918 - Efficacy of Low Dose Botulinum Toxin Injections in Patients with Chronic Migraine and concurrent Shoulder pain- A Case series

Case Diagnosis: Three patients presenting with chronic migraine headaches and concurrent shoulder pain experienced significant improvement in migraine headache symptoms after receiving under 100 units of botulinum toxin, compared to the standard botulinum toxin dose of 155 units as established by the Phase III Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) trials.

Case Description: Three male patients, between the ages of 40 to 60, diagnosed with chronic migraine headaches received botulinum toxin injections of less than 100 units at initial and follow up visits. All patients reported concurrent shoulder pain so botulinum toxin injections to the trapezius and cervical paraspinal muscles were avoided.. The tailored regimen of botulinum toxin was under 100 units (75-90 units) and injections were repeated every 3-5 months. Despite the lower dose of botulinum toxin, patients reported high satisfaction with their treatment and had consistent 50-90% reduction in the frequency or severity of their migraine headaches.

Discussions: These findings suggest that an individualized protocol of less than 100 units of botulinum toxin can produce significant improvement in migraine headache frequency and intensity. This tailored regimen avoids destabilization of the shoulder girdle and neck while maintaining efficacy for the management of chronic migraines. In addition, the reduced doses of botulinum toxin may delay or decrease tolerance towards the toxin, thereby extending the duration of relief for the patient.

Conclusions: Many patients with migraine headaches also present with musculoskeletal complaints. While botulinum toxin may provide relief for migraine headaches, it also weakens musculature needed for neck and shoulder stability. A tailored regimen with a low dose of botulinum toxin of under 100 units may be an option for these patients. Larger scale investigations may provide clinicians better guidance for managing migraine headaches in patients with concurrent neck and shoulder musculoskeletal conditions.