What is the efficacy of botulinum toxin (BTX) injections in the treatment of tension headaches?

Updated: Jun 19, 2018
  • Author: Anthony H Wheeler, MD; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Tension-type headache as an entity was addressed by numerous published observations and studies to determine whether or not BTX treatment was a potentially effective treatment. Evolution of episodic tension headaches into a chronic pain disorder has been postulated to occur when myofascial driven peripheral nociception compels mechanisms that lead to central sensitization.

A study by Zwart et al refuted the notion that BTX might be useful as a treatment for tension headache when BTX-A induced paralysis of the temporalis muscles did not show pain reduction, thereby rejecting theories proposing that increased muscle tension was a significant or primary cause of tension-type headaches. [122] However, two subsequent small, open-label studies using BTX-A for the treatment of tension-type headaches did show reduced headache duration, pain intensity, and muscle tenderness. [118, 123]

Additional case reports and open label studies suggested that BTX-A was an effective therapy for chronic tension-type headache syndromes. [124, 125, 126, 127] Porta compared treatment responses between BTX-A and methylprednisolone injections in patients with tension-type headaches. [128] Although both groups improved, patients treated with BTX experienced improvement for a greater duration of time (>60 d) compared with the methylprednisolone group.

In a randomized, controlled study of 37 patients with tension-type headache, participants received either 100 U of BTX-A or placebo into 6 injection sites (2 in the temporalis muscles and 4 in cervical sites). [129] At 3 months postinjection, the treatment group showed a statistically significant reduction in headache severity compared with the placebo group. Similarly, 3 subsequent double-blind, placebo-controlled studies demonstrated significant benefit from BTX-A treatment of chronic tension headaches. [130, 131, 132]

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