Exploding vs. imploding headache in migraine prophylaxis with Botulinum Toxin A

Abstract

Migraine headache is routinely managed using medications that abort attacks as they occur. An alternative approach to migraine management is based on prophylactic medications that reduce attack frequency. One approach has been based on local intramuscular injections of Botulinum Toxin Type A (BTX-A). Here, we explored for neurological markers that might distinguish migraine patients who benefit from BTX-A treatment (100 units divided into 21 injections sites across pericranial and neck muscles). Responders and non-responders to BTX-A treatment were compared prospectively (n=27) and retrospectively (n=36) for a host of neurological symptoms associated with their migraine. Data pooled from all 63 patients are summarized below. The number of migraine days per month dropped from 16.0+/-1.7 before BTX-A to 0.8+/-0.3 after BTX-A (down 95.3+/-1.0%) in 39 responders, and remained unchanged (11.3+/-1.9 vs. 11.7+/-1.8) in 24 non-responders. The prevalence of aura, photophobia, phonophobia, osmophobia, nausea, and throbbing was similar between responders and non-responders. However, the two groups offered different accounts of their pain. Among non-responders, 92% described a buildup of pressure inside their head (exploding headache). Among responders, 74% perceived their head to be crushed, clamped or stubbed by external forces (imploding headache), and 13% attested to an eye-popping pain (ocular headache). The finding that exploding headache was impervious to extracranial BTX-A injections is consistent with the prevailing view that migraine pain is mediated by intracranial innervation. The amenability of imploding and ocular headaches to BTX-A treatment suggests that these types of migraine pain involve extracranial innervation as well.

Scalp periarterial saline efficacy in migraine and relation to exploding and imploding headache

“…According to Jakubowky et al [7], pain was classified as ''explosive'' when reported as ''inside the head pointing outward'' or similar; ''implosive'' when reported as ''crushing/piercing outside the skull pointing inward'' or ''driving spikes into the head'' or similar; ''ocular'' when intraorbital pain, with the sensation of eye pulled or popped out, or pushed in, or similar. The localization of arteries was carried out by detecting their pulse with a fingertip (finger pressure on occipital arteries should be light, or the pulse frequently disappears); in a few cases, a phono-doppler apparatus was used.…”

“…Concerning the relationship between the type of pain (implosive, explosive and ocular, according to Jakubowsky et al [7]), and the response to injection, results are shown in Table 2. No significant differences were found in relief in relation to the type of pain.…”

“…However, a role for extracranial innervation has been suggested. Jakubowski et al [7] found that 74% of 39 responders to pericranial injections of botulinum toxin offered accounts of their pain as imploding (i.e., they perceived their head ''to be crushed, clamped or stubbed by external forces'') suggesting a role of extracranial structures; on the contrary, 92% of non-responders to the toxin described ''a build-up of pressure inside their head'' (exploding headache, suggesting a role for the intracranial innervation).…”

Botulinum Neurotoxin a for Chronic Migraine Headaches: Does it Work and How?

“…The findings of these studies provide insight into which headache types might respond to BoNTA, but definitive predictors of individual patient response have not yet been identified. A single study reported a higher response rate to BoTNA when migraine patients who reported 'imploding' headaches, where pain is perceived as emanating from external pressure and includes a significant ocular component, were compared with those reporting 'exploding' headache, where pain is perceived to come from inside the head [6]. Chronic migraine is also more prevalent in women, but whether response to BoNTA differs in a sex-related manner is not known.…”

Botulinum Toxin Type A for the Treatment of Headache

“…Jakubowski et al 29 found in a sample of 63 migraineurs that 74% of those who improved after BoNT-A treatment described their headache as a pressure from outside (imploding headache) or as a feeling of eyepopping (ocular headache). Conversely, 92% of those who did not respond to BoNT-A treatment described their headache as a pressure building up from inside (exploding headache).…”