In the 1990s there was a prominent research undertaken for finding out he utility of botulinum toxin in dealing with headaches. It was established that no immediate benefit was seen however a subset of the group tested who were diagnosed with persistent migraine, a marked improvement was seen and could be of potential benefit. Since then it has now been close to 2 decades but with a greater push to find the answer to treating chronic migraines, botulinum toxin has now answered the called to reduce the suffering of patients.
The PREEMPT trials that have occurred in the United Kingdom and perhaps best provide information regarding Chronic Migraine treatment with anti migraine injections. Here is the National Health and Medical Research Councils take on the procedure:
COURTESY OF THE NHMRC GUIDELINES
The PREEMPT trialsTwo Phase 3 Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) trials recruited 1384 patients with chronic migraine, and randomised them to treatment with botulinum toxin or placebo. These patients were suffering on average 20 days of headache each month, of which 18 were moderate or severe. Those randomised to botulinum toxin received fixed-site, fixed dose injections every 12 weeks over 56 weeks. These injections covered seven specific areas of the head and neck, with a total dose of between 155-195 units. At six months, after two cycles of treatment, those treated with botulinum toxin had on average eight less days of headache each month. After 12 months, 70% of those treated had ≤50% the number of headaches that they had done originally. Botulinum toxin was well-tolerated, the commonest side effects being neck pain (6.7%), muscular weakness (5.5%), and drooping of the eyelid (3.3%). No serious irreversible side effects have ever been reported in trials of botulinum toxin in headache.
How does botulinum toxin work in chronic migraine?
The simple answer is that we don’t know – yet. Unlike many of the other conditions in which it is used, it is not thought to work by relaxing overactive muscles. Botulinum toxin has been shown to reduce pain in a number of disease states, including cervical dystonia, neuropathic pain, lower back pain, spasticity, myofascial pain, and bladder pain. Botulinum toxin is believed to inhibit the release of peripheral nociceptive neurotransmitters, which may then have a knock-on effect on the central pain processing systems that generate migraine headaches.
Is botulinum toxin right for me?
Chronic migraine is defined as headaches occurring on 15 or more days each month, at least half of which have migrainous features. There are, however, other treatments available to patients with chronic migraine, and it is important that patients have an informed discussion of their headaches and the options for treatment with a practitioner experienced in the diagnosis and management of headaches before a decision to use botulinum toxin is taken.
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