Botulinum toxin type A injections: a new treatment option for headache sufferers
Headache is the most common pain, and almost everyone experiences headache in their lifetime. Chronic, prolonged and severe headaches can seriously affect people’s productivity and quality of life. The 2001 World Health Report released by the World Health Organization (WHO) ranked common diseases in terms of years of healthy life lost, with migraine ranking in the top 20, and identified severe migraine as the most disabling chronic disease.
Common types of headaches in neurology clinics
Headache may be a transient symptom or a concomitant symptom of another disorder, but it may also be a disorder in its own right. There are many different types of headache disorders, and the most common types of headache in outpatient clinics are: migraine, tension-type headache, cluster headache, and cervicogenic headache.
1. Migraine
Migraine is one of the most common diseases that affects daily life and work. It can occur at any age, with the first onset occurring in adolescence, and is especially common in brain workers. The prevalence of migraine is about 12% worldwide, with female:male = 4:1. It is a recurrent primary functional brain disorder, and in women, attacks often coincide with menstrual periods. Each attack can last from 4 hours to 2 days, but usually lasts more than 10 hours.
The main clinical manifestations of migraine are.
(1) Severe throbbing headache with recurrent attacks, mostly on one side of the head, but can also manifest as bilateral headache with nausea and vomiting.
(2) Hypersensitivity to strong light, noisy and sharp noise, and some odors.
(3) The headache may worsen when walking, especially when walking up or down stairs.
(4) Some patients may experience visual abnormalities before or during an attack, such as flashes of light, jagged patterns, or dark spots in the visual field.
Etiology and triggers of migraine.
The exact cause of migraine is unclear. It is relatively well established that the disease has a genetic predisposition. What is clear is that during a migraine attack, the level of a chemical in the brain called 5hydroxytryptamine decreases, causing abnormalities in cerebrovascular function and dysregulation of other chemicals in the brain, resulting in headaches and other symptoms.
In addition, a number of factors can trigger migraine attacks, called migraine triggers, the common ones are.
(1) Strong flashes of light, such as prolonged gazing at a television, computer screen, or other video display device.
(2) Constant, sharp noise.
(3) Smoking, or inhaling tobacco, fragrances, and some other odors.
(4) Changes in sleep rhythms, such as sleeping in, staying up late, or working at night.
(5) excessive fatigue, including physical or mental exertion.
(6) Eating less, or too long between meals, such as skipping breakfast, etc.
(7) Certain foods, such as red wine, cheese, smoked fish, bacon, chicken liver, hot dogs, chocolate, nuts, etc.
(8) Lack of water in the body.
(9) Endocrine disorders, such as puberty, menstruation, oral contraceptives, menopause, hormone replacement therapy, etc.
Treatment of migraine.
It includes both treatment during attacks and treatment during interictal period. Mild to moderate migraine attacks should be treated with pain medication, such as pain relieving tablets and Tylenol. If vomiting occurs at the same time, you should also take anti-emetic drugs, such as Gastrodia. For severe headaches that do not respond well to the above drugs, trimipramine, such as sumatriptan (Eusul) and zolmitriptan (Slippery), can be used. Patients with intermittent attacks generally only need to avoid triggers as much as possible and do not need medication. However, for patients with frequent attacks, such as more than 3 attacks per month, they should take medications to prevent migraine attacks, such as beta-blockers and antidepressants (amitriptyline, etc.). Patients with frequent attacks can use botulinum toxin injection therapy. Do not take commercially available painkillers frequently on your own to avoid rebound headaches.
Prevention of migraine attacks.
Migraine attacks are associated with certain triggers, and identifying and paying attention to avoiding these triggers in daily life can help reduce the frequency of headache attacks. Patients can also take the following measures.
(1) Keep a migraine diary. The contents include the time of headache attacks, the effect of medication, and possible triggering factors. By analyzing the attacks and the pre-injury living and eating conditions, the triggers of migraine can be identified.
(2) Avoid these triggers in daily life, such as flashing lights, noise, etc.
(3) When you have to use computer or other video display devices for a long time, pay attention to rest at work.
(4) Drink more water and less alcoholic or caffeine-containing beverages.
(5) Maintain a regular sleep.
(6) Outdoor activities, fresh air, exercise.
(7) Eat regular and moderate meals. Avoid foods that may trigger headache. Through proper treatment and lifestyle adjustment, migraine patients can reduce headache attacks and alleviate the pain during attacks, thus improving their quality of life.
