503 - Combination Trigger Point Dry Needling and Botulinum Toxin Injection For Treatment Refractory Migraine : A Case Report

Case Diagnosis: Persistent Treatment-Refractory Migraine in a 66-year-old Male.

Case Description: A 66-year-old male with a 10-year history of chronic migraines, experiencing approximately 30 migraine attacks per month, each lasting hours to days, was initially managed with Depakote. However, as the medication's effectiveness diminished, he transitioned to a monthly regimen of Fremanezumab with sumatriptan for breakthrough pain. Additionally, he received botulinum toxin injections every two months, starting with an initial dose of 155 units, which provided relief for two years. Subsequently, the patient returned to the clinic with a persistent migraine affecting his bilateral temporalis muscles. Trigger point dry needling (TDN) was introduced concurrently with botulinum toxin injections, leading to a significant reduction in acute attacks during follow-up visits.

Discussions: Migraines are highly prevalent and debilitating primary headaches, affecting about one billion people worldwide, with a higher incidence in women. Characterized by unilateral throbbing headaches accompanied by symptoms such as nausea, sensory hypersensitivity, and fatigue, initial treatments include various medications. Emerging drugs like CGRP inhibitors are used for migraine prevention. In cases of treatment-resistant migraines, botulinum toxin injections have shown efficacy. However, the combined use of TDN and botulinum toxin injections, as demonstrated in this case, remains an underexplored approach.

Conclusions: This case highlights a unique and successful approach to managing chronic migraines in a patient who had not responded well to medication and botulinum toxin therapy alone. The addition of TDN alongside botulinum toxin injections led to a reduction in acute attacks. Clinicians managing migraines should consider exploring this combination therapy in patients with refractory headaches to optimize treatment outcomes.