Treatment of Chronic Refractory Intractable Headache with Botulinum Toxin Type A: A Retrospective Study

Abstract

Chronic refractory daily headache is a relatively common problem in the Australian population. Several million working hours per year are lost due to this illness. Generally not responding to conventional therapies. We treated 22 such patients diagnosed as severe refractory migraine and/or mixed tension headache at our multidisciplinary pain management center. Before inclusion to our study, they received maximal medical management, which included cognitive behavior therapy, but failed to respond. These patients received between 30 and 100 units of botulinum toxin type A. Our study showed 84% (19 of 22) achieved significant improvement in their pain complaint. There was significant reduction of medications particularly opioids. The duration of pain relief ranged from 1 to 6 months. Repeat injections were necessary in several of the patients. There were minor complications but these reversed spontaneously without further treatment.

Efficacy of Botulinum Toxin in Tension‐Type Headaches: A Systematic Review of the Literature

“…In total, 22 analyses were included in this review (Figure ). Refer to Table for more data on these studies …”

“…Nine studies were prospective, nonrandomized, and uncontrolled, 8 were randomized, double blinded, and placebo controlled, 3 were randomized, double blinded, and placebo controlled with a crossover, open‐label portion,, and one was a comparative, randomized, single‐blinded evaluation of botulinum toxin vs. methylprednisolone injections . One study was a retrospective evaluation of patients in a dermatology clinic, which was included due to prospective enrollment for wrinkle treatment, but included headache response …”

“…Even among those with a standardized approach, no studies had the same injection protocol. Multiple studies showed positive outcomes, with toxin dosing ranging from 30 to 200 unitsthough studies using more than 200 units and less than 50 units did not demonstrate much benefit. Therefore, optimal dosing is unclear.…”

“…The review by Jackson et al. also did not include a number of trials that are described in this review that were available at the time of their publication, possibly related to their exclusion criteria . In their review, a few studies in the CM group also included patients with TTH, and evaluated studies of patients with both chronic and episodic TTH .…”

Rational Combination Therapy in Refractory Migraine

“…As with GONB, botulinum toxin has evidence of benefit for RM and is an option for those who are hesitant to add additional medications or seek to limit the potential for drug–drug interactions. Side effects include injection site reactions, ptosis, and lacrimation 21,86‐88 …”