2.Tension-type headache
Tension-type headache.
It is the most common type of headache among adults, accounting for about 40% of headache sufferers. It is divided into two types, episodic and chronic tension-type headache, according to the frequency of attacks. The disease is most common in adults, with typical cases starting around the age of 20, and the prevalence increases with age. Its onset is associated with psychosocial stress, anxiety, depression, psychiatric factors, muscle tension, and abuse of pain medications.
Clinical features of tension-type headache.
It generally manifests as bilateral persistent mild to moderate dull pain in the occipital or frontal region that may extend to the whole head, often with a feeling of heaviness of pressure or tightness around the head, although sometimes there may be mild dizziness, blurred vision or tinnitus, but rarely with prodromal symptoms such as nausea, vomiting photophobia or phonophobia, visual impairment and general discomfort. Many patients may suffer from insomnia, anxiety or depression. Daily life is not affected during headache. There may be tenderness or pressure points in the muscles at the site of pain, and sometimes pain when pulling hair; there is stiffness in the muscles in the back of the transverse shoulder, and the muscles feel comfortable when pinching.
The onset of the disease may be related to the following factors: The onset of tension-type headache has the following mechanisms.
(1) High serum potassium ion concentration, which stimulates chemoreceptors leading to headache.
(2) Increased sympathetic excitability during tension, which increases the release of neurotransmitters (norepinephrine, 5–hydroxytryptamine, catecholamines, etc.) and leads to vasoconstriction.
(3) Persistent contraction of the head and neck muscles. It is now believed that psychological factors play an important role in the development of tension-type headache, and tension and apprehension can trigger the disease.
Treatment of tension-type headache.
(1) Pharmacological treatment: Acute attacks can be treated with acetaminophen, aspirin, NSAIDs, ergotamine or dihydroergotamine, and muscle relaxants such as eperisone hydrochloride. Prophylactic treatment with selective 5–hydroxytryptamine reuptake inhibitors (e.g., amitriptyline or cloxetine) is often effective, and tretinoin is useful in some cases.
(2) Planetary ganglion block, pain point block or occipital greater nerve block.
(3) Physical therapy, commonly used are massage, transcutaneous electrical stimulation, heat therapy, bioinformatic waves, ion guides, and acupuncture.
(4) Psychotherapy, to relieve the patient’s anxiety and depression, regular work and rest, and increase confidence in overcoming the disease.
(5) Botulinum toxin type A injection.
Prevention of tension-type headache.
(1) Pay attention to keeping warm in the morning and evening, and pay attention to the increase or decrease of clothes in the morning, midday and evening.
(2) Pay attention to the diet with more sour and sweet things that nourish Yin, such as tomatoes, lilies, green vegetables, strawberries, oranges, etc. Avoid spicy and greasy food.
(3) Regulate your emotions, don’t give yourself too much pressure, don’t bury your head in books all day and night, get out of the house more often to exercise outdoors and try to relieve and relax your emotions.
3.Conglomerative headache
Cluster headache, also known as migraine neuralgia, is seen in young people, and is 4–7 times more common in men than in women, usually without family history. Patients suddenly develop a series of severe headaches within a certain period of time, usually without a precursor.
Clinical features of cluster headache: The headache attacks seem to come in clusters, manifesting as a series of intense headache attacks. The pain starts around the eye sockets on one side and extends rapidly to the frontotemporal region, and in severe cases may involve the opposite side. The pain is pulsating and is accompanied by a drilling or burning pain. The characteristic concomitant symptoms include facial flushing, sweating, tearing on the affected side, conjunctival congestion, eyelid edema, or nasal congestion and runny nose. In addition to superficial temporal artery anger, there is also incomplete Horner’s syndrome such as narrowing of the affected pupil and drooping eyelids. The attacks are periodic, and many patients have headache at a fixed time, often in the afternoon or early morning, and can have 1 – 2 attacks per day, each attack lasts about tens of minutes to 2 – 3 hours, and the attacks disappear quickly and can be relieved by themselves, and the remission The duration is long. About 10% of patients have chronic symptoms. Drinking alcohol or nitroglycerin can trigger headache attacks.
Treatment of cluster headache.
(1) Pharmacological treatment: Oxygen can be administered during the attack, and sumatriptan or dihydroergotamine can rapidly relieve the headache; oral prednisone can also significantly improve the symptoms. Prevention of recurrence during attacks: oral ergots or calcium antagonists (ciprofloxacin, isoptin extended-release type, etc.) can be taken. Prevention of nocturnal seizures: rectal suppository of ergotamine & subcutaneous injection of dihydroergotamine at bedtime.
