How is botulinum toxin (BTX) for pain management administered using a fixed-site, fixed-dose protocol?

Updated: Jun 19, 2018
  • Author: Anthony H Wheeler, MD; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Answer

Answer

This BOTOX® protocol uses a fixed-site, fixed-dose injection paradigm. Prior to injection the skin over the intended and targeted injection site should be cleaned with an alcohol swab. Each injection consists of 0.1 mL of reconstituted BOTOX® (5 U). This injection protocol is characterized by fixed injection doses into specific muscle sites (eg, a fixed number and location of all injection sites with a fixed total dose of BOTOX®). Hold the needle hub with one hand so that it can be angled appropriately away from any danger and to avoid the periosteum. The bevel of the needle and the numbers on the syringe that delineate measurements on the syringe contents should face upward. The second hand controls the plunger.

The first recommended injection sites are the corrugators. The corrugator muscle injection site (MIS) is located approximately 1 fingerbreadth (approximately 1.5 cm) above the superior edge of the medial orbital ridge. Inject with the beveled needle pointing upward at a 45º angle away from the medial aspect of the muscle to avoid ptosis of the eyelid. The Allergan protocol also suggests starting on the left and moving to the right.

First the left then the right corrugator MIS are each dosed with 0.1 mL or 5 U of BOTOX®. See A in the image below.

Injection paragdigm for chronic migraine. Injection paragdigm for chronic migraine.

Corrugator, procerus, frontalis, and temporalis muscles are all injected (by order of protocol) with the patient supine. Each designated muscle site is injected with 0.1 mL of BOTOX® solution. The procerus is located midline on the forehead approximately 1 fingerbreadth above and midline to the medial superior aspect of the orbital ridge of each eye. The injection site for this muscle should appear approximately midway between both corrugator injection sites. A single straight line should connect all 3 of the injection sites. The injection technique is repeated with a beveled needle upward and the needle pointing approximately 45º upward and away from the pain-sensitive periosteum. The procerus is injected with 1 mL.

See B in the image below.

Injection paragdigm for chronic migraine. Injection paragdigm for chronic migraine.

Next, with the patient remaining supine, a line is drawn upward on the forehead from the medial edge of the orbital ridge about 1 fingerbreadth above each corrugator MIS. These are marked and additional sites are parallel, approximately 1 fingerbreadth lateral to the first 2 frontalis MIS . Each site is injected, first on the left and then on the right. Each of the 4 MIS receives 0.1 mL or 5 units of BOTOX® solution.

See C in the image below.

Injection paragdigm for chronic migraine. Injection paragdigm for chronic migraine.

Next the temporalis muscles are dosed with 4 injections of 0.1 mL each bilaterally. The patient is asked to clinch his or her teeth, whereby the examiner is able to palpate the anterior aspect of the temporalis muscle. The first injection is performed about 2 fingerbreadths beyond this point and beneath the hairline. The second injection is performed 0.5 cm superior and approximately 1 fingerbreadth posterior to the first injection into the medial aspect of the muscle. Injection 3 should be parallel and 1.5 cm posterior to the second injection. Injection 4 should be approximately 1.5 cm below and perpendicular to the second injection into the medial aspect of the muscle.

See D in the image below.

Injection paragdigm for chronic migraine. Injection paragdigm for chronic migraine.

Next, the patient is moved to a sitting posture. Occipital injection sites are identified by palpating the external occipital protuberance. The examiner continues palpation superior to the supranuchal ridge on either side of the occipital protuberance. Beginning with the left occipitalis muscle, the first injection is placed just above the occipital protuberance along the supranuchal ridge, and 1 cm leftward of the external occipital protuberance. The second injection is 1 cm lateral and 1 cm above the first injection site. The third injection is 1 cm medial and superior to the first injection site.

See E in the image below.

Injection paragdigm for chronic migraine. Injection paragdigm for chronic migraine.

Next, the cervical paraspinal muscle injections are performed. The first injection into the cervical paraspinal muscles is placed about 1 cm to the left of the midline and 3-5 cm inferior to the occipital protuberance. The second injection site is 1 cm superior diagonally toward the ear from the first injection. The same injection sites are measured as mirror images on the right, leading to a total of 4, each receiving 0.1 mL or 5 units.

See F in the image below.

Injection paragdigm for chronic migraine. Injection paragdigm for chronic migraine.

The trapezius muscle is a triangular shaped superficial muscle that spans from the neck to the shoulder. Visualize a proportion of the muscle from the neck to the shoulder into 3 sections per side. Injections are placed into the middle of each of these sections. The protocol recommends that the injector begin by treating the left trapezius muscle. Each of the 3 sites on the left and then on the right (totaling 6) receives 0.1 mL or 5 U of BOTOX® solution.

See G in the image below.

Injection paragdigm for chronic migraine. Injection paragdigm for chronic migraine.

Following the procedure the patient is asked to remain vertical for 2-3 hours and not to rub the injected areas in any vigorous manner. The patient may return to their normal activities on the following day.


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