Acta Neurol Scand. 2018;138:99. wileyonlinelibrary.com/journal/ane
© 2018 John Wiley & Sons A/S.
Published by John Wiley & Sons Ltd
LETTER TO THE EDITOR
The effects/injections of botulinum toxin in chronic migraine
We have taken interest in the recently published article in your
journal by Do et al
While we completely agree with the authors’
proposal for perisutural injection of the toxin, we have some con-
cerns as regards the effectiveness of perineural BoNT injection at
supraorbital and greater occipital nerves. As it is widely accepted,
the toxin is actively internalized through the terminal nerve end-
ings at the presynaptic membrane.
Hence, rather than injecting
around the main nerve trunk(s) or their proximal branches, we ad-
vocate that the BoNT should be targeted to the aforementioned
nerve terminals. In practice, this could be performed by multiple
injections in the painful dermatomal, that is, temporal, frontal, oc-
cipital areas. Of note, the injections need to be confined to the
subcutaneous layer (or to perisutural areas) in order not to cause
any untoward paralysis in the neck and scalp muscles. Moreover,
because frontal and occipital muscles are innervated by facial
nerve rather than branches of trigeminal nerve, BoNT injection
into abovementioned muscles should be avoided.
Last but not
least, either for perisutural or subcutaneous injections, we suggest
that ultrasound imaging/guidance can effectively/conveniently be
used (unpublished data).
CONFLICT OF INTEREST
Department of Physical and Rehabilitation Medicine, Hacettepe
University Medical School, Ankara, Turkey
İstanbul Physical and Rehabilitation Medicine Research and Training
Hospital, İstanbul, Turkey
1. Do TP, Hvedstrup J, Schytz HW. Botulinum toxin: a review of the
mode of action in migraine. Acta Neurol Scand. 2018;137:442-451.
2. Keller JE, Cai F, Neale EA. Uptake of botulinum neurotoxin into cul-
tured neurons. Biochemistry. 2004;43:526-532.
3. Drake R, Vogl AW, Mitchell AWM, eds. Head and neck. In: Gray’s
Anatomy for Students E-Book. London: Churchill Livingstone;