Botulinum Toxin for Pain Management

 

Botulinum toxin Type A (Botox A) is a natural, biological toxin derived from live bacteria, it is not a chemically synthesized drug. They are structurally more complex than drugs and have higher variability. Botox A works at the neuromuscular junction in very small doses by inhibiting the release of neurochemical acetylcholine. This toxin action is reversible and can last 2 to 6 months in the human body.

Current FDA approved indications for Botox A include writer’s cramp, spascticity, Frey’s syndrome, hyperhidrosis,anismus, detrusor-spincter dysnergia, focal Limb dystonias and achalasia.

 

Many other conditions that benefit from Botox A include essential type tremor, chronic neck and back pain, migraine and tension type headache, TMJ dysfunction, stuttering, myofascial pain syndrome, stiff person’s syndrome, sialorrhea.

 

Of special interest is the possibility of using Botox A treatment in combination with all the other advance therapeutic modalities available at Grace Life Medical Center. Before Botox was used to treat migraine, other modalities have been used with success for many years to help over 80% of the migraine sufferers. After a careful history and examination, Dr. Wong prefer first to use other methods of less cost and side effects (No paralyzed muscles) to alleviate the pain. In refractory cases, selected muscles of higher importance (e.g. corrugator supercilii muscle, Spenius capitus insertion) in producing pain can be then injected with Botox A.

 

Botox A may be useful for transformed migraine, chronic tension type headache, new daily persistent headache, hemicrania continua, rebound analgesic headache.

 

Those patients that might benefit more from botox A injection usually have pericranial muscle tension. They might describe pain that radiates from the back of the head (occiput) to the side of the head (temple) and across the front eyes. In severe cases, the headache may also present with bright lights, tunnel vision, and spasm of the muscles with a throbbing sensation.

 

The clinical data presented at the 45th Annual Scientific Meeting of the American Headache Society (AHS) in June 2003 by Dr. Blumenfeld found that Botulinum toxin type A is an effective preventative therapy for headache and Migraine pain in chronic sufferers.

  

In the study, patients were treated every three months, with a minimum of 2 treatments and a maximum of 5 treatments.

• 80% (217) said their head pain episodes were less frequent, less intense or both.
• 60.5% (164) reported good to excellent pain relief.
• 19.5% (53) reported some pain relief.
• 20% (54) reported no relief.

side effects reported are few and minor

• eyebrow drooping (1%)
• neck muscle weakness (1%)
• other effects such as flu-like symptoms or head pain (2%).

References

1.       Robbins L, Maides J. Efficacy of preventive medications for chronic daily headache. American Journal of Pain Management, October 1999, vol. 9, 4:130-138.

2.       Robbins L. Management of Headache and Headache Medications. 2nd ed. New York: Springer-Verlag:2000:126-132.

3.       von Ermengem E. Ueber einen neuen anaeroben Bacillus und seine Beziehungen zum Botulismus. Zeitschrift fur Hygeine und Infektionskrankheiten 1897; 26: 1-56; (translation reprinted in Reve Infect Dis 1979; 1:710-719).

4.       Scott AB. Botulinum toxin injection into extraocular muscules as an alternative to strabismus surgery. Ophthalmology 1980; 87:1044-1049.

5.       Brin MF. Botulinum toxin: chemistry, pharmacology, toxicity, and immunology. Muscle Nerve 1997; Supp. 6: S146-168.

6.       Goadsby PJ, Zagami AS, Lambert GA. Neural processing of craniovascular pain: a synthesis of the central structures involved in migraine. Headache 1991; 31: 365-371.

7.       May A, Goadsby PJ. The trigeminovascular system in humans: pathophysiologic implications for primary headache syndromes of the neural influences on the cerebral circulation. J Cereb Blood Flow Metab. 1999:19; 115-127.

8.       Weiller C, May A, Limmroth V, Juptner M, Kaube H, Schayck RV, Coenen HH, Diener HC. Brainstem activation in spontaneous migraine attacks. Nat Med. 1995; 1:658-660.

9.       Goadsby PJ, Edvinsson L, Ekman R. Release of vasoactive peptides in the extracerebral circulation of man and the cat during activation of the trigeminovascular system. Ann of Neurol. 1988: 23:193-196.

10.   Markowitz S, Saito K, Moskowitz MA. Neurogenically mediated leakage of plasma proteins occurs from blood vessels in dura mater but not in brain. J Neuroscience. 1987: 7: 4129-4136.

11.   Raskin, NH. Headache, 2nd edition, Churchill Livingston, New York: 1988 pp.215-224.

12.   Silberstein S, Lipton R, Dalessio D. Wolff’s Headache and other head pain. 2001: 260-265; 290-291.

13.   Lambert, GA, Bogduk N, Goadsby PJ, et al. Decreased carotid arterial resistance in cats in response to trigeminal stimulation. J Neurosurgery. 61:307-315.

14.   Goadsby, PJ, Edvinsson L. Human in vivo evidence for trigeminovascular activation in cluster headache. Brain. 117:427-434.

15.   May A, Bahra A, Buchel C, et al. Hypothalamic activation in cluster headache attacks. Lancet. 352:275-278.

16.   Gobel H, Heinze A, Katja Heinze-Kuhn, Austermann K. Botulinum toxin A in the treatment of headache syndromes and pericranial pain syndromes. Pain. 2001.91:195-199.

17.   Brin MF, Swope DM, O’Brain C, Aboasi S, Pogoda JM. Botox for migraine: double-blind, placebo controlled region-specific evaluation. Cephalalgia 2000: 20:421-422.

18.   Priori A, Beradrelli A, Mercuri B, Manfredi M. Physiological effects produced by botulinum toxin treatment of upper limb dystonia: changes in reciprocal inhibition between forearm muscles. Brain. 1995: 118:801-807.

19.   Simons DG. Fibrositis/Fibromyalgia: a form of myofascial trigger points? Amer J Med 1986:81 (Suppl 3A): 9-98.

20.   Rosales RL, Arimura K, Takenaga S, Osame M. Extrafusal and intrafusal muscle effects in experimental botulinum toxin-A injection. Muscle Nerve. 1996: 19 (4): 488-496.

21.   Ishikawa H, Mitsui Y, Yoshitomi, Mashimo K, Aoki S, Mukano K, Shimizu K. Presynaptic effects of botulinum toxin type A on the neuronally evoked response of albino and pigmented rabbit iris sphincter and dilator muscles. Jpn J Ophthalmol. 2000: 44(2):106-109.

22.   Van den Bergh P, De Beukelaer M, Deconinck N. Effect of muscle denervation on the expression of substance P in the ventral raphe-spinal pathway of the rat. Brain Res. 1996: 707 (2): 206-212.

23.   Hohne-Zell B, Galler A, Schepp W et al. Functional importance of synaptobrevin and SNAP-25 during exocytosis of histamine by rat gastric enterochromaffin-like cells. Endocrinology. 1997: 138:5518-5526.

24.   Weigand H, Wellhoner HH. The action of botulinum A neurotoxin on the inhibition by antidromic stimulation of the lumbar monosynaptic reflex. Naunyn Schmiedebergs Arch Pharmacol 1977: 298(3):235-238.

25.   Silberstein S, Mathew N, Saper J, Jenkins S. Botulinum toxin type A as a migraine preventive treatment. Headache 2000; 40:445-450.