Current Review of Pain

, Volume 4, Issue 1, pp 31–35

Comparative trial of botulinum toxin type A and methylprednisolone for the treatment of tension-type headache

  • Mauro Porta


Tension-type headache (TH) is a common condition, the pathophysiology of which remains undetermined. Evidence implicates sustained contraction of pericranial muscles to be a major cause. A recent preliminary study demonstrated the effectiveness of botulinum toxin type A (BTX-A) in patients suffering from chronic TH. To further investigate this, we performed a study to compare the efficacy of BTXA with the steroid methylprednisolone (both administered with the local anesthetic lidocaine), when administered by injection into the tender points of cranial muscles in patients with TH.

A significant decrease in the median pain score (assessed using a standard visual analogue scale [VAS]) was observed at 60 days post injection of BTX-A compared with the pain score achieved following steroid therapy. All patients treated with BTX-A experienced a gradual decrease in median pain severity scores at 30 days and 60 days post treatment. The beneficial effects of BTX-A therapy continued to improve 60 days following injection, whereas the effects of steroid therapy at this time point began to decline. This study clearly demonstrates the effectiveness of BTX-A for the treatment of TH.


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References and Recommended Reading

  1. 1.
    Rasmussen BK, Jensen R, Schroll M, et al.: Epidemiology of headache in a general population-a prevalence study. J Clin Epidemiol 1991, 44:1147–1157.CrossRefPubMedGoogle Scholar
  2. 2.
    Rasmussen BK: Epidemiology. In The Headaches. Edited by Olesen J et al. New York: Raven Press; 1993:439–443.Google Scholar
  3. 3.
    Schoenen J: Tension-type headache: differential diagnosis. In The Headaches. Edited by Olesen J et al. New York: Raven Press; 1993:509–510.Google Scholar
  4. 4.
    Bogduk N: Anatomy and pathology. In The Headaches. Olesen J et al. New York: Raven Press; 1993:445–454.Google Scholar
  5. 5.
    International Headache Society Committee on Clinical Trials: Guidelines for trials of drug treatments in tension-type headache. First edition. Cephalalgia 1995, 15:165–179.CrossRefGoogle Scholar
  6. 6.
    Drummond PD: Scalp tenderness and sensitivity to pain in migraine and tension headache. Headache 1987, 27:45–50.CrossRefPubMedGoogle Scholar
  7. 7.
    Langemark M, Olesen J: Pericranial tenderness in tension headache. Cephalalgia 1987, 7:249–255.CrossRefPubMedGoogle Scholar
  8. 8.
    Olesen J, Schoenen J: Synthesis. In The Headaches. Edited by Olesen J et al. New York: Raven Press; 1993:493–496.Google Scholar
  9. 9.
    Olesen J, Langemark M: Mechanisms of tension headache: a speculative hypothesis. In Basic Mechanisms of Headache. Edited by Olesen J, Edvinsson L. Amsterdam: Elsevier; 1988:457–461.Google Scholar
  10. 10.
    Ohrbach R, Gale EN: Pressure pain threshold in normal muscles: reliability, measurement effects, and topographic differences. Pain 1989, 37:257–263.CrossRefPubMedGoogle Scholar
  11. 11.
    Headache Classification Committee of the International Headache Society: Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988, 8(suppl 7):1–96.Google Scholar
  12. 12.
    Olesen J: Clinical and pathophysiological observations in migraine and tension-type headache explained by integration of vascular, supraspinal, and myofascial inputs. Pain 1991, 46:125–132.CrossRefPubMedGoogle Scholar
  13. 13.
    Jensen R, Rasmussen BK, Pedersen B, et al.: Muscle tenderness and pressure pain thresholds in headache: a population study. Pain 1993, 52:193–199.CrossRefPubMedGoogle Scholar
  14. 14.
    Prichard DW: EMG cranial muscles levels in headache sufferers before and during headache. Headache 1989, 29:103–108.CrossRefGoogle Scholar
  15. 15.
    Pfaffenrath V, Isler H: Evaluation of the nosology of chronic tension-type headache. Cephalalgia 1993, 13(suppl 12):60–62.PubMedGoogle Scholar
  16. 16.
    Merskey H, Bogduk N: Classification of Chronic Pain, edn 2. Seattle: IASP Press; 1994.Google Scholar
  17. 17.
    Silberstein SD: Tension-type headaches. Headache 1994, 34:S2-S7.CrossRefPubMedGoogle Scholar
  18. 18.
    Simons DG, Mense S: Understanding and measurement of muscle tone as related to clinical muscle pain. Pain 1998, 75:1–17. Explains the importance of measuring muscle tone in clinical conditions of pain associated with muscle spasm. Clinical conditions associated with painful muscle spasm include TH and spasmodic torticollis.CrossRefPubMedGoogle Scholar
