Botulinum toxin as a novel therapeutic approach for auriculotemporal neuralgia

Abstract

A 44-year-old female patient was evaluated in the emergency department for persistent and refractory right temporoparietal headache lasting for 10 weeks. She had a medical history of migraine without aura, eosinophilic esophagitis, anxiety, and was allergic to nonsteroidal anti-inflammatory drugs (NSAIDs). The headache was continuous, of moderate to severe intensity (numeric pain scale 7/10), with occasional more intense paroxysms (9/10), and was partially relieved by sleep. She denied aura and dysautonomic signs. During this period, she had attended different neurologists and was prescribed topiramate 75 mg twice a day. She had been taking eletriptan 20 mg and a combination of analgesics (acetaminophen 400 mg + caffeine 100 mg + ergotamine 1 mg + belladonna alkaloids 0.1 mg) daily, but did not achieve pain relief. The patient was afebrile. The neurological examination, full blood tests, and non-contrast computed tomography (CT) were unremarkable. She was sequentially and unsuccessfully prescribed intravenous (iv) fluid therapy, acetaminophen 1 g iv, metoclopramide 10 mg iv, prednisolone 250 mg iv and sodium valproate 1 g iv, assuming a prolonged migraine status. She was admitted to a neurology ward. After careful review of the patient's complaints, we identified the right supra-auricular region as the most painful area. The pain was exacerbated by touch at the emergence of the auriculotemporal nerve. The patient was evaluated by a stomatologist, who ruled out temporomandibular joint pathology. Regional magnetic resonance imaging (MRI) excluded auriculotemporal nerve entrapment; brain MRI and magnetic resonance angiography (MRA) were also unremarkable. We presumed idiopathic auriculotemporal neuralgia as a plausible secondary diagnosis to migraine and performed an auriculotemporal nerve block with lidocaine 1% 1 cc. She achieved temporal pain relief but retained parietal dull pain, which we attributed to

Botulinum Toxin Type A for the Treatment of Auriculotemporal Neuralgia—A Case Series

“…ATN is a rare disorder and treatments proposed in the literature are not evidence-based; therefore, most clinicians prescribe medications used in other forms of neuralgia, such as gabapentin or carbamazepine [9][10][11][12]; in our cohort, the patients that were on medications had no significant pain relief with these drugs. Treatment with BoNT/A injections had been previously reported in only one case of ATN with satisfactory results [18]. Moreover, it was proven to be effective in other cranial neuralgias, such as trigeminal and occipital neuralgia [22,23].…”

“…The literature is scarce with regard to the therapy of refractory cases, but a recent article reported one case of successfully treated refractory ATN with botulinum toxin type A (BoNT/A) [18]. Botulinum toxin (BoNT) is produced by clostridium botulinum and there are seven different serotypes (A, B, C, D, E, F, and G), but only serotypes A and B are currently used in clinical practice.…”

Associations between Zygoma Fracture and Post-Traumatic Headache: A Study among Taiwanese Population

“…In addition, surgical scars resulting from craniotomy or plastic surgeries were the most common damaging mechanism [20]. At present, nerve decompression surgery [21], peripheral nerve blockade [22], and botulinum toxin injection [23] are widely used for managing distal nerve compression pressure.…”

Virtual issue: Cranial neuralgias

“…While select terminal branch neuralgias were included in the ICHD‐2, 18 these were removed from the ICHD‐3, 2 leaving clinicians without a clear way to indicate the focality of symptoms. A case of auriculotemporal neuralgia (based on therapeutic response to repeated blocks of the auriculotemporal nerve) 19 published by Pinto et al is included as an example of a neuralgia seemingly isolated to a terminal nerve branch.…”