Which neurological marker may predict benefit from botulinum toxin A (BTX-A) for the management of migraine headaches?

Updated: Jun 19, 2018
  • Author: Anthony H Wheeler, MD; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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A study by Jakubowski et al explored whether specific neurological markers could be identified that might predict the benefit from BTX-A treatment. [121] Researchers used 100 U of BTX-A spread over 21 standard cranial and cervical muscular sites. A prospective study (n=27) identified BTX-A responders between 4-12 weeks after the injection session. Responders were defined as subjects who had 80% or higher reduction in the mean number of days that they experienced migraine per month (attack frequency X attack duration). Nonresponders were defined as patients who dropped 33% or below migraine days per month.

Among multiple migraine-associated symptoms, the pertinent marker was identified as patient-perceived directionality of head pain. Ninety-two percent of nonresponders characterized their headaches as a build up of pressure from inside the head, termed by the authors as "exploding," whereas 74% of responders described an "imploding headache," a perception that the head was being crushed or assaulted by external forces. All subjects were responders in a smaller third group (n=5) who reported pain as pressure localized behind the eye, hence the classification "ocular headaches."

The results from the prospective study were replicated in a retrospective analysis of 36 patients, thereby suggesting reliability. However, directionality of head pain is a subjective symptom report that would benefit from further study with a standardized and validated psychometric instrument. Any deduction that this study provides specific insight into the pathophysiology of migraine or analgesic mechanisms of BTX-A for headache is speculative at this time.

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