For 20 years botulinum toxin A has been used for the treatment of a variety
of disorders characterised by pathologically increased muscle contraction.
Recently, treatment of tension headache, migraine, cluster headache, and m
yofascial pain syndromes of neck, shoulder girdle, and back with botulinum
toxin A has become a rapidly expanding new field of research. Several modes
of action are discussed for these indications. The blockade of cholinergic
innervation reduces muscular hyperactivity for 3 to 6 months. Degenerative
changes in the musculoskeletal system of the head and neck are prevented.
Nociceptive afferences and blood vessels of the pericranial muscles are dec
ompressed and muscular trigger points and tender points are resolved. The n
ormalisation of muscle spindle activity leads to a normalisation of muscle
tone and central control mechanisms of muscle activity. Oromandibular dysfu
nction is eliminated and muscular stress removed. However, the effect of bo
tulinum toxin A cannot be explained by muscular actions only. Its retrograd
e uptake into the central nervous system modulates the expression of substa
nce P and enkephalins in the spinal cord and nucleus raphe. Recent findings
suggest an inhibition of sterile inflammation which may lead to a blockade
of the neurogenic inflammation believed to be the pathophysiological subst
rate of primary headache disorders. The efficacy of botulinum toxin A in th
e treatment of pain disorders is being investigated in several studies at t
he moment. The results and experiences obtained so far present new alternat
ives in the treatment of chronic pain disorders. The practical use of botul
inum toxin A is demonstrated.