884 - Can Reduction in the Dose of Botulinum Toxin still be effective for Migraine Headache: A Case Series

Friday, February 23, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

MB

Merideth Byl, DO, MBA

PGY-3
UCLA/VA
Culver City, California, United States

Co-Author(s)

JT

Jennifer Tram, MD

PM&R Resident
UCLA/VA Greater LA
Los Angeles, California, United States
MJ

Michelle Jin, MD

PM&R Resident
UCLA/VA Greater LA
Los Angeles, California, United States
QP

Quynh G. Pham, MD

PM&R Attending Physician
UCLA/VA Greater LA
Los Angeles, California, United States
QC

Quinn Convery, PharmD, BCPS

Clinical Pharmacist
West Los Angeles VA
Los Angeles, California, United States
LN

Laura Navaja, CPhT, BA

Pharmacy Technician
West Los Angeles VA
Los Angeles, California, United States

Case Diagnosis: Four patients demonstrated significant relief, defined as at least 80% reduction in frequency or severity of migraine headaches, despite reduction in the initial dose of botulinum toxin.

Case Description: We present four patients who were seen in the Interdisciplinary Headache clinic after being diagnosed with migraine headaches in the Neurology clinic. All patients experienced greater than 15 migraine episodes per month and failed adequate therapeutic responses to beta blockers, antidepressants, antiepileptics, and triptans. These patients received the initial dose of 150 to 90 units of botulinum toxin injection to the facial/neck muscles with significant pain relief. Over the course of 2 years, they underwent a dose reduction of 25% to 40%. Despite the reduction in the dosage, the treatment efficacy did not change.

Discussions: Prolonged treatment with botulinum toxins can result in tolerance due to action of the neutralizing antibodies. Our goal is to use the minimal effective dose to reduce this phenomenon. We found that an individualized Botox migraine protocol, using fewer units than the standard (155-95 U), can be effective. Most of the reduction was done due to patients’ concerns for muscle weakness in the upper trapezius and posterior neck muscles. The gradual reduction in dosage did not lessen the effectiveness of the migraine treatment, in fact, sustained, significant relief was experienced. Fewer injections also diminish the risk of infection, promoting patient safety. Moreover, by potentially reducing toxin tolerance, patients may experience prolonged therapeutic benefits.

Conclusions: The individualized Botox migraine protocol, with gradually reduced dosing offers a promising avenue for cost-effective and patient-friendly migraine treatment. These findings call for further investigation through larger-scale studies to validate our observations and potentially transform migraine management practices.