**Management of Migraine Headaches: OnabotulinumtoxinA Injection Management of Migraine Headaches: OnabotulinumtoxinA Injection**

Michael Chung, Xingchen Li, Kyle Sanniec and Bardia Amirlak Michael Chung, Xingchen Li, Kyle Sanniec and Bardia Amirlak Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/67308

#### **Abstract**

[31] Mathew, P.G., *A critical evaluation of migraine trigger site deactivation surgery*. Headache,

[32] Guyuron, B., *A discussion of "critical evaluation of migraine trigger site decompression sur-*

[33] Guyuron, B., D. Harvey, and D. Reed, *A prospective randomized outcomes comparison of two temple migraine trigger site deactivation techniques*. Plast Reconstr Surg, 2015. **136**(1):

[34] Amirlak, B., et al., *The Anatomical Regional Targeted (ART) BOTOX injection technique. A new injection paradigm for the treatment of chronic headaches and migraines*. Plast Reconstr

[35] Liu, M.T., B.S. Armijo, and B. Guyuron, *A comparison of outcome of surgical treatment of migraine headaches using a constellation of symptoms versus botulinum toxin type A to identify* 

[36] Guyuron B, B.D., *Plastic Surgery: Indications and Practice*. Surgical management of migraine headaches, ed. T.T. Guyuron B, Davis J. 2008: Saunders: Elsevier, Health

[37] Totonchi, A., N. Pashmini, and B. Guyuron, *The zygomaticotemporal branch of the trigemi-*

[38] Sanniec, K., E. Borsting, and B. Amirlak, *Decompression-avulsion of the auriculotemporal nerve for treatment of migraines and chronic headaches*. Plast Reconstr Surg Glob Open, 2016.

[39] Lee, M., et al., *The role of the third occipital nerve in surgical treatment of occipital migraine* 

*nal nerve: an anatomical study*. Plast Reconstr Surg, 2005. **115**(1): pp. 273–7.

*headaches*. J Plast Reconstr Aesthet Surg, 2013. **66**(10): pp. 1335–9.

*the trigger sites*. Plast Reconstr Surg, 2012. **129**(2): pp. 413–9.

2014. **54**(1): pp. 142–52.

128 Current Perspectives on Less-known Aspects of Headache

Surg Glob Open, *In Press* 2016.

pp. 159-65.

Sciences Division.

**4**(4): p. e678.

*gery"*. Headache, 2014. **54**(6): pp. 1065–72.

Chronic migraines are a common debilitating headache disorder. Recently, there has been increasing interest in the use of onabotulinumtoxinA as a preventative treatment, as studies have shown significant benefits. In line with current accepted theories on the pathophysiology of migraines, the toxin works by both direct and indirect means to prevent peripheral and central nerve sensitization. While efficacy has been established, the technique for extracranial delivery of onabotulinumtoxinA continues to see changes in an effort to seek better outcomes. The PREEMPT injection protocol is the original injection paradigm design targeting broad muscle groups. The ART injection paradigm offers the ability to deliver onabotulinumtoxinA closer to culprit nerves, thus increasing its effect and also decreasing adverse effects. OnabotulinumtoxinA is an effective and well-tolerated option for selective patients seeking relief from migraine headaches.

**Keywords:** BTX, onabotulinum toxin, migraine, ART, PREEMPT, trigger site theory

## **1. Introduction**

Chronic migraines are the most common type of headache in patients that seek treatment, according to the data compiled from several specialty headache centers in the United States [1–3]. It is a debilitating disorder that not only has the ability to severely reduce the quality of life, but also causes a heavy economic burden. However, among the high number of patients that suffer from chronic migraines, only a third receive prophylactic treatments [4].

Over the last couple of decades, there has been an increasing interest in the use of onabotulinumtoxinA (BTX-A) as a preventative treatment for migraine headaches. Over time, a number

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

of well-designed large-scale studies demonstrated that this neurotoxin to be effective in reducing several measures of migraine symptomology [5–11]. The first major landmark study, called the PREEMPT (Phase III Research Evaluating Migraine Prophylaxis Therapy) trials, indicated that BTX-A is indeed effective and safe in treating migraine headaches. These studies showed a statistically significant reduction in the primary endpoint of headache day frequency in chronic migraine patients. They also demonstrated significant reductions in several other measures of migraine symptomology such as cumulative hours of headaches, headache days, and days of moderate/severe headaches [9]. Further studies indicated efficacy in reducing disease burden based on patient quality of life questionnaires [10, 11]. However, studies evaluating the effect of BTX-A on episodic migraines so far have not shown significant benefits [12–15]. This led to BTX-A being approved by the Food and Drug Administration (FDA) for the treatment of chronic migraine headaches. The injection paradigm used in the PREEMPT trails was designed based on the initial injection sites reported in earlier phase II trials [16, 17]. While the PREEMPT injection protocol is proven to be effective, research is ongoing with several other BTX-A injection techniques that have been developed. One in particular is the targeted approach, which was first done to pre-screen surgical decompression and later developed into a more formal technique used solely for preventative treatment purposes.

Currently, BTX-A is used to provide safe and effective long-term treatment for chronic migraine headaches. To appreciate the differences and advantages in BTX-A injection techniques between the two specialties, it is important to understand the different targets of injection, the trigger point and nerve compression hypothesis, mechanism of action of BTX-A in the treatment of migraines, and the anatomy of various muscles and nerves has only recently been elucidated by studies done between Cleveland and Dallas [6, 7, 18–20]. In this chapter, we discuss the PREEMPT injection paradigm and the Anatomical Regional Targeted (ART) BTX-A paradigm.
