Evaluation of Electromyoghraphy Guided Botolenium Toxin Type A Injection in Treating Chronic Migraine in Babylon Province

Farah Nabil Abbas
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Keywords : Botox, migraine headache, Botolenium Toxin Type A.
Medical Journal of Babylon  14:3 , 2018 doi:1812-156X-14-3
Published :06 January 2018

Abstract

BOTOX is the first and only FDA-approved preventive treatment for chronic migraine. It s also the only treatment for people with chronic migraine. Current migraine preventive therapies are often unsatisfactory because of their limited efficacy, adverse effects, and drug interactions., Migraines typically present with pulsing head pain, nausea, photophobia (sensitivity to light) and phonophobia (sensitivity to sound). The aim of this study to evaluate the benefit of Botox injection in patients presented with chronic migraine and to determine the efficacy and safety for this kind of treatment in Babylon province. This was an interventional study of 37 subjects with a history of chronic migraine (28 female and the other 9 were male), The patients received botulinum toxin type A, 100 U into 21 intramuscular injections using a 0.5-inch-long needle EMG guided connected to the machine. and for 3 months following injection, subjects kept daily diaries in which they recorded headache frequency, duration, severity, and the occurrence of associated symptoms. The study were done during the period from January/ 2017 until July/2017. There were significant differences in patients with chronic migraine before and after treatment , in which there is significant decrease in migraine attacks per month, with reduction severity of these attacks, a significant decrease of hours in each attack and reduced incidence of migraine-associated symptoms. Pericranial injection of EMG guided BTX-A, 100U, was found to be a safe treatment that significantly reduced migraine frequency, duration, migraine severity, and reduced associated symptoms.

Introduction

BOTOX is the first and only FDA-approved preventive treatment for chronic migraine and tension headache [1]. Current migraine preventive therapies are often unsatisfactory because of their limited efficacy, adverse effects, and drug interactions. Migraines typically present with pulsing head pain, nausea, photophobia (sensitivity to light) and phonophobia (sensitivity to sound). Usually migraine attack affects one half of the head, which is pulsating in nature, and may last from 2 to 72 hours. And usually the attack became more worse by any exertion or physical activity [3]. Migraines may be due to a mixture of genetic and environmental factors. The majority of cases related to family history, hormonal imbalance, in which migraines affect women about two to three times more than men [4,5]. The exact cause of migraine are not well known. It is, however, contributed to a neurovascular disorder [6]. Migraine may be due to increase excitability of the cerebral cortex and abnormal neural control of trigeminal nucleus of the brainstem [7]. Migraines can also cause numbness of the skin. People with severe migraines also have nausea, vomiting and light sensitivity. Medications, certain foods, smells, loud noises and bright lights can all trigger a migraine headache [8]. Photophobia and visual symptoms are one of the most common associated symptoms of migraine [9] and grating patterns of definite spatial frequency may persist even between attacks [10,11]. Visual symptoms such as light flashes has been found in migraineurs with aura [12]. Some of the theories regarding the pathophysiology of migraine include Depolarization theory in which there is an electrical depolarization spreads to involve the whole cortex of the brain, in which there will be release of inflammatory mediators that cause irritation of the cranial nerve roots, specially the trigeminal nerve, which is responsible about the impulses conduction that concerned with head and face sensation. At the beginning of the attack, a large part of the brain involved by this depolerization, even the hypothalamus [13]. Vascular theory is another theory in which the wall of the head blood vessels contract and there will be spasm of the corresponding arteries leading to reduction in the blood flow mainly to the occipital lobe which give an explanation of aura that followed by migraine [14]. Neurotransmitter theory specially serotonin which acts as a mood stabilizer and pain regulator as well as its effect in the constriction and dilation of the brain blood vessels. This theory agreed with the fact that patient who suffer from migraine usually recorded low serotonin levels, [15]. Thyroid dysfunction mainly decrease level of thyroid hormones may be contributed to the cause of migraine attacks. In which decrease metabolic rate leads to fluid retention and mucin accumulation that affect the blood vessels and lead to the corresponding headache [16]. Botulinum toxin type A (BTX-A) used nowadays in majority of disorders which related to muscle contractions, such as spasticity, cervical dystonia, rectal sphincter spasm with fissure, blepharospasm, and achalasia as well as hyperhidrosis. In addition reducing pain associated with these conditions. BTX-A is a neurochemical toxin, which effect the neuromuscular junction by blocking the ability of nerves in contracting the muscles. It means that it cause paralysis to the muscles [17]. In order to contract the muscle, the nerve endings release a neurochemical transmitter which represented by acety-lcholine at the neuromuscular junction that attached to a special receptors in the muscle fiber leading to contraction and relaxation of the muscles, so BTX -A prevents the release of acetylcholine in which it prevents contraction of the muscle fiber [18]. The aim of this study to evaluate the benefit of EMG guided BTX-A injection in patients presented with the main common primary headaches represented by chronic migraine and to determine the efficacy and safety for it regarding the frequency of the attacks, duration, intensity as well as other associated symptoms.

