Onabotulinumtoxin treatment of chronic migraine headache in veterans with traumatic brain injury reduces headache frequency and severity—a case series.
Onabotulinumtoxin A (Botox) has been FDA approved to treat chronic migraine headaches as a second or third line treatment option. However, there is limited literature regarding treatment of chronic posttraumatic migraines following traumatic brain injury (TBI) with Botox, with only one notable cohort study relating to military service members.
Materials and methods
This IRB approved, retrospective case series were collected from a multidisciplinary chemodenervation clinic at Jesse Brown Veterans Administration (JBVA) for veterans with chronic migraines, on whom the FDA approved protocol of 31 botulinum toxin injection sites for treatment of migraines every 3 months was implemented. A subset of patients who developed chronic migraine after traumatic brain injury was used for our study, recording type of headache, type and severity of brain injury, length of time headache was present, frequency of headache before and after Botox intervention, severity of headache before and after Botox intervention, and treatments attempted prior to Botox intervention.
Nine subjects (8:1= male: female) with mean age of 45.4 +12.8 (range 31-70) years were evaluated and treated from 2013 to 2017. The most common type of injury was blast injuries (6 out of 9 patients; 66%). 78% of patients (7 out of 9 ) described more than 1 headache type and 44% of patients (4 out of 9 ) reported continuous pain. The most common diagnosis was mixed continuous headache with migraine features and 89% of patients (8 out of 9 ) reported more than 15 days per month. The mean time from injury to the first injections was 99+ 105 (24-360) months. All patients who were treated with Botox reported improvement including reduced headache frequency with average reduction of 12 days per month (range: 0-26) and/or reduction in severity seen in 50% of the patients by the third Botox treatment (5 out of 9 patients improved after first treatment, 3 after second treatment, and 1 after third treatment). None of the patients discontinued treatment due to side effects.
This case series demonstrated significant improvement in headache frequency in patients with post-traumatic chronic migraine treated with Botox. Based on this case series, Botox also seemed to improve frequency and severity of other types of headache besides migraine. Blast injuries were the most common inciting injury in our population. Given the significant clinical change, further prospective investigation is recommended with a larger sample size, for consideration of using Botox as a first line treatment method for post-traumatic chronic migraine
Onabotulinum Toxin A for the Treatment of Headache in Service Members With a History of Mild Traumatic Brain Injury: A Cohort Study