Subcutaneous peri-incisional injections of onabotulinum toxinA (onabotA) may represent an effective approach for alleviating chronic head pain associated with lateral skull base surgery and temporoparietal fascial flap harvest, according to a case series published in Headache.

The case series included 4 patients reporting postoperative headache lasting between 3 and 9 years after temporoparietal flap reconstruction for a complex septal perforation (n=1) or lateral skull base surgery for resection of a vestibular schwannoma (n=3). Patients were treated with peri-incisional onabotA at a single center in Tennessee.

In the first case, a 43-year-old woman with preoperative mild headache symptoms and a history of migraine underwent resection of a vestibular schwannoma. Approximately 2 years after the surgery, the patient had persistent neuropathic head pain that affected her quality of life. She reported significant improvement in head pain following treatment 4 years after surgery with 20 units of onabotA at the incision site. The patient received another 4 injections over a 14-month period, with associated pain relief lasting 2 months following each onabotA injection.

Another patient, a 56-year-old woman with chronic migraines who also underwent resection of a vestibular schwannoma, reported preoperative and postoperative persistent head pain. Her pain symptoms were suggestive of neuropathic and migrainous features. After limited efficacy with gabapentin and topiramate, she was treated with 155 units of onabotA injected in several sites in the head and neck. She reported significant relief from her head pain that lasted approximately 3 months.

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The third patient was a 51-year-old woman who presented with facial weakness and intermittent unilateral postoperative head pain that persisted over 3 years. The patient was injected with 10 units of onabotA at a site adjacent to the incision. She reported noticeable pain reduction for 2 weeks after injection.

The fourth patient, a 40-year-old woman with postoperative left temporal head pain, experienced relief of left eye twitching and headache symptoms after being injected with 40 units of onabotA distributed over her left temporoparietal fascia harvest site. After 6 weeks, her symptoms returned and she received an additional 80 units of onabotA, resulting in dramatic reductions in headache intensity.

Limitations of this case series include the small number of patients, the sole inclusion of patients with the most severe forms of postoperative headache, and the retrospective nature of the study.

 “Peri-incisional onabotA may represent an effective, minimally invasive, and etiology-nonspecific treatment option for patients with chronic postoperative head pain following lateral skull base surgery,” noted the series authors.

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Reference

Dang S, Shinn JR, Sowder J, Ries WR, Stephan SJ. Peri-incisional botulinum toxin therapy for treatment of intractable head pain after lateral skull base surgery: a case series [published online August 31, 2019]. Headache. doi:10.1111/head.13616