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Letters to the Editor May 2013

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Trigger Point Identification for Botox Injection in Migraine Patients

Thank you for your article on the use of botulinum toxin (Botox) in migraines.1 While the scope of the article was not intended to step outside of a review of the current literature for the use of Botox in migraines, I would like to offer an important “pearl” that I have discovered with my patients, and as a chronic migraineur myself.

Botox works best when patients can literally put their fingertip on the spot or spots where their migraines begin. These are classically located near the supraorbital foramen, center of the forehead, temples, and/or ophthalmic artery. Most patients have two to four of these spots. If they can very clearly identify their “trigger points” for their migraines—ie, the spots that flare up and start hurting before the actual onset of the migraine, and the same spots that hurt the worst during the migraine (these are typically the spots patients rub with their fingers when in pain)—then a small dose of Botox (3-7 units) directly into these areas can be incredibly beneficial, and additional areas of injection are either not needed or not beneficial. I don’t think that the “shotgun” approach that was studied for FDA approval is the most efficacious, and certainly ends up costing the patient more out of pocket than targeted injections.

In my experience, if patients can’t put their fingertips on their trigger points, it’s likely that Botox will not help them.

—Heather Williamson, DO
Family Practice
O’Fallon, MO

Dear Dr. Williamson,
I want to thank Dr. Williamson for her insights. There have been numerous chronic migraine Botox studies; most were positive, some negative. The FDA approved a dose of 155 units; 31 injections around the head is evidence based, but that does not mean that this paradigm is right for everyone. I believe it is a case-by-case basis, with some requiring 155 units, others needing 70 to 100 units, and occasionally we use more than 155 units. Whether it is worthwhile to “chase the pain” is open to debate, and there are experienced Botox injectors on each side of this argument. I do feel that some patients do well with localized, limited injections, but this is not as evidence based as the FDA protocol.

Dr. Williamson raises important points about using “trigger points” to identify optimum injection spots. She also mentions cost issues. Particularly for cash paying patients, limited, targeted injections may be the most practical approach.

—Lawrence Robbins, MD
Northbrook, IL

Treating Temporomandibular Disorders as Orthopedic Problems

I have been a Diplomate of the American Academy of Pain Management, amongst other Boards and Academies, for years now. I was shocked to see the article, "Central Sensitization: Common Etiology in Somatoform Disorders," authored by Roberts, Lorduy, and Gatchel, in which temporomandibular disorders were generally and arbitrarily addressed as "TMJ," and lumped in with other "non-organic disorders," for which "modern diagnostic testing can find no organic explanation for 10% of reported and persisting physical symptoms."2

Shame on Roberts et al, for promulgating such biopsychosocial pseudoscience, and shame on Practical Pain Management (PPM) for giving them a forum to do so. PPM has dropped immeasurably in value in the estimation of myself and my esteemed colleagues in the real world, where in such disorders are rightfully diagnosed and treated as essentially orthopedic problems, dealing with bone and disc and synovium and ligaments, and not with the ethereal profferings of those who choose to link everything they encounter to the Diagnostic and Statistical Manual of Mental Disorders, in choosing the path of least resistance.

—John D. Petkanas, DDS
Associates in Oro-Facial Pain, LLC<
Saddle Brook, NJ

Dear Dr. Petkanas,
In an editor's note preceding the article about which you disagree, we carefully stated that PPM didn't necessarily agree with the authors. We published the article to steer debate and interest to the theories about centralized pain. Obviously, you don't believe that "TMJ" is non-organic and that the treatment requires physical measures. Personally, I agree with you but believe fibromyalgia and some other conditions often have a central origin. Thanks for responding, as our goal in publishing such a controversial piece was to stimulate thought as to what painful conditions are central or peripheral.

—Forest Tennant, MD, DrPH

Tapering Patients off High-dose Opioids

Dear Dr. Tennant,
I just wanted to pass on that I love PPM's opioid calculator! But I am wondering, is there a calculator available for opioid tapering as well? I am not looking at transitioning from one opioid to another, but for a total taper off high-dose opioids. Are there any guidelines that can be followed regarding tapers?

—Lorraine Granau, PharmD
Tempe, Arizona

Dear Dr. Granau,
Your inquiry about opioid tapering is a practical one. No, there isn't a calculation for tapering, but there is an old standard that comes out of methadone maintenance for opioid addicts. The taper was to average about 5% to 10% of the daily methadone dosage each week. In this manner, the addict would be methadone free after about 3 to 4 months. As this old standard was practiced, practitioners found they could start the taper as high as 20% in the first couple of weeks, but the end part of the taper might be as little as 1% to 3%. Interestingly, the addict will sometimes taper down to as little as 1 mg to 5 mg per day, but can't go to zero.

The pain patient who is maintained on opioids can use the same schedule of 5% to 10% per week only if the patient has cured or totally eliminated their pain. In a controlled setting, it can be done much faster and in a matter of days. The key is whether the patient's pain has resolved. This actually happens sometimes because opioid maintenance can act as a "pharmacologic splint" and allows the patient to participate in an exercise, nutrition, motivation, or regeneration program that proves to be curative.

If the patient still has pain and wants to taper, reducing the dosage to zero is probably not realistic, as the pain will re-emerge in a major way at some point during the taper. In other words, if you taper the opioid dosage in a patient who still has pain, be prepared to maintain the patient at a lower opioid dosage or with a different opioid.

Last updated on: June 4, 2013
First published on: May 1, 2013