Efficacy of Botulinum Toxin in Tension‐Type Headaches: A Systematic Review of the Literature

Abstract

& AbstractBackground: Botulinum toxin is approved to treat chronic migraine and has been shown to confer significant benefit in refractory cases. Due to its effect on pain by sensory modulation, there may also be efficacy in its use in chronic tension-type headache (CTTH). Methods: A systematic review of the literature was performed using our predefined inclusion and exclusion criteria. We targeted prospective trials, randomized or nonrandomized, studying botulinum toxin in tension-type headaches (TTHs) in adults. Results: Twenty-two studies were included, including 9 nonrandomized, uncontrolled studies, 8 randomized, placebo-controlled and double-blinded trials (RCTs), 3 RCTs with a crossover, open-label period, 1 comparative, randomized, single-blinded evaluation, and 1 retrospective study with prospective evaluation of headache response to cosmetic botulinum toxin. Studies included 11 to 300 subjects, with duration typically less than 6 months and with only 1 treatment period. Results were mixed, likely due to variable study design, including toxin dosing, injection paradigms, duration/frequency of treatment, and outcome measures. There was moderate-quality evidence that botulinum toxin improved VAS scoring, and some studies demonstrated efficacy based on improved frequency/severity. Conclusion:This systematic review demonstrates variable study designs contributing to the low quality of evidence available regarding botulinum toxin in TTH, but some data suggest efficacy. There does not appear to be irrefutable evidence of a lack of efficacy of botulinum toxin in TTH. Using the paradigm for botulinum toxin in chronic migraine may prove fruitful in treating CTTH. Further studies are warranted to evaluate the utility of botulinum toxin in this common debilitating condition. &

Botulinum Toxin in the Treatment of Headache

“…A systematic review of OBTA in chronic tension-type headache found 11 RDBPC trials but concluded more research was needed. In contrast to positive results from non-randomized trials, the authors found "low evidence supporting any conclusions" in the RDBPC trials [53].…”

A bibliometric analysis and visualization of tension-type headache

“…The dominant opinion on the underlying mechanism of botulinum toxin is to inhibit the release of peripheral neurotransmitters or inflammatory mediators, with a secondary effect on the central sensitization, preventing the progression to chronic TTH ( 65 ). Several studies have identified that chronic TTH could benefit from the use of botulinum toxin-based on careful patient selection, specific injection patterns, and clear treatment targets ( 66 ). Although there are studies indicated that compared with placebo, botulinum toxin was not associated with chronic TTH ( 67 ).…”

Psychiatric Comorbidity and Emotional Dysregulation in Chronic Tension-Type Headache: A Case-Control Study

“…Currently, the management of CTTH focuses especially on the symptomatic pharmacological treatment of pain, anxiety and depression comorbidity, and their repercussions (with analgesics, anxiolytics and muscle relaxants, and antidepressants); it may also be associated with other types of pharmacological and non-pharmacological options, such as: physiotherapy (electrotherapy, myofascial trigger point treatment, cervical manipulation) [ 52 , 53 , 54 ], psychological therapy (biofeedback, relaxation techniques) [ 55 ], or botulinum toxin [ 56 ], with uncertain efficacy in the medium and long terms. We believe that re-education and emotional support techniques that reinforce positive affect can contribute to a sustained supportive benefit for these patients; it has been observed that it is possible to re-educate negative thinking, and this implies better coping with pain, preventing pain chronification and catastrophizing conditions [ 24 , 57 , 58 , 59 ].…”