TBI
QueenDenise Okeke, DO
Resident Physician
St. Clair Health
Pittsburgh, Pennsylvania, United States
QueenDenise Okeke, DO
St. Clair Health
Pittsburgh, Pennsylvania, United States
Intractable chronic migraine with aura and status migrainosus, accompanied by cervical dystonia, secondary to traumatic brain injury (concussion).
Case Description:
A 27-year-old male with a long-standing history of chronic migraine and cervical dystonia following multiple concussions while playing soccer presented with intractable chronic migraine with aura and status migrainosus, accompanied by cervical dystonia. He experienced approximately 15–20 migraine attacks per month, each lasting hours to days. The migraines are sharp, throbbing 9/10 pain in the right temporal area. He reports associated neck and shoulder tension, nausea, vomiting, photophobia, phonophobia, and visual disturbances. On physical exam, there was tenderness over the right occipital notch and increased spasm of the cervical paraspinals and left trapezius. His migraines remained refractory to multiple preventive medications, including newer CGRP inhibitors. He was started on botulinum toxin injections every 3 months, with 200 units for chronic migraine and 100 units for cervical dystonia. After 3 injection series, there was a significant reduction in migraine attacks to 1-2 per week and improvement in cervical dystonia.
Discussions:
Concussions often lead to post-traumatic headaches. In a small number of patients, significant head trauma is a well-recognized precipitating factor in dystonia. The case demonstrates the efficacy of botulinum toxin injections in the treatment of chronic migraine and dystonia concurrently. However, data on the safety of treating ≥2 comorbid conditions concomitantly with botulinum toxin are limited, which can lead to delayed or reduced treatment, which may negatively impact patient care.
Conclusions:
Botulinum toxin injections can effectively treat chronic migraine and dystonia concurrently.
When administering Botulinum toxin, providers should consider whether a patient is being treated for multiple indications, coordinate dosing schedules if possible, and alleviate patient burden.
