terms “Spock eyebrow” or “Mephisto sign” are used . Based on the results of the present study, it can be assumed that in those cases laterally oriented frontalis muscle fiber are present which were not affected by the (centrally positioned) neuromodulator injection.…”

Dynamic evaluation of facial muscles: 3D skin displacement vector analysis using a facial painting model

“…Since skin displacement is also observed outside the temporal line, the outer boundary of the frontalis muscle will be located further lateral to the temporal line. Therefore, in the treatment of forehead wrinkles, botulinum toxin must be injected along the temporal line to prevent aesthetically unappealing outcomes such as the “Spock eyebrow” or “Mephisto sign.” 14 Increased muscle activity caused by increased muscle mass results in larger skin displacement; thus the stronger side requires a higher dose of a neuromodulator to achieve a comparable clinical effect. 15 , 16 …”