Efficacy of Onabotulinumtoxin A Botox Injections Compared to
Efficacy of Onabotulinumtoxin. A (Botox) Injections Compared to Oral Topiramate in Reduction of Migraines Suffered in Adults Stephanie N. Blaha, MMS (c) Faculty Advisor: Michael Huber, MMS, PA-C, DFAAPA Department of Medical Science Abstract Results Discussion Migraines are a leading cause of disability in many adults worldwide. Therefore, it is critical that there are therapies to prevent migraines rather than just treat them acutely. After conducting a literature search and analyzing seven studies, both Botox and Topiramate were found to significantly reduce the severity, frequency, and duration of migraines. Due to limited sample sizes, different methods used to measure outcomes, and lack of data on long-term efficacy, it is hard to determine which prophylaxis is more effective. While further research is necessary, the choice ultimately is the patients based on multiple variables. Ashtari et al v Migraine frequency decreased from 6. 07 to 1. 83 episodes per month with Topiramate Bussone et al v Topiramate led to significant reduction in migraine frequency in pooled studies Goldman et al v Migraine frequency decreased from 9 to 2. 75 days per month after Botox injections (75. 9% patients responded) Grazzi & Usai v After 3 Botox injections, headache days suffered decreased from 27. 1 ± 6. 8 days to 15. 6 ± 8. 7 days Luo et al v Mean frequency of migraine attacks decreased from 4. 6 ± 1. 4 to 2. 6 ± 0. 9 after 12 months with Topiramate (72. 7% responders) Mei et al v 63% of patients had 50% reduction in migraine frequency with Topiramate Russo et al v 17. 4% had 50% reduction in migraines, 38. 4% had 30% reduction in migraines after 6 months of Botox Strengths v All of the studies found both Topiramate and Botox to significantly reduce migraine duration, severity, and frequency v Majority of studies had adequate (>12 weeks) timeline and inclusion criteria Introduction Chronic migraines defined by International Classification of Headache Disorders as: Mi v 15 headache days per month v Migraine-associated features required only 8 of the 15 days v Medication overuse can exist concurrently with diagnosis Migraine etiologies v Overuse of medication (ex: triptans, ergotamines, opioids) v Side effects of medications (ex: birth control, proton pump inhibitors) v Stress, poor sleep, caffeine, hormonally being female v Elevation of calcitonin gene-related peptide (CGRP) and pituitary adenylate cyclase-activating polypeptide (PACAP), both of which cause vasodilation of arteries in the brain v Chronic neck pain Prophylactic therapies v Botox prevents exocytosis of neurotransmitters and neuropeptides (CGRP) v Topiramate limits contraction of arteries' muscle walls and reduces neuronal excitability by blocking sodium channel firing Methods v Literature search through Google Scholar and EBSCO in September and November 2018 v. Total of seven articles consisting of randomized, cohort, and metaanalysis studies chosen v. Studies selected based on relevance to research question, sample population, methods, and results v. Results of studies and treatment methods analyzed and compared Study Ashtari et al Design RCT Total N 62 Pooled: Bussone et Meta-analysis 758 al Open label: 567 Goldman et al Grazzi & Usai Luo et al Mei et al Russo et al Cohort RCT Cohort 110 75 Population Tx All women Topiramate, Propranolol Outcome measure 8 weeks Visual Analog Scale, Headache diary Pooled: 26 weeks Open label: 8 mths Not indicated Topiramate, Propranolol, Placebo All women Botox w/ or w/out hyaluronic acid Not indicated Pre- and posttreatment surveys Botox 1 year (4 injections) MIDAS and HIT-6 scores 1 year Visual Analog Scale, Headache diary 16 weeks Headache diary 9 mths (3 injections) MIDAS score, BDI-II score, Headache diary Not indicated 150 Topiramate, Out of those who Flunarizine, completed study, 36 Combination of men, 90 women Topiramate + Flunarizine 115 Out of those who completed study, 33 men, 39 women 52 Length of study 6 men, 46 women Topiramate, Placebo Botox Key: RCT= Randomized Control Trial; MIDAS= Migraine Disability Assessment, HIT-6= Headache Impact Test 6, BDI-II= Beck Depression Inventory II Limitations v Small sample sizes v Short duration for studies v Lack of follow up v Outdated articles for Topiramate (2004 -2012) v Difficulty in comparing Topiramate and Botox between the studies due to different forms of measurement Future Studies v Larger sample size v More diverse population v Studies of longer duration v Determine most effective dose of Topiramate Conclusion Both treatments are effective, but which is more effective ultimately depends on patient based on: Comorbidities v Botox also treats overactive bladder, hyperfunctional facial lines, cervical dystonia v Topiramate also treats epilepsy, alcoholism, binge-eating disorders Tolerability v Botox side effects: wheals at injection sites, neck pain, eyebrow elevation v Topiramate side effects: nausea, weight loss, paresthesias Compliance v Botox: 1 injection every 3 months v Topiramate: 2 pills daily Socioeconomic status v Botox: hundreds to thousands of dollars v Topiramate: few dollars with a coupon
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