Treatment of Chronic Refractory Intractable Headache with Botulinum Toxin Type A: A Retrospective Study

Physical medicine rehabilitation approach to pain

A physical medicine and rehabilitation approach to acute and chronic pain syndromes includes a wide spectrum of treatment focus. Whether assessing or treating acute or chronic pain syndromes, management should include a biopsychosocial approach. Assessment may include a focused joint and functional examination including more global areas of impairment (ie, gait, balance, and endurance) and disability. More complicated multidimensional chronic pain conditions may require the use of a more collaborative continuum of multidisciplinary and interdisciplinary treatment approaches. Regardless of the scope of care that each individual patient requires, treatment options may include active physical therapy, rational polypharmacy, CBT, and the use of passive modalities. Treatment goals generally emphasize achieving analgesia, improving psychosocial functioning, and reintegration of recreational or leisure pursuits (ie, community activities and sports). Progress in all therapies necessitates close monitoring by the health care provider and necessitates ongoing communication between members of the treatment team. Although this article focuses on diagnoses related to acute and chronic low back pain, OA, and musculoskeletal disorders, assessment and treatment recommendations may be generalized to most other pain conditions.

A series of three sequential, randomized, controlled studies of repeated treatments with botulinum toxin type A for migraine prophylaxis

We examined the effects of multiple treatments with low doses of botulinum toxin type A (BoNTA; BOTOX(R), Allergan Inc., Irvine, CA) versus placebo for prophylaxis of episodic migraine. This was a series of 3 sequential, randomized, controlled studies of 418 patients with a history of 4 to 8 moderate to severe migraines per month. In study I, patients were randomized to treatment with placebo or BoNTA (7.5 U, 25 U, or 50 U) in predetermined fixed injection sites on the front and sides of the head only. In study II, patients continued to receive, or were randomized to, 2 consecutive treatments with 25 U or 50 U. In study III, patients were randomized to placebo or continuation of 25 U or 50 U. Injection cycles were each 4 months long. BoNTA and placebo produced comparable decreases from baseline in the frequency of migraines at each time point examined (P >or= .201). No consistent, statistically significant differences were observed for any efficacy variable. Adverse events were similar among the groups within each study. In these exploratory studies of episodic migraine patients, repeated injections of low doses of BoNTA into fixed frontal, temporal, and glabellar sites were not more effective than placebo. BoNTA was safe and well tolerated.

PERSPECTIVE

Beneficial effects of BoNTA in the treatment of migraine have been reported, but positive results are not universal, possibly because the optimal patient population and regimen are not yet definitively established. This study explores the effects of multiple injections of low BoNTA doses into fixed sites for episodic migraine.

Botulinum Toxin a Injection of the Obturator Internus Muscle for Chronic Perineal Pain

Chronic perineal pain is often a difficult condition to manage. Current treatments include pudendal nerve injections and pudendal nerve release surgery. The obturator internus muscle has a close relationship to the pudendal nerve and might be a potential target for therapeutic intervention.

PERSPECTIVE

A case is presented of refractory perineal pain that was successfully treated by injecting the obturator internus muscle with botulinum toxin A.