Three patients ranging from 49 to 61 years-old presented to our pain clinic after failing multiple treatment attempts for debilitating, chronic post-traumatic headaches, neck pain and involuntary muscle spasm following gunshot wounds to the head, neck and face. Concurrent cervical dystonia was noted in each patient on presentation. All patients were treated with onabotulinumtoxin A (ONA) injections in the head and neck. Each patient reported between 70% and 100% improvement of their headache pain, neck pain and spasm with a significant reduction in the frequency, duration and intensity of their headaches. This level of improvement has been successfully maintained in all three patients with regular ONA injections at 90-day intervals. Two patients experienced a single relapse in symptoms when scheduling conflicts caused them to miss their regularly scheduled ONA injections by several weeks. These symptoms resolved when their ONA injections resumed, suggesting that ONA is the causative agent alleviating their symptoms.
Occipital neuralgia is characterized by severe pain, accompanied by tenderness and trigger points, in the distribution of the greater, lesser, and/or third occipital nerves. Occipital neuralgia is typically idiopathic, but also is characterized as a common form of posttraumatic headache. Typical treatments include nerve blocks with local anesthetic, nerve stimulation, pulsed radiofrequency, and cryoablation. OnabotulinumtoxinA (ONA) has recently been utilized in nerve blocks to treat occipital neuralgia, with the potential for a longer duration of pain relief than local anesthetic. Our study retrospectively examined 63 patients treated for occipital neuralgia, including 19 with ONA. 80 -155 units of ONA were administered bilaterally in the surrounding musculature. A total of 61 patients, including 17 of those subsequently treated with ONA, were treated with local anesthetic, using a 1:1 mixture of 0.25% bupivacaine and 1% lidocaine, plus triamcinolone. Patients reported VAS pain scores before and after their procedures, and again during 4-week follow-up visits. Information on opioid use, overall pain relief, and duration of full relief was also recorded upon followup. Patients treated with ONA exhibited significant decreases in average VAS pain scores from 4.1 ± 2.6 pre-procedure to 2.1 ± 2.4 post-procedure (p = 2 × 10 −5 ), and 3.0 ± 2.5 4 weeks later (p = 0.0234). Mean overall relief was 75.8% ± 25.0%. Treatment with local anesthetic suggested equally efficacious reduction of VAS scores; however, treatment with ONA showed a significantly higher percentage of overall pain relief leading to follow-up. Opioid use did not exhibit significant change, regardless of treatment type. Our results support the hypothesis that use of OnabotulinumtoxinA in occipital nerve blocks leads to significant decreases in pain, while possibly exhibiting a longer duration of action than that of local anesthetic.
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