(2) Stellate ganglion block, pterygopalatine ganglion block or disruption.
(3) Botulinum toxin type A injection treatment.
4.Cervicogenic headache
Cervicogenic headache is most common in women aged 20-60 years old, especially in ambulatory workers. It is a group of syndromes with chronic, unilateral head pain caused by lesions of the structures innervated by the high cervical nerve (C1–3). In the early stage, it is mostly discomfort in the occipital area, behind the ear, and under the ear, and later it turns into stuffiness or soreness, and gradually pain appears. The pain area may extend to the forehead, temporal region, top, and neck. Some patients may have pain in the upper limbs of the ipsilateral shoulder and back at the same time. Some patients have tinnitus, ear swelling, eye stuffiness, and stiffness in the neck. Those with longer disease duration have decreased work efficiency, reduced concentration and memory, depressed mood, irritability, irritability, and significantly reduced quality of life and work. Different degrees of cervical degeneration can be seen on imaging.
Pathogenesis and triggers of cervicogenic headache.
(1) Most of the high cervical nerves leave the spinal canal and travel within the soft muscle tissue. Inflammation, ischemia, injury, compression and even inappropriate massage of the soft tissue can affect the function of the nerves and trigger headache.
(2) Degenerative degeneration of the cervical spine and intervertebral discs causes intervertebral foraminal stenosis, non-bacterial inflammation, and edema.
(3) Muscle spasm in the neck and shoulder. Common triggers include: prolonged head-down work, lengthy and tedious mental activities or physical labor are common causes of cervicogenic headache. Cold, exertion, alcohol consumption, and emotional excitement can induce an increase in pain.
Treatment of cervicogenic headache.
(1) Oral administration of non-steroidal anti-inflammatory drugs such as Fenbid can reduce headache symptoms.
(2) Treatment for lesions of high cervical nerve and its innervated small joints, intervertebral disc, dura and blood vessels.
(3) Botulinum toxin type A, which is more effective for cervicogenic headache caused by lesions of cervical muscle tissue.
What kind of headache patients are suitable for treatment with botulinum toxin type A.
Botulinum toxin type A, a new type of drug for the treatment of chronic headache, has been found to have significant efficacy with mild and transient adverse effects in recent years. It can be used to treat the following types of headaches.
(1) Chronic primary moderate-to-severe headache, including migraine, tension-type headache, and cluster headache, which have been treated with medication for several months to a year with poor results.
(2) Chronic headache with ineffective prophylactic medication or severe intolerable adverse reactions.
(3) Refusal to take daily medication or contraindications to oral medication.
(4) Migraine combined with cranial or cervical dystonia or lateral migraine muscle spasm.
(5) Migraine combined with myotonic headache.
(6) Cervicogenic headache caused by lesions in the musculature of the neck. Specific assessment by a specialist is required.
What kind of patients are not suitable for Botulinum toxin type A injection treatment?
(1) Pain medication dependence.
(2) Pregnant and lactating women.
(3) Coagulopathy or concomitant anticoagulation therapy.
(4) Injection site infection.
(5) Patients with systemic neuromuscular diseases such as myasthenia gravis, Lambert–Eaten syndrome, motor neuron disease, etc.
(6) Use of certain drugs that aggravate transmission disorders of the neuromuscular junction, such as quinine, aminoglycoside antibiotics, morphine, etc., within the last 1 week.
(7) A history of allergic reactions or asthma.
(8) Severe cardiac, hepatic and renal insufficiency, diabetes mellitus.
(9) Patients with mental disorders.
Can Botulinum toxin type A treat pain in other parts of the body besides headache?
As a drug that works by blocking nerves, botulinum toxin type A can also be used to treat trigeminal neuralgia, post-herpetic neuralgia, and chronic pain in other parts of the body. Botulinum toxin type A is also used to treat a variety of myasthenic disorders, such as strabismus, ophthalmic spasm, facial spasm, spastic squint, and post-stroke spasm.
Duration of the effect of Botulinum toxin type A to relieve headache symptoms: the effect is generally maintained for 3 – 6 months, and repeated injections are effective.
Side effects of botulinum toxin type A injection: The adverse reactions are mild, mainly local slight swelling, pain at the injection site, weakness in frowning, weakness in lifting the head, drooping eyelids, and these symptoms last for several days to two or three weeks to recover.