How Botulinum toxin injections can worsen neck instability and pain - a ...

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"Results: All seven patients in this study were female with a mean age of 45, ranging from 25 to 64 years. Their diagnoses were intractable migraine headache, cervicogenic headache and/or cervical dystonia. Among them, four patients were initially treated by four other practitioners. OnabotulinumtoxinA was utilized with injection dose ranging from 100 units to 200 units. Following injection, all subjects had prolonged severe neck pain and headache, and neck “weakness”. Subsequently, five patients received repeated injections with a modified protocol including avoidance or reduction of cervical muscle injection. Four out of five of these patients reported significant improvement in headache control without neck pain, and one patient reported partial improvement with both headache and neck pain.

Conclusions: Patients with EDS have ligamentous laxity. Significant cervical muscle hypertrophy and increased muscular tone are often seen in these patients, likely representing muscular compensation to ligamentous laxity to help with joint stability. Botulinum toxin may break such compensation, leading to head and neck instability, worsening of pain and even serious injuries. Extra caution should be exercised for Botulinum toxin injection in patients with hypermobility EDS. Muscles involving head and neck stabilization should be avoided. A large prospective study is warranted to shed light on safety and efficacy of Botulinum toxin injection in hypermobility EDS patients".