Injection Technique With OnabotulinumtoxinA in Chronic Migraine

Abstract and Introduction

Abstract

Background: The objective is to review the technique of onabotulinumtoxinA injection treatment in the glabellar and frontal regions using the PREEMPT (Phase III REsearch Evaluating Migraine Prophylaxis Therapy) paradigm, with review of the aesthetic issues related to the procedure. OnabotulinumtoxinA is an effective medication for the prevention of chronic migraine. The PREEMPT injection paradigm has been validated in randomized clinical trials and real-world settings. This treatment includes injections in the forehead and glabella area. In addition, for aesthetic uses, glabella onabotulinumtoxinA injections are done in similar muscles specifically the procerus, corrugator supercilii, and frontalis muscles. Often patients who have been injected with onabotulinumtoxinA for chronic migraine have concerns about their appearance and will ask if they can see an aesthetic injector to improve this. This is a difficult issue as onabotulinumtoxinA should be injected with an interval of 10–12 weeks to avoid development of antibodies against onabotulinumtoxinA, so all injections (migraine and aesthetic) should ideally be done close together; however, if an aesthetic injection is done on the same day as a PREEMPT injection, the effect of the PREEMPT injection will not yet be visible as it takes time for onabotulinumtoxinA effects to be seen. Thus, there is a risk of a potential overdose in a particular area if aesthetic injections are done without input from the PREEMPT injector.

Methods: This is a narrative review supported by photographic documentation showing the technique of onabotulinumtoxinA injection of the upper face, considering anatomical differences between patients, and combining the needs in neurology and aesthetic medicine fields.

Results: Practitioners treating chronic migraine often modify some of the principles of the PREEMPT paradigm. Many practitioners are unsure about injections in the glabellar and frontal areas. The authors present a technique for using the PREEMPT protocol and adapting this to the individual patient's anatomy to prevent an unsightly appearance or ptosis. In addition, sites are provided where an aesthetic injector could inject to improve the patient's appearance without overlapping with the PREEMPT injection sites.

Conclusion: Adherence to the PREEMPT injection protocol provides an evidence-based approach to achieving clinical benefit for patients with chronic migraine. Aesthetic elements of the treatment of the glabella and forehead require additional attention. The authors provide practical considerations and recommendations regarding this.

Table 1. Summary of considerations for injecting onabotulinumtoxinA in chronic migraine.
Before the procedure	Examine the patient carefully before injection and evaluate their anatomy
Take photographs or videos before the injection
Explain to the patient the risk of brow ptosis after the procedure, especially if they have a low forehead and pre-existing pseudo-ptosis
The PREEMPT protocol	Always follow the PREEMPT protocol to optimize efficacy with a minimum of 31 fixed site injections
If the patient requires additional doses of onabotulinumtoxinA, 40 U of the drug from the "Follow-The-Pain" protocol may be used
Remember that the injection point differs from the actual medication delivery point
Treatment of the glabella	Inject the glabella area at least three points according to the PREEMPT protocol, administering 5 U of onabotulinumtoxinA in each site
Direct the needle perpendicularly into the corrugator above the STN orifice, trying not to touch the periosteum
If the patient's anatomy indicates an active and strong corrugator skin attachment, 1 U of onabotulinumtoxinA can be injected superficially and intradermally, not crossing the mid-pupillary line
The procerus is injected at the midpoint in the glabella area precisely between the injections in the corrugators, or 5 mm slightly below, on the line connecting the inner corners of the eye. Inject the medication superficially at this point, at 90, without touching the bone
Treatment in the forehead	Administer four doses in the forehead, directing the needle upwards at 45°. The medial point is precisely on the line connecting the previous corrugator injection sites, and the lateral point is on the line running through the lateral border of the iris
If the patient has a high forehead and there are several horizontal lines of wrinkles, consider injecting additional doses of onabotulinumtoxinA, but not lower than the convergence line, in several points
If there is a risk of the Mephisto appearance, administer 1 U of onabotulinumtoxinA 1–2 cm laterally above the maximal elevation point of the lateral eyebrow
After the procedure	Do not massage the injection site for 2 h after the procedure. Ask the patient to come for a follow-up visit after at least 2 weeks and take photographs after the procedure
Continue treatment according to the PREEMPT protocol, administering onabotulinumtoxinA every 12 weeks with a minimum of three cycles to assess the therapeutic effect

Table 1. Summary of considerations for injecting onabotulinumtoxinA in chronic migraine.

Before the procedure

Examine the patient carefully before injection and evaluate their anatomy

Take photographs or videos before the injection

Explain to the patient the risk of brow ptosis after the procedure, especially if they have a low forehead and pre-existing pseudo-ptosis

The PREEMPT protocol

Always follow the PREEMPT protocol to optimize efficacy with a minimum of 31 fixed site injections

If the patient requires additional doses of onabotulinumtoxinA, 40 U of the drug from the "Follow-The-Pain" protocol may be used

Remember that the injection point differs from the actual medication delivery point

Treatment of the glabella

Inject the glabella area at least three points according to the PREEMPT protocol, administering 5 U of onabotulinumtoxinA in each site

Direct the needle perpendicularly into the corrugator above the STN orifice, trying not to touch the periosteum

If the patient's anatomy indicates an active and strong corrugator skin attachment, 1 U of onabotulinumtoxinA can be injected superficially and intradermally, not crossing the mid-pupillary line

The procerus is injected at the midpoint in the glabella area precisely between the injections in the corrugators, or 5 mm slightly below, on the line connecting the inner corners of the eye. Inject the medication superficially at this point, at 90, without touching the bone

Treatment in the forehead

Administer four doses in the forehead, directing the needle upwards at 45°. The medial point is precisely on the line connecting the previous corrugator injection sites, and the lateral point is on the line running through the lateral border of the iris

If the patient has a high forehead and there are several horizontal lines of wrinkles, consider injecting additional doses of onabotulinumtoxinA, but not lower than the convergence line, in several points

If there is a risk of the Mephisto appearance, administer 1 U of onabotulinumtoxinA 1–2 cm laterally above the maximal elevation point of the lateral eyebrow

After the procedure

Do not massage the injection site for 2 h after the procedure. Ask the patient to come for a follow-up visit after at least 2 weeks and take photographs after the procedure

Continue treatment according to the PREEMPT protocol, administering onabotulinumtoxinA every 12 weeks with a minimum of three cycles to assess the therapeutic effect

Injection Technique of the Upper Face With OnabotulinumtoxinA in Chronic Migraine

Abstract and Introduction

Abstract

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Authors and Disclosures

Authors and Disclosures

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