Materials and methods

This study was carried out through the period from January 2017 to June 2017 , at Hilla city in Babylon province. By using the history, as a cross section observational study so it was an interventional study of 37 subjects with a history of chronic migraine diagnosed by neurologist ranging from (18-59) years with (28 females and 10 males), The patients were asked to note a daily diaries one month before the injection and three months after the injection including headache frequency per month, duration per hour for each attack,  severity, and the occurrence of associated symptoms. A After dissolving 100 units of BTX-A (Allergan) in a 4 ml normal saline we select about 21 site for injecting the toxin by using a 0.5-inch-long needle EMG guided connected to the machine that it gives an important information about the exact site of injection by detecting the full interference pattern for the muscle contraction by the EMG machine in which the optimum point for injection could be localized.  The mentioned muscles were injected: occipital (10 U for one site in each side; frontal (five U for seven sites); trapezius (five U in two sites for each side); temporalis (three and quarter U for two sites in each side); splenius capitis (two and a half U in one site for both sides); semispinalis (two and a half U in one site for both sides) [19], Following injection for three months later patients asked to record daily diaries in which they mentioned exactly the frequency of headache attacks in each month, duration of each attack by recording the number of hours, intensity for each attack and the occurrence of associated ymptoms such as nausea, vomiting , photophobia, photophobia,  as it recorder previously.
The exclusion criteria were (1) any medical condition or any contraindication for BTX-A (2) a history of complicated migraine, (3) pregnant or lactating women (4) known allergy or sensitivity to BTX-A (5) patients with other types of headache (6) patient taking any prophylactic medication during the three months before and 3 months after BTX-A injections.
Statistical analysis were performed depending on SPSS version 19 [20].




Results

37 patients (28 female, 9 male) with chronic migraine involved in this study. Their weights ranged from 53 to 99 kg , while their heights from 155 to 190 cm , and their ages ranged from 18 to 59 years. In this study table (1) and figure (1) shows the mean ± standard deviation frequencies of the migraine attacks of the involved patients before and after injection respectively (5.6 8± 2.08, 3.97 ± 1.8, 3.54 ± 1.83, 3.38 ± 1.77) in which there is significant decrease in the number of attacks per month.

Discussions

The evaluation of EMG guided BTX-A injection in treating patients with the chronic migraine in this study found that it plays a role in decreasing the frequency of attacks per month before and after injection as well as the duration of the attacks, while there were decline in the intensity and severity of each attack after the injection. Regarding the associated symptom which may occur during each attack there were prominent decrease in them and these results consistent with many others who found the same results [21-23] while it disagreed with others who found that BTX-A failed to play a role in this kind of treatment [24]. The simplest explanation for this efficacy contributed to the effect of this toxin on the muscle contraction that plays a major role in the pathophysiology of migraine [25] as well as its powerful effect in reducing pain which gives an explanation for reducing migraine intensity and frequency. Even so it considered as an exocytotic inhibitors, [26] that gives its role in pain signals inhibition , in which the effect on the sensory system is unknown yet [27 ]. The role of BTX-A in treating chronic migraine was related to the release of acetyl choline at the neuromuscular junction and its attachment to the specific receptors which lead to muscle contraction , so this toxin will cause reduction of this attachment leading to muscle relaxation instead of contraction or its role in inhibiting the depolarization of the cerebral cortex of the central nervous system specially the trigeminal nucli in the brain stem as well as the hypothalamus which related to the associated symptoms. In spite of its role for acting centrally in treating migraine, BTX-A can acts peripherally through inhibiting the peripheral sensory fibers in which the tingling and numbness of the corresponding skin related to it [21]. The role of this toxin in suppressing the sensory peripheral signals contributed to its effect in reducing the release of substance P from embryonic dorsal root ganglion neurons [28], or CGRP from trigeminal ganglion neurons [29], or glutamate from the dorsal horn of the peripheral nociceptors [30]. Using quantitative sensory testing, however, [31] showed that the injection of this toxin cannot effect the threshold of pain to cold, heat ,as well as mechanical and electrical stimulation, giving the idea that BTX-A can exert its effect in blocking pain signals through neurochemical inhibition or anti-inflammatory action, rather than by direct peripheral anti nociceptive signals. Regarding the mechanism of action of BTX-A on nervous system depends on whether it exert its effect peripherally or centrally and weather inside the cranium or outside the cranium. The pathophysiology of the extracranial tissue involvement has been mentioned before five decades ago [32,33] If so, it means that it works on the extracranial nociceptors that innervate the scalp.

Conclusions

EMG guided BTX-A injection was found to be effective treatment that significantly reduced chronic migraine frequency attacks, duration, severity, and associated symptoms in Babylon province.

References

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