Botulinum toxin treatment of migraine

Andrew M Blumenfeld MD (Dr. Blumenfeld, Director of The Headache Center of Southern California, received honorariums from Allergan for intellectual property, consultancy, and research; honorariums from Merck, GlaxoSmithKline, Pfizer, Forrest, Zogenix, MAP, and Ipsen for membership on speakers' bureaus; and research grants from Medtronics.)
Stephen D Silberstein MD, editor. (Dr. Silberstein, Director of the Jefferson Headache Center at Thomas Jefferson University, receives honorariums from Allergan, Avanir Pharmaceuticals, Curelator, Depomed, Dr. Reddy's Laboratories, eNeura,  INSYS Therapeutics, Lilly USA, Supernus Pharmacerticals,  Thernica and Trigemina for consulting. He is also the  principal investigator for a clinical trials conducted by Alder Biopharmaceuticals, Amgen, electroCore Medical, Lily USA and Teva.)
Originally released December 3, 2003; last updated December 2, 2014; expires December 2, 2017


One of the most intriguing developments in the management of headaches is the use of botulinum toxin. The author explains the basics and provides a practical guide to preventing migraine with botulinum toxin, including patient selection, injection site considerations, dosing, and technique. He describes the injection protocols and offers tips based on his personal experience and published caveats. Recent double-blind, placebo-controlled studies have been published on the effects of onabotulinumtoxinA on chronic migraine, and these data are included in this update.

Historical note and terminology

OnabotulinumtoxinA (botulinum toxin type A, BOTOX®) is a focally acting neurotoxin that inhibits the release of acetylcholine and other neurotransmitters from presynaptic nerve endings, resulting in muscle relaxation. Preclinical evidence has shown that onabotulinumtoxinA also reduces inflammation and has antinociceptive properties (Cui et al 2000; Cui et al 2002; Aoki 2002). OnabotulinumtoxinA is a safe and effective treatment for chronic migraine (Smuts et al 1999; Binder et al 2000; Freund and Schwartz 2000; Silberstein et al 2000; Mathew et al 2005; Blumenfeld et al 2008; Dodick et al 2009; Aurora et al 2010; Blumenfeld et al 2010; Diener et al 2010; Dodick et al 2010), and understanding about its anti-inflammatory and antinociceptive action is evolving.

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