What is the role of botulinum toxin (BTX) injections in the treatment of occipital neuralgia?

Updated: Jun 19, 2018
  • Author: Anthony H Wheeler, MD; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Occipital neuralgia can present as a paroxysmal or persistent neuropathic pain disorder. It is usually accompanied by shooting or radiating pain and paresthesiae involving the occipital and parietal regions of the scalp within the distribution of the greater and/or lesser occipital nerves. It frequently generates secondary headaches. Common causes of occipital neuralgia include irritation, injury as seen in WAD, and sometimes focal entrapment of the nerves by regional muscle spasm or MPS.

A pilot study looked at the efficacy of occipital nerve blocks for providing prolonged and significant pain relief in study participants with chronic occipital neuralgia who were treated with BTX-A reconstituted into 3 cc of NS. [159] Subjects were instructed to report their daily pain level (on a VAS), their ability to perform daily activities (on several quality of life instruments) and their daily pain medication usage (based on a self-reported log). Psychometric/outcome measures were compared between baseline prior to injection and then at 12 weeks after chemodenervation.

Pain characterized as dull/aching, or as having associated paresthesia did not show statistically significant improvement during the study. Sharp/shooting type pain showed improvement during most of the trial period. Quality of life measures specific to headache showed significant improvement by 6 weeks, which continued through week 12. General health-related and depression-related measures showed no statistical improvement. No significant reduction in pain medication usage was demonstrated.

A retrospective case series of 6 patients with severe refractory occipital neuralgia associated with severe headaches were treated with BTX-A following failure of response of multiple trials of conventional oral, injectable, and/or surgical treatments. [160] Each patient underwent bilateral occipital nerve blocks using BTX-A (50 U for each block, 100 U if bilateral). Significant reduction in pain scores as measured by a visual analog scale and improvement in the Pain Disability Index (PDI) were observed at 4 weeks in 5 of the 6 patients after receiving the BTX-A blocks. When the authors compared these same psychometrics in all 6 patients who received a injection of 0.5% bupivacaine prior to receiving BTX-A, the authors concluded that this small group of patients demonstrated a longer duration of meaningful pain relief and improved PDI scores with occipital nerve blocks using BTX-A.

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