Janis Jeffrey E, Barker Jenny C, Palettas Marilly
Department of Plastic Surgery, The Ohio State University Medical Center, and Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio.
Plast Reconstr Surg Glob Open. 2017 Mar 28;5(3):e1270. doi: 10.1097/GOX.0000000000001270. eCollection 2017 Mar.
Onabotulinumtoxin A (BOTOX) is an FDA-approved treatment for chronic migraine headaches (MHs) that involves on-label, high-dose administration across 31 anatomic sites. Anatomically specific peripheral nerve trigger sites have been identified that contribute to MH pathogenesis and are amenable to both BOTOX injection and surgical decompression. These sites do not always correlate with the on-label FDA-approved injection pattern, but represent a more targeted approach. The efficacy of peripheral nerve-directed BOTOX injection as an independent long-term therapeutic option has not been investigated.
The technique for peripheral nerve-directed therapeutic long-term BOTOX injection is described. A retrospective review was subsequently completed for 223 patients with MH. Sixty-six patients elected to proceed with diagnostic BOTOX injections. Of these, 24 continued long-term therapeutic BOTOX injections, whereas 42 matriculated to surgery. Outcomes were tracked.
Initial outcomes included significant improvement in migraine headache index (MHI) (53.5 ± 83.0, < 0.006), headache days/mo (9.2 ± 12.7, < 0.0009), and migraine severity (2.6 ± 2.5, < 0.00008) versus baseline. MHI improved from the initiation of diagnostic injections to the establishment of steady-state injections ( < 0.002), and further improved over time ( < 0.05, mean follow-up 615 days) with no desensitization observed. Decompressive surgery resulted in significant improvement in MHI (100.8 ± 109.7, < 0.0000005), headache days/mo (10.8 ± 12.7, < 0.000002), migraine severity (3.0 ± 3.8, < 0.00001), and migraine duration in hours (16.8 ± 21.6, < 0.0007). MHI improvement with surgery was better than long-term BOTOX injections ( < 0.05).
Though inferior to surgical decompression, preliminary data demonstrate that targeted peripheral nerve-directed BOTOX injection is an effective primary therapy for MH representing a possible alternative to nondirected BOTOX injection with decreased dosage requirements and potentially decreased cost.
A型肉毒毒素（保妥适）是一种经美国食品药品监督管理局（FDA）批准用于治疗慢性偏头痛的药物，涉及在31个解剖部位进行标签标注的高剂量给药。已确定了对偏头痛发病机制有影响且适合进行肉毒毒素注射和手术减压的特定解剖部位的外周神经触发点。这些部位并不总是与FDA批准的标签标注注射模式相关，但代表了一种更具针对性的方法。外周神经导向的肉毒毒素注射作为一种独立的长期治疗选择的疗效尚未得到研究。
描述了外周神经导向的长期肉毒毒素治疗性注射技术。随后对223例偏头痛患者进行了回顾性研究。66例患者选择进行诊断性肉毒毒素注射。其中，24例继续进行长期治疗性肉毒毒素注射，而42例接受了手术治疗。对结果进行了跟踪。
初始结果包括与基线相比，偏头痛头痛指数（MHI）（53.5±83.0，P<0.006）、每月头痛天数（9.2±12.7，P<0.0009）和偏头痛严重程度（2.6±2.5，P<0.00008）有显著改善。从诊断性注射开始到建立稳定状态注射期间，MHI有所改善（P<0.002），并且随着时间的推移进一步改善（P<0.05，平均随访615天），未观察到脱敏现象。减压手术使MHI（100.8±109.7，P<0.0000005）、每月头痛天数（10.8±12.7，P<0.000002）、偏头痛严重程度（3.0±3.8，P<0.00001）和偏头痛持续时间（小时）（16.8±21.6，P<0.0007）有显著改善。手术治疗后的MHI改善情况优于长期肉毒毒素注射（P<0.05）。
尽管不如手术减压，但初步数据表明，靶向外周神经导向的肉毒毒素注射是一种有效的偏头痛主要治疗方法，与非靶向肉毒毒素注射相比，可能是一种替代方法，具有降低剂量需求和潜在降低成本的特点。
