By Ed Susman, Contributing Writer, MedPage Today
Published: March 29, 2011
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston.
WASHINGTON — The type of migraine appears to make a difference in whether onabotulinum toxin A (Botox) can provide symptomatic relief from the debilitating headaches, researchers said here.
In a study that reviewed outcomes among 105 patients with refractory chronic migraine, Steve C. Lee, MD, a clinical fellow in anesthesiology at Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, said that all but seven patients showed some improvement when treated with onabotulinum toxin A — and 66% of the patients achieved more than a 30% improvement in their conditions for up to five years. Most of the improved patients were those with “imploding” headaches.
“We were able to retreat these patients with onabotulinum toxin A injections about every three months without experiencing resistance to the drug,” Lee told MedPage Today at his poster presentation during the annual meeting of the American Academy of Pain Medicine.
“About 80% of the initial and long-term responders in our study have either imploding or ocular-type headaches,” co-author Zahid H. Bajwa, MD, associate professor of anesthesia (neurology) at Harvard, told MedPage Today in an email. He said that the researchers observed that these patients appeared to respond better to the onabotulinum toxin A injections than people with exploding-type headaches.
With imploding headaches, patients often describe the pain as: “Someone is tightening a vise around my head” or “Someone is crushing my skull” or “someone is driving spikes into my head” of “Something heavy is sitting on my forehead.”
Lee said patients with ocular type migraine describe the sensation in these ways: “I want to take a spoon and pull my eye out” or “My eye is popping out” or “Someone is pushing a finger in my eye.”
The exploding headaches are described in these terms: “My head feels as if it is going to explode” or “The left side of my head is splitting from the right” or “I’d like to drill a hole in my head to let the pressure out.”
The researchers suggested that because treatment works differently for different types of headaches, it raises questions regarding the mechanisms of action of onabotulinum toxin A that will require further research.
“Using specific characteristics, we may divide migraine into various categories with presumed different mechanisms,” the authors suggested. “Using these criteria, we may use different treatments for different subgroups of chronic severe migraine patients.
“It has been proposed that imploding migraine involves extracranial neurovascular pathology, while the neuro-anatomical basis of exploding migraine is intracranial neurovascular pathology.”
Lee noted that onabotulinum toxin A’s best known mechanism of action is through inhibition of acetylcholine release from nerve endings, which reduces neuromuscular transmission and local muscle activity. That, he suggested, might explain why the toxin injections work better in the imploding type of pathology.
“This is a very interesting study,” commented Lyndal Stoutin, MD, a private practice pain management specialist and anesthesiologist affiliated with St. Joseph Regional Medical Center, in Lewiston, Idaho. “We use injections of local anesthetic and sometimes steroids in patients with refractory chronic migraine headaches.”
“We have problems of reimbursement with onabotulinum toxin therapy,” he told MedPage Today while he reviewed the poster presentation. He said that third-party payers have balked at paying for more expensive treatments, such as onabotulinum toxin A injections, so he uses other remedies.
He said the use of injections with onabotulinum or other agents might also negate the use of narcotics for treatment of the headaches, and suggested that injections such as those being used in the Harvard study would help a good percentage of patients without having to resort to systemic therapy.
In turn, he said, “That might eliminate drug-seeking activity on the part of some individuals with addictions or those with misuse behavior.”
Since the recent FDA approval of the use of onabotulinum toxin A for the treatment of migraine headaches, Dr. Stan Farrell has been successfully utilizing this type of treatment on many of our migraine patients. As the research indicated, 66% of the patients achieved greater than a 30% improvement in their conditions for up to 5 years. We are seeing these types of results here at AZ TMJ, as well. If you’ve exhausted all your treatment options for your headaches, you owe it to yourself to come and have a consultation with Dr. Farrell and see if this type of treatment would be beneficial for you. Additionally, we are seeing more insurance companies begin to cover many of the costs associated to this type of treatment. Call 480-945-3629 and schedule an appointment today. www.headpaininstitute.com
