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Positive Botulinum Toxin Type A (BTA) Response is a Prognosticator for Migraine Surgery Success
Michelle Lee, MD, Mikhal A. Monson, Tommy Liu, Deborah Reed, MD, Bahman Guyuron, MD.
Case Western Reserve University, Cleveland, OH, USA.

PURPOSE: Botulinum toxin type A (BTA) has been used to identify and treat migraine headaches (MH). It has been long hypothesized that MH patients who respond to BTA injections will respond favorably to migraine surgery. The objective of the study is to determine whether response to BTA injections can serve as a prognosticator for migraine surgery success.
METHODS: A retrospective chart review was performed on all patients undergoing migraine surgery by the senior author from January 2000 to December 2010. Patients were included if they have (1) BTA injection prior to migraine surgery (2) complete post-BTA injection MH questionnaire data and (3) greater than one year follow-up post migraine surgery. The outcome variables were migraine headache quality post BTA injection and post migraine surgery. Success in treating MH is defined as >50% reduction in frequency, intensity or duration of migraines.
RESULTS: Analysis of database identified 194 patients who met the inclusion criteria. The study population was divided into two groups: 144 patients who reported successful MH reduction after BTA injection (BTA success group) and 50 patients who did not experience adequate MH reduction post BTA injection (BTA failure group). The migraine surgery success rate for the BTA success group was 90.3% as compared to 74% for the BTA failure group (p= 0.004). The patients were also subdivided based on migraine surgery site. Successful BTA injection was most prognostic for migraine surgery at site I (corrugator resection). For trigger site I, surgery success rate for the BTA success group was 93% compared to 80% for the BTA failure group (p=0.0007). Positive correlation between BTA success group and successful surgery at trigger sites II and IV was noted but not statistically significant. It was also noted that all patients who had trigger site III surgery alone (n=6) belonged to the BTA failure group.
CONCLUSION: Positive botulinum type A response is a significant predictor of migraine surgery success, especially at trigger site I (corrugator resection). For patients who fail to respond to BTA injections, trigger site III (nasal) pathology should be considered.


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