[Botulinum toxin for the treatment of major depressive disorder]

The Development of Psychiatric Illness and Chemoprophylaxis of Botulinum Toxin in Migraine: A Narrative Review

A migraine is not just a headache. It is an extremely prevalent neurological condition marked by periodic episodes of unilateral headache, with more than 10 million cases yearly. Migraine often begins at the age of puberty. It substantially impacts the brain and, consequently, psychiatric behavior linked with frequent migraine attacks that may be moderate to severe in intensity. A crucial aspect of migraine variability is comorbidity with other neurological diseases, vascular diseases, and mental illnesses. Psychiatric disorders related to migraine include anxiety disorders, panic disorder, bipolar disorder, depression, etc. It is also estimated that people suffering from migraine are about five times more likely to develop depression than others without migraine. The stimulus for migraine is stress, lack of sleep, skipped meal or fasting, visual stimulation due to high intensity of light, auditory stimulus due to noise, and olfactory stimulus due to a pungent smell. A majority of patients suffer from migraine attacks triggered by noise, some due to visual stimulation, and a few due to perfumes or other odors that trigger their migraine. Diagnosis of this is primarily dependent on history taking and clinical evaluation. Migraine can be classified depending on whether an aura is present or absent. It can further be divided based on the frequency of headaches into episodic migraine or chronic migraine, which may be determined by the duration of the headache. The development of migraine is influenced by both genetics and the environment. It has a detrimental effect on children's quality of life. A comprehensive analysis of psychiatric illnesses in migraine contributes to early diagnosis and proper treatment of the disease. Also, having a healthy lifestyle (including exercise, a balanced diet, and enough sleep) seems to prevent and improve the condition. Headache in migraine is resistant to medical treatment but responds well to botulinum toxin. This review primarily focuses on the psychiatric issues like depression and anxiety that often accompany migraine. The article also highlights the effects of botulinum toxin on migraine.

High efficacy of onabotulinumtoxinA treatment in patients with comorbid migraine and depression: a meta-analysis

BACKGROUND

Migraine and depression are highly prevalent and partly overlapping disorders that cause strong limitations in daily life. Patients tend to respond poorly to the therapies available for these diseases. OnabotulinumtoxinA has been proven to be an effective treatment for both migraine and depression. While many studies have addressed the effect of onabotulinumtoxinA in migraine or depression separately, a growing body of evidence suggests beneficial effects also for patients comorbid with migraine and depression. The current meta-analysis systematically investigates to what extent onabotulinumtoxinA is efficient in migraineurs with depression.

METHODS

A systematic literature search was performed based on PubMed, Scopus and Web of Science from the earliest date till October [Formula: see text], 2020. Mean, standard deviation (SD) and sample size have been used to evaluate improvement in depressive symptoms and migraine using random-effects empirical Bayes model.

RESULTS

Our search retrieved 259 studies, eight of which met the inclusion criteria. OnabotulinumtoxinA injections administered to patients with both chronic migraine and major depressive disorder led to mean reduction of [Formula: see text] points (CI [[Formula: see text]], [Formula: see text]) in the BDI scale, of [Formula: see text] points (CI [[Formula: see text]], [Formula: see text]) in the BDI-II scale and of [Formula: see text] points (CI [[Formula: see text]], [Formula: see text]) in the PHQ-9 scale, when evaluating depressive symptoms. In the case of the migraine-related symptoms, we found mean reductions of [Formula: see text] (CI [[Formula: see text]], [Formula: see text]) points in the HIT6 scale, [Formula: see text] (CI [[Formula: see text]], [Formula: see text]) in the MIDAS scale, [Formula: see text] (CI [[Formula: see text]], [Formula: see text]) points in the VAS scale and of [Formula: see text] (CI [[Formula: see text]], [Formula: see text]) migraine episodes per month. Comorbid patients showed slightly better improvements in BDI, HIT6 scores and migraine frequency compared to monomorbid patients. The latter group manifested better results in MIDAS and VAS scores.

CONCLUSION

Treatment with onabotulinumtoxinA leads to a significant reduction of disease severity of both chronic migraine and major depressive disorder in patients comorbid with both diseases. Comparative analyses suggest an equivalent strong effect in monomorbid and comorbid patients, with beneficial effects specifically seen for certain migraine features.

Botulinum Toxin versus Placebo: A Meta-Analysis of Prophylactic Treatment for Migraine

BACKGROUND

The purpose of this study was to assess the efficacy of botulinum toxin in reducing the frequency of migraine headaches.

METHODS

The MEDLINE, Embase, and Cochrane Library databases were searched to identify randomized, double-blind, placebo-controlled trials that compared patients receiving botulinum toxin versus placebo injections in the head and neck muscles, for the preventive treatment of migraine. The primary outcome was change in the number of headache episodes per month from baseline to 3 months.

RESULTS

There were 17 studies including a total of 3646 patients. Overall analysis reported a tendency in favor of botulinum toxin over placebo at 3 months, with a mean difference in the change of migraine frequency of -0.23 (95 percent CI, -0.47 to 0.02; p = 0.08). The reduction in frequency of chronic migraines was significant, with a mean differential change of -1.56 (95 percent CI, -3.05 to -0.07; p = 0.04). Analysis of chronic migraine frequency was also significant after 2 months. The findings also highlighted an improvement of the patient's quality of life at 3 months in the botulinum toxin group (p < 0.00001). Further adverse events were traced in the botulinum toxin type A group with a statistically significant risk ratio of 1.32 (p = 0.002).

CONCLUSIONS

This meta-analysis reveals that botulinum toxin type A injections are superior to placebo for chronic migraines after 3 months of therapy. For the first time, a real benefit in patient quality of life is demonstrated with only few and mild adverse events.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Brain functional changes in patients with botulism after illegal cosmetic injections of botulinum toxin: A resting-state fMRI study

BACKGROUND

Botulinum toxin type A (BoNT-A) is generally considered safe and is widely used to treat a variety of clinical conditions involving muscle hyperactivity and for cosmetic purposes. However, the effects of BoNT-A poisoning (botulism) on brain function are poorly understood.

METHODOLOGY/PRINCIPAL FINDINGS

Herein, we investigated brain functions in 9 patients who received illegal cosmetic injections of botulinum and 18 matched controls by combining the analysis methods of regional homogeneity (ReHo) and amplitude of low-frequency fluctuation (ALFF) based on resting-state fMRI. Compared with the controls, the patients with botulism exhibited significantly reduced ReHo values in the left posterior lobe of the cerebellum extending to the right anterior lobe of the cerebellum, as well as in the right anterior lobe of the cerebellum extending to the parahippocampal gyrus and right posterior lobe of the cerebellum. The patients with botulism also showed weakened ALFF values in the right anterior lobe of the cerebellum extending to the left anterior lobe of the cerebellum and right posterior lobe of the cerebellum, as well as in the right anterior lobe of the cerebellum.

CONCLUSIONS/SIGNIFICANCE

The results indicate that BoNT-A may modulate cerebral activation in specific areas, which may play roles in both the adverse effects of botulism and the mechanism underlying clinical treatment with BoNT-A.