I began using Botulinum type A neurotoxin in April 2000 initially on patients with intractable neck muscle spasm and headaches.  After very satisfactory initial results I began injecting additional patients with intractable headaches who had failed other preventive therapies, such as calcium channel blockers, beta blockers or anticonvulsants.  I also began using BOTOX in patients with chronic daily headaches (defined as more than 15 headache days per month), especially those who were taking large amounts of over-the-counter medications or prescription pain pills and/or narcotic preparations.  Every attempt was made to gradually wean patients off all analgesic medication.

Another selection criteria, enhanced by some physical examination techniques learned during my lecture tours, primarily from physiatrists, was the presences of palpable muscle spasms or "trigger points" in the temporalis, trapezius, rhomboids or levator scapulae, which I found in a large number of patients when I began looking for the finding.  Usually the muscles were tender as well and guided the areas of injection.

Generally I kept patients on the preventive medication they were currently taking if it had minimal side effects or seemed to be helping a little.  If it were deemed not at all helpful it was discontinued.  Patients were instructed that there would likely be little effect in the first two weeks, but the onset should occur shortly thereafter.  The average time of onset, now that 707 patient injections have been performed in 264 patients, is 2 1/2 to 3 weeks, with some patients reporting an effect in a little as a week and others with onset only after a month.  The duration also varies from as little a a month (rare) to an average of 3 months, but some patients have reported cessation of headache and neck muscle spasm for as long as 5-6 months only to have it then return, requiring reinjection.

Responses were graded on an analogue scale of 1-5, with the patient picking the response after 3 weeks: 1= no response 5=total cure.  The results of this open label, uncontrolled set of observations will be reported at a national neurological meeting in June 2002.