PREEMPT study: Phase III research evaluating migraine prophylaxis therapy
Combination of 2 largest placebo-controlled clinical trials of chronic migraine population that evaluated efficacy and safety of onabotulinumtoxinA
Scalp block targets following 6 nerves
Supraorbital and supratrochlear nerves originate from ophthalmic division (V1) of trigeminal nerve and innervate forehead and upper eyelids
Auriculotemporal nerve is trigeminal branch of mandibular division (V3) and innervates anterior and superior areas of ears
Zygomaticotemporal nerve originates from maxillary division (V2) of trigeminal nerve and innervates lateral to outer cantus of eyes
Greater occipital nerves originate from dorsal ramus of C2 and innervate posterior scalp medial to occipital artery
Lesser occipital nerves originate from ventral rami of C2 and C3 and innervate scalp behind ear
Botulinum toxin type A (BoNT-A): Commercial forms are marketed under following brand names
Botox (onabotulinumtoxinA)
Original BoNT-A product approved by FDA
Dysport (abobotulinumtoxinA)
Botox and Dysport differ in purification procedure; Dysport is reported to exhibit greater spread, and dose ratios between Dysport and Botox is commonly estimated to be 3:1
Xeomin (incobotulinumtoxinA)
Xeomin:Botox ratio is reported to be near 1:1, without any significant differences in safety and efficacy; by stripping BoNT-A of complexing proteins, Xeomin is hypothesized to carry reduced risk of sensitization or antibody formation, which have yet to be validated in literature
Botulinum toxin type B (BoNT-B)
Myobloc (rimabotulinumtoxinB)
This is only BoNT-B commercially available in USA, indicated only for treatment of cervical dystonia in adults
Compared to BoNT-A, it shows more rapid onset and greater diffusion but shorter duration of actions and more painful injections
Conversion from Botox to Myobloc is reported to be in range of 1:50-100
Note: There is no established conversion method for equivalent dosing among different BoNT products
Each unit injection from one product is not interchangeable with other preparations
They offer different safety and efficacy characteristics, and, thus, interventionalist must be familiar with selected product prior to their use
PREPROCEDURE
Indications
Contraindications
Getting Started
PROCEDURE
Procedure Steps
POST PROCEDURE
Expected Outcome
OUTCOMES
Complications
Selected References
FDA website. Botox prescribing information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/125274s112lbl.pdf. Published 2018. Reviewed July 2019. Accessed July 2019.
Vikelis M et al: Sustained onabotulinumtoxinA therapeutic benefits in patients with chronic migraine over 3 years of treatment. J Headache Pain. 19(1):87, 2018
Awan KH: The therapeutic usage of botulinum toxin (Botox) in non-cosmetic head and neck conditions - an evidence based review. Saudi Pharm J. 25(1):18-24, 2017
Janis JE et al: Targeted peripheral nerve-directed onabotulinumtoxin A injection for effective long-term therapy for migraine headache. Plast Reconstr Surg Glob Open. 5(3):e1270, 2017
Pihut M et al: The efficiency of botulinum toxin type A for the treatment of masseter muscle pain in patients with temporomandibular joint dysfunction and tension-type headache. J Headache Pain. 17:29, 2016
Scaglione F: Conversion ratio between Botox®, Dysport®, and Xeomin® in clinical practice. Toxins (Basel). 8(3), 2016
Mor N et al: Temporomandibular myofacial pain treated with botulinum toxin injection. Toxins (Basel). 7(8):2791-800, 2015
Bebawy JF et al: A modified technique for auriculotemporal nerve blockade when performing selective scalp nerve block for craniotomy. J Neurosurg Anesthesiol. 26(3):271-2, 2014
McNicholas E et al: Transient facial nerve palsy after auriculotemporal nerve block in awake craniotomy patients. A A Case Rep. 2(4):40-3, 2014
Guilfoyle MR et al: Regional scalp block for postcraniotomy analgesia: a systematic review and meta-analysis. Anesth Analg. 116(5):1093-102, 2013
Aurora SK et al: OnabotulinumtoxinA for treatment of chronic migraine: pooled analyses of the 56-week PREEMPT clinical program. Headache. 51(9):1358-73, 2011
Amsterdam, James et al: Regional Anesthesia of the Head and Neck. Roberts, Hedges. Clinical Procedures in Emergency Medicine. 5th ed. Philadelphia: Saunders Elsevier. 510-2, 2010
Aurora SK et al: OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 1 trial. Cephalalgia. 30(7):793-803, 2010
Diener HC et al: OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 2 trial. Cephalalgia. 30(7):804-14, 2010
Osborn I et al: "Scalp block" during craniotomy: a classic technique revisited. J Neurosurg Anesthesiol. 22(3):187-94, 2010
Loukas M et al: Identification of greater occipital nerve landmarks for the treatment of occipital neuralgia. Folia Morphol (Warsz). 65(4):337-42, 2006
Chikhani L et al: [Bruxism, temporo-mandibular dysfunction and botulinum toxin.] Ann Readapt Med Phys. 46(6):333-7, 2003
Gain P et al: [Facial anesthetic blocks in the treatment of acute pain during ophthalmic zoster.] J Fr Ophtalmol. 26(1):7-14, 2003
Dimitriou V et al: Blockade of branches of the ophthalmic nerve in the management of acute attack of migraine. Middle East J Anaesthesiol. 16(5):499-504, 2002
Related Anatomy
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Related Differential Diagnoses
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References
Tables
Tables
KEY FACTS
Terminology
