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Botulinum neurotoxins in the treatment of refractory pain

Nature Clinical Practice Neurology volume 4, pages 676–685 (2008)Cite this article

Abstract

The proper management of pain is a critical issue in the practice of medicine. Despite the availability of a large number of analgesic medications, management of pain that is refractory to conventional treatments remains a challenge for both clinicians and surgeons. Botulinum neurotoxin (BoNT) has recently emerged as a potential novel approach to control pain. Animal studies have revealed a number of mechanisms by which BoNTs can influence and alleviate chronic pain, including inhibition of pain peptide release from nerve terminals and sensory ganglia, anti-inflammatory and antiglutaminergic effects, reduction of sympathetic neural discharge, and inhibition of muscle spindle discharge. In humans, prospective, placebo-controlled, double-blind studies have also provided evidence for effectiveness of BoNT therapy in a number of painful disorders. These include cervical dystonia, pelvic pain, low back pain, plantar fasciitis, postsurgical painful spasms, myofascial pain syndromes, migraine, and chronic daily headaches. Long-term studies on cervical dystonia and low back pain have demonstrated safety and sustained efficacy after repeated injections. This Review focuses on the analgesic effects of BoNT and the mechanisms of its pain control as revealed by animal models, and provides evidence-based data on the efficacy of BoNT therapy in various pain syndromes in humans.

Key Points

  • Animal studies have shown that botulinum neurotoxins (BoNTs) inhibit the release of pain mediators, thereby reducing the inflammatory response to pain-producing agents

  • Controlled class I and II studies of BoNTs in humans provide evidence for significant pain relief in cervical dystonia, and suggest pain relief in chronic migraine, neuropathic pain, plantar fasciitis, low back pain, postoperative painful spasms and pelvic pain

  • The data on BoNT in myofascial pain syndromes and chronic daily headache are inconsistent, and studies of episodic migraine and tension headaches have failed to show efficacy to date

  • Confounding factors that could account for apparent treatment failure include poor selection of primary outcomes, injection sites or dosage, and inclusion of patients with medication overuse

  • Long-term studies of BoNT/A in cervical dystonia and low back pain demonstrate reproducibility of favorable results with repeated treatments, as well as a good safety profile

  • Newly developed neurotoxins retargeted to primary nociceptive afferents might significantly improve the outcomes of BoNT therapy in pain syndromes

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Author notes

  1. Department of Neurology, Yale University, LCI 708, 15 York Street, New Haven, CT 06520, USA bahman.jabbari@yale.edu

Authors and Affiliations

  1. B Jabbari is Professor of Neurology and Director of the Program in Parkinson's Disease and Movement Disorders at Yale University School of Medicine, New Haven, CT, USA.,

    Bahman Jabbari

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The author has received research and educational grants from Allergan, Merz and Solstice.

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Jabbari, B. Botulinum neurotoxins in the treatment of refractory pain. Nat Rev Neurol 4, 676–685 (2008). https://doi.org/10.1038/ncpneuro0948

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