Clinical Use of Botulinum Neurotoxins: Pain

  • Bahman Jabbari
  • Duarte G. Machado
Part of the Current Topics in Neurotoxicity book series (Current Topics Neurotoxicity, volume 5)


Animal data have shown that botulinum neurotoxins (BoNTs) inhibit the release of pain neurotransmitters/neuromodulators (glutamate, substance P, calcitonin-gene-related peptide) and pro-inflammatory agents (prostaglandins, bradykinin, histamine) from peripheral nerve endings and sensory ganglia and reduce the phenomena of peripheral and central sensitization, major factors for pain chronicity. A review of class I and II studies (double blind, placebo controlled) using the criteria set forward by the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology shows different levels of efficacy for a large number of human pain disorders: There exists level A evidence (two or more class I studies—established efficacy) for pain of cervical dystonia, chronic migraine and chronic lateral epicondylitis and level-B evidence (one class I or two class II studies—probably effective) for postherpetic and posttraumatic neuralgia, pain of plantar fasciitis, piriformis syndrome and pain in total knee arthroplasty. Level C evidence (one class II study—possibly effective) denotes allodynia of diabetic neuropathy, chronic low back pain, painful knee osteoarthritis, anterior knee pain with vastus lateralis imbalance, pelvic pain, postoperative pain in children with cerebral palsy after adductor hip release surgery, postoperative pain after mastectomy and sphincter spasms and pain after hemorrhoidectomy. The myofascial pain syndrome and chronic daily headaches have level U evidence (efficacy not proven due to controversial results). Results of BoNT treatment trials in episodic migraine and chronic tension headaches justify level A evidence for treatment failure. The end of each assessed category includes a medical comment and suggestions for improvement of future studies. For certain pain syndromes, figures are provided to illustrate the suggested number and site of injections and the appropriate doses.


Botulinum neurotoxin Migraine Neuropathic Headache Analgesic Neuralgia Plantar fasciitis Myofascial pain 



Narges Moghimi, M.D, helped with the literature search and with final production of the manuscript.


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Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Department of NeurologyYale University School of MedicineNew HavenUSA

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