Preprocedure
Procedure
Post Procedure
TERMINOLOGY
Abbreviations
Electromyography (EMG)
Temporomandibular joint (TMJ)
Botulinum neurotoxin (BoNT)
Definitions
PREEMPT study: Phase III research evaluating migraine prophylaxis therapy
Combination of 2 largest placebo-controlled clinical trials of chronic migraine population that evaluated efficacy and safety of onabotulinumtoxinA
Scalp block targets following 6 nerves
Supraorbital and supratrochlear nerves originate from ophthalmic division (V1) of trigeminal nerve and innervate forehead and upper eyelids
Auriculotemporal nerve is trigeminal branch of mandibular division (V3) and innervates anterior and superior areas of ears
Zygomaticotemporal nerve originates from maxillary division (V2) of trigeminal nerve and innervates lateral to outer cantus of eyes
Greater occipital nerves originate from dorsal ramus of C2 and innervate posterior scalp medial to occipital artery
Lesser occipital nerves originate from ventral rami of C2 and C3 and innervate scalp behind ear
Botulinum toxin type A (BoNT-A): Commercial forms are marketed under following brand names
Botox (onabotulinumtoxinA)
Original BoNT-A product approved by FDA
Dysport (abobotulinumtoxinA)
Botox and Dysport differ in purification procedure; Dysport is reported to exhibit greater spread, and dose ratios between Dysport and Botox is commonly estimated to be 3:1
Xeomin (incobotulinumtoxinA)
Xeomin:Botox ratio is reported to be near 1:1, without any significant differences in safety and efficacy; by stripping BoNT-A of complexing proteins, Xeomin is hypothesized to carry reduced risk of sensitization or antibody formation, which have yet to be validated in literature
Botulinum toxin type B (BoNT-B)
Myobloc (rimabotulinumtoxinB)
This is only BoNT-B commercially available in USA, indicated only for treatment of cervical dystonia in adults
Compared to BoNT-A, it shows more rapid onset and greater diffusion but shorter duration of actions and more painful injections
Conversion from Botox to Myobloc is reported to be in range of 1:50-100
Note: There is no established conversion method for equivalent dosing among different BoNT products
Each unit injection from one product is not interchangeable with other preparations
They offer different safety and efficacy characteristics, and, thus, interventionalist must be familiar with selected product prior to their use
PREPROCEDURE
Indications
Contraindications
Getting Started
PROCEDURE
Procedure Steps
POST PROCEDURE
Expected Outcome
OUTCOMES
Complications
Selected References
FDA website. Botox prescribing information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/125274s112lbl.pdf. Published 2018. Reviewed July 2019. Accessed July 2019.
Vikelis M et al: Sustained onabotulinumtoxinA therapeutic benefits in patients with chronic migraine over 3 years of treatment. J Headache Pain. 19(1):87, 2018
Awan KH: The therapeutic usage of botulinum toxin (Botox) in non-cosmetic head and neck conditions - an evidence based review. Saudi Pharm J. 25(1):18-24, 2017
Janis JE et al: Targeted peripheral nerve-directed onabotulinumtoxin A injection for effective long-term therapy for migraine headache. Plast Reconstr Surg Glob Open. 5(3):e1270, 2017
Pihut M et al: The efficiency of botulinum toxin type A for the treatment of masseter muscle pain in patients with temporomandibular joint dysfunction and tension-type headache. J Headache Pain. 17:29, 2016
Scaglione F: Conversion ratio between Botox®, Dysport®, and Xeomin® in clinical practice. Toxins (Basel). 8(3), 2016
Mor N et al: Temporomandibular myofacial pain treated with botulinum toxin injection. Toxins (Basel). 7(8):2791-800, 2015
Bebawy JF et al: A modified technique for auriculotemporal nerve blockade when performing selective scalp nerve block for craniotomy. J Neurosurg Anesthesiol. 26(3):271-2, 2014
McNicholas E et al: Transient facial nerve palsy after auriculotemporal nerve block in awake craniotomy patients. A A Case Rep. 2(4):40-3, 2014
Guilfoyle MR et al: Regional scalp block for postcraniotomy analgesia: a systematic review and meta-analysis. Anesth Analg. 116(5):1093-102, 2013
Aurora SK et al: OnabotulinumtoxinA for treatment of chronic migraine: pooled analyses of the 56-week PREEMPT clinical program. Headache. 51(9):1358-73, 2011
Amsterdam, James et al: Regional Anesthesia of the Head and Neck. Roberts, Hedges. Clinical Procedures in Emergency Medicine. 5th ed. Philadelphia: Saunders Elsevier. 510-2, 2010
Aurora SK et al: OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 1 trial. Cephalalgia. 30(7):793-803, 2010
Diener HC et al: OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 2 trial. Cephalalgia. 30(7):804-14, 2010
Osborn I et al: "Scalp block" during craniotomy: a classic technique revisited. J Neurosurg Anesthesiol. 22(3):187-94, 2010
Loukas M et al: Identification of greater occipital nerve landmarks for the treatment of occipital neuralgia. Folia Morphol (Warsz). 65(4):337-42, 2006
Chikhani L et al: [Bruxism, temporo-mandibular dysfunction and botulinum toxin.] Ann Readapt Med Phys. 46(6):333-7, 2003
Gain P et al: [Facial anesthetic blocks in the treatment of acute pain during ophthalmic zoster.] J Fr Ophtalmol. 26(1):7-14, 2003
Dimitriou V et al: Blockade of branches of the ophthalmic nerve in the management of acute attack of migraine. Middle East J Anaesthesiol. 16(5):499-504, 2002
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