What are dosing considerations for BOTOX® injections in pain management?

Updated: Jun 19, 2018
  • Author: Anthony H Wheeler, MD; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Suggested dosing considerations for BOTOX® are as follows:

  • Currently, only BOTOX® is FDA-approved for the treatment of chronic migraine, and Allergan approves of a specific FDA-approved injection procedure that will be discussed in detail below. However, before FDA approval, injection techniques varied, and many injectors used the "follow the pain" paradigm, and dosed the neurotoxin variably, as outlined above.

  • Significant side effects are uncommon. Pain, especially in the neck; muscle weakness; and rarely flulike symptoms have been reported. Spread of the toxin with weakness involving muscles that were not directly injected, even distal from the injection sites have been noted. Anticholinergic side effects are stronger and more commonly seen with type B toxin.

  • Contraindications to treatment with BTX include pregnancy (category C); the concurrent use of any drug that adversely effects neuromuscular transmission e.g., aminoglycoside antibiotics; myasthenia gravis and Eaton-Lambert syndrome, or any disease that impairs transmission across the neuromuscular junction; or known sensitivity to the neurotoxins.

  • Treating more frequently than the recommended interval of 12 weeks may lead to the development of antibodies to the neurotoxin, which may be associated with the development of clinical resistance.

  • There is no valid or reliable method available at present for consistent and accurate conversion of a specific dose of type A toxin to a specific dose of type B toxin. Nor are their specific methods available at present for accurate conversions between commercially available type A toxins.

  • The use of BTX for pain management is part of a comprehensive treatment program that has been developed based on an accurate diagnosis.

  • Be aware of current storage and handling recommendations for each of the neurotoxins.

  • Whenever possible, use an injection technique, including needle size, that is the least likely to cause additional pain.

  • Guidance techniques such as EMG, CT, or fluoroscopy should be used at the discretion of the injector.

  • Prolonged observation following the injections is generally not necessary or warranted.

  • Follow-up should be arranged for 4-6 weeks following injections.

  • More than one series of injections, >12 weeks apart, may be required to achieve maximal analgesic response

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