Baş Ağrısı Tedavisinde Botulinum Toksin Uygulamaları
Özet
Kronik baş ağrıları, hastaların yaşam kalitesini bozarak günlük aktivitelerini engellemekte, ciddi iş gücü ve ekonomik kayıplara yol açmakta ve depresyon gibi psikiyatrik bulguları ortaya çıkarmaktadır. Medikal tedavilerden yarar görmeyen dirençli grupta, son yıllarda Onabotulinum toksin serotip-A (BoNT-A) enjeksiyonu ruhsatlı ve etkili bir yöntem olarak öne çıkmaktadır. BoNT-A, sinir-kas kavşağında asetilkolin salınımını inhibe ederek kas paralizisine yol açan ve periferik/santral sensitizasyonu engelleyerek ağrıyı azaltan bir nörotoksindir. PREEMPT klinik çalışmaları, baş ve boyundaki 31 sabit noktaya toplam 155-195 ünite uygulanan BoNT-A'nın plaseboya göre kronik migren ağrı sıklığını, depresyon ve anksiyete skorlarını anlamlı düzeyde azalttığını göstermiştir. Ülkemizde en az 3 oral koruyucu tedaviye dirençli kronik migren hastalarında Botox® markasıyla Sağlık Bakanlığı ruhsatlı olarak kullanılmaktadır. BoNT-A ayrıca hemiplejik migren, ilaç aşırı kullanım baş ağrısı, trigeminal nevralji, küme baş ağrısı ve oksipital nevraljide de olumlu sonuçlar vermektedir. Tedavi genellikle 12 haftada bir uygulanır; pitoz, sırt ve baş ağrısı gibi geçici yan etkileri mevcuttur. Oküler ağrı fenotipi, yüksek CGRP plazma seviyeleri ve belirli genetik polimorfizmler iyi tedavi yanıtı göstergeleriyken, periakuaduktal gri cevherdeki demir birikimi negatif yanıtla ilişkilidir.
Chronic headaches impair patients' quality of life, prevent daily activities, lead to serious labor and economic losses, and induce psychiatric symptoms like depression. In the refractory group non-responsive to medical treatments, Onabotulinum toxin serotype-A (BoNT-A) injection has recently emerged as an approved and effective method. BoNT-A is a neurotoxin that causes muscle paralysis by inhibiting acetylcholine release at the neuromuscular junction and reduces pain by preventing peripheral and central sensitization. PREEMPT clinical trials demonstrated that 155-195 units of BoNT-A applied to 31 fixed points in the head and neck significantly reduced chronic migraine headache frequency, depression, and anxiety scores compared to placebo. In our country, it is used under the Botox® brand with Ministry of Health approval for chronic migraine patients resistant to at least 3 oral prophylactic treatments. BoNT-A also provides positive outcomes in hemiplegic migraine, medication overuse headache, trigeminal neuralgia, cluster headache, and occipital neuralgia. Treatment is generally administered every 12 weeks, with temporary side effects including ptosis, back pain, and headache. While the ocular pain phenotype, high CGRP plasma levels, and certain genetic polymorphisms indicate a good treatment response, iron deposition in the periaqueductal gray matter is associated with a poor response.
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