Botulinum-Toxin A in der Therapie von Kopfschmerzerkrankungen und perikranialen Schmerzsyndromen

Abstract

For 20 years botulinum toxin A has been used for the treatment of a variety of disorders characterised by pathologically increased muscle contraction. Recently, treatment of tension headache, migraine, cluster headache, and myofascial pain syndromes of neck, shoulder girdle, and back with botulinum toxin A has become a rapidly expanding new field of research. Several modes of action are discussed for these indications. The blockade of cholinergic innervation reduces muscular hyperactivity for 3 to 6 months. Degenerative changes in the musculoskeletal system of the head and neck are prevented. Nociceptive afferences and blood vessels of the pericranial muscles are decompressed and muscular trigger points and tender points are resolved. The normalisation of muscle spindle activity leads to a normalisation of muscle tone and central control mechanisms of muscle activity. Oromandibular dysfunction is eliminated and muscular stress removed. However, the effect of botulinum toxin A cannot be explained by muscular actions only. Its retrograde uptake into the central nervous system modulates the expression of substance P and enkephalins in the spinal cord and nucleus raphe. Recent findings suggest an inhibition of sterile inflammation which may lead to a blockade of the neurogenic inflammation believed to be the pathophysiological substrate of primary headache disorders. The efficacy of botulinum toxin A in the treatment of pain disorders is being investigated in several studies at the moment. The results and experiences obtained so far present new alternatives in the treatment of chronic pain disorders. The practical use of botulinum toxin A is demonstrated.

The Therapeutic Potential of Botulinum Toxin

“…Additionally, retrograde uptake of BTX‐A into the central nervous system is believed to influence the substance P and enkephalins levels in the spinal cord and nucleus raphe. This could lead to a blockade of pain seen in migraine 33 . BTX‐A has been shown to block autonomic pathways, 27 and there is evidence that BTX has a direct effect on afferent fibers, suggesting an inhibition potential of the sensory system 28–30 .…”

“…This could lead to a blockade of pain seen in migraine. 33 BTX-A has been shown to block autonomic pathways, 27 and there is evidence that BTX has a direct effect on afferent fibers, suggesting an inhibition potential of the sensory system. [28][29][30] BTX may reduce various substances that ''sensitize nociceptors, and as a result, BTX-A and BTX-B are now being actively studies in nociceptive and neuropathic pain disorders to better define their roles as analgesics.''…”

Botulinumtoxin bei Kopfschmerzen: Ende eines langen Weges?

“…auch hochfrequenter episodischer Migräne ein Hinweis für eine mögliche Wirksamkeit von Botulinumtoxin A. In den Übersichtsarbeiten finden sich unterschiedliche Beurteilungen der Ergebnisse: Von z. T. äußerst positiven Einschätzungen [12], bis zu eher skeptischen [27,28] oder sogar klar ablehnender [29] Beurteilung des therapeutischen Potenzials von Botulinumtoxin. Zu einem anderen Kopfschmerzsyndrom mit obligater Aktivierung des trigemino-vaskulären Systems, dem Clusterkopfschmerz gibt es bisher keine kontrollierten Studien.…”

“…Zu einem anderen Kopfschmerzsyndrom mit obligater Aktivierung des trigemino-vaskulären Systems, dem Clusterkopfschmerz gibt es bisher keine kontrollierten Studien. In den vorliegenden kleinen offenen Fallstudien (z. T. nur als Abstrakt publiziert) findet sich aber überraschenderweise in etwa 50 % der Patienten, meist mit chronischen Formen, ein positiver Effekt (Übersicht in: [12]) [30]. Zusammen mit den Ergebnissen aus den Studien zur episodischen Migräne lassen auch diese Ergebnisse sich dahingehend deuten, dass therapeutische Effekte von [43].…”