  19. 19.
    Jensen K, Andersen H, Olesen J, et al.: Pressure pain threshold in human temporal region. Evaluation of a new pressure algometer. Pain 1986, 25:313–323.CrossRefPubMedGoogle Scholar
  20. 20.
    Jensen K, Jensen R: Myogenic nociception and pain thresholds. In The Headaches. Edited by Olesen J et al. New York: Raven Press; 1993:227–231.Google Scholar
  21. 21.
    Jensen R, Schoenen J: Pain thresholds. In The Headaches. Edited by Olesen J et al. New York: Raven Press; 1993:483–487.Google Scholar
  22. 22.
    Magni G: The use of antidepressants in the treatment of chronic pain: a review of the current evidence. Drugs 1991, 42:730–748.CrossRefPubMedGoogle Scholar
  23. 23.
    Holroyd K: Behavioural treatment strategies. In Tension-Type Headache: Classification, Mechanisms and Treatment. Edited by Olesen J, Schoenen J. New York: Raven Press; 1993:245–254.Google Scholar
  24. 24.
    Acquadro M, Borodic G: Treatment of myofascial pain with botulinum A toxin. Anesthesiology 1994, 80:705–706.CrossRefPubMedGoogle Scholar
  25. 25.
    Cheshire WP, Abashian SW, Mann JD: Botulinum toxin in the treatment of myofascial pain syndrome. Pain 1994, 59:63–69.CrossRefGoogle Scholar
  26. 26.
    Porta M, Perretti A, Gamba M, et al.: Compartment botulinum toxin injection for myofascial pain relief [abstract]. DOLOR 1997, 12(suppl 1):42. Reports the beneficial effects of compartmental injection of botulinum toxin type A in the treatment of myofascial pain syndrome.Google Scholar
  27. 27.
    Yue SK: Initial experience in the use of botulinum toxin A for the treatment of myofascial related muscle dysfunctions. J Musculoskeletal Pain 1995, 3(suppl 1):22.Google Scholar
  28. 28.
    Dykstra DD, Sidi AA, Scott AB, et al.: Effects of botulinum A toxin on detrusor-sphincter dyssynergia in spinal cord injury patients. J Urol 1988, 139:919–922.PubMedGoogle Scholar
  29. 29.
    Schurch B, Hauri D, Rodic B, et al.: Botulinum-A toxin as a treatment of detrusor-sphincter dyssynergia: a prospective study in 24 spinal cord injury patients. J Urol 1996, 155:1023–1029. The muscle relaxing properties of botulinum toxin type A are used, in this study, to correct detrusor-sphincter dyssynergia in 24 patients with spinal cord injury. The effects of botulinum toxin type A were reported to last for 3 to 9 months.CrossRefPubMedGoogle Scholar
  30. 30.
    Relja M: Treatment of tension-type headache by local injection of botulinum toxin. Eur J Neurol 1997, 4(suppl 2):S71-S73. Demonstrates the effectiveness of botulinum toxin type A in the treatment of TH. All 10 patients showed a significant decrease in tenderness scores of the frontalis, trapezius, and sternocleidomastoideus muscles 1 to 2 weeks post injection and clinical improvement lasted up to 8 weeks.Google Scholar
  31. 31.
    Wheeler AH: Botulinum toxin A, adjunctive therapy for refractory headaches associated with pericranial muscle tension. Headache 1998, 38:468–471. Discusses the role of pericranial muscle tension in refractory headaches. Reduction of pericranial muscle tension by injection of botulinum toxin type A may be useful for reducing primary myalgia and secondary headache.CrossRefPubMedGoogle Scholar
  32. 32.
    Ahnert-Hilger G, Bigalke H: Molecular aspects of tetanus and botulinum neurotoxin poisoning. Prog Neurobiol 1995, 46:83–96.CrossRefPubMedGoogle Scholar
  33. 33.
    Sjaastad O: So-called “tension-headache”: a term in need of revision? Curr Med Res Opin 1980, 8:41–44.CrossRefGoogle Scholar
  34. 34.
    Kudrow L: Muscle contraction headache. In Handbook of Clinical Neurology. Edited by Vinken PJ, Bruyn GW. Amsterdam: North Holland Publishing Company; 1986:343–352.Google Scholar
  35. 35.
    Zwart J-A, Bovim G, Sand T, et al.: Tension headache: botulinum toxin paralysis of temporal muscles. Headache 1994, 34:458–462.CrossRefPubMedGoogle Scholar
  36. 36.
    Gordh T, Karlsten R, Kristensen J: Intervention with spinal NMDA, adenosine and NO systems for pain modulation. Ann Med 1995, 27:229–234.CrossRefPubMedGoogle Scholar
  37. 37.
    Choi Y, Raja SN, Moore LC, Tobin JR: Neuropathic pain in rats is associated with altered nitric oxide synthase activity in neural tissue. J Neurol Sci 1996, 138:14–20.CrossRefPubMedGoogle Scholar

Copyright information

© Current Science Inc 2000

Authors and Affiliations

  • Mauro Porta
    • 1
  1. 1.Pain Center, Department of NeurologyPoliclinico San Marco, Centro Terapia del Dolore, Corso Europa 7Zingonia/BergamoItaly

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