Using Botox to Treat Cervical Dystonia

Overview of Cervical Dystonia

Cervical dystonia is a rare medical condition that causes the neck muscles to contract into abnormal positions involuntarily.(1,2,3) It can cause repetitive twisting movements of the neck and head. The severity of the condition varies from person to person, and the movements can happen either intermittently, in spasms, or they can even be constant. In some cases, cervical dystonia can be disabling and painful. The exact cause of Cervical dystonia is unknown, though there are treatments that can help you manage the symptoms of Cervical dystonia.(4,5)

The most common and challenging symptom of cervical dystonia is pain. The pain tends to typically occur on the same side of the head as the twist or tilt. Since the condition causes abnormal movement, you are likely to experience twisting of the head and chin to the side, towards your shoulder. This is known as torticollis. Other abnormal movements that may include the head doing the following:

Using Botox to Treat Cervical Dystonia

  • Tilting sideways, ear to shoulder – a condition known as laterocollis
  • Tipping forward, chin downward – a condition known as anterocollis
  • Tilting backward, chin upward – a condition known as retrocollis

Excitement or stress are known to worsen the symptoms, and some physical positions may also trigger the symptoms.

For most people, the symptoms typically start gradually and may get worse, and finally reach a plateau. Other symptoms of cervical dystonia include:

  • Neck pain that radiates down to the shoulders
  • Hand tremors
  • Headache
  • A raised shoulder
  • Head tremor – this affects nearly half of the people with cervical dystonia(6)
  • Unawareness of physical movements that are not affected by dystonia
  • Enlargement of the neck muscle – this affects nearly 75 percent of all people with cervical dystonia(7)

Botox for Treating Cervical Dystonia

Botox (onabotulinumtoxinA) is a common prescription brand name medication that the Food and Drug Administration has approved for the treatment of cervical dystonia in adults. Here are some facts about Botox:

  • Drug Class: neurotoxin
  • Active Ingredient: OnabotulinumtoxinA
  • Drug Form: Available in liquid solution and administered as an intramuscular injection for treating cervical dystonia.
  • Not available as a generic.

Botox contains the active drug onabotulinumtoxinA and is made from a neurotoxin that is produced by a bacteria known as Clostridium botulinum.(8) For most purposes, Botox is administered as an intramuscular injection, meaning it is injected into a muscle in different parts of the body, depending on what condition is being treated.

Botox works by stopping the nerves from functioning. The nerves communicate with all the other parts of the body by using a neurotransmitter known as acetylcholine.(9) Neurotransmitters are a type of chemical messengers that are present throughout the body. Botox works by preventing the nerves from releasing the neurotransmitter acetylcholine, due to which the nerves are not able to send messages to the muscles telling them when to spasm or contract. In cases of cervical dystonia, Botox prevents the nerves from causing the muscles to spasm or contract in the neck.

However, over a period of time, the effects of Botox injections can begin to wear off because the nerves slowly develop new endings that start releasing acetylcholine again.

Since the Food and Drug Administration approved the use of Botox for treating cervical dystonia, your doctor may recommend Botox and determine the exact amount of Botox that you will need.(10,11) The dosage of Botox for the treatment of cervical dystonia depends on several factors, including:

  • The severity of your condition
  • The muscle or group of muscles that are affected
  • The level of pain you are in due to your condition

Once your doctor determines the exact dosage of Botox for your condition, the treatment will be divided into multiple injections for the affected muscle or muscles. During clinical studies, the average dosage of Botox for cervical dystonia was determined to be 236 units.(12)

Your doctor will start you off on a low dosage, and they may increase the dose depending on how your body and symptoms respond.

It has been observed that people who are given the Botox injections for treating cervical dystonia start noticing an improvement in their condition within the first two weeks of receiving the injection.

What are the Side Effects of Botox for Cervical Dystonia?

The use of Botox for treating cervical dystonia may cause some mild or serious side effects. When it comes to mild side effects, these can be temporary and just last for a few days or weeks. However, if they last for a longer time, or they start to become severe and disrupt your daily life, it is important to let your doctor know about the symptoms.

Some of the common mild side effects caused by Botox injections for the treatment of cervical dystonia include:

This is why it is crucial that you watch out for muscle weakness, loss of strength, vision problems, or dizziness after receiving the Botox injections. You may experience these side effects within hours, a few days, or sometimes even weeks after receiving the Botox injection. If you experience any side effects, you should avoid driving a car or heavy machinery or take part in any type of dangerous activities. Immediately let your doctor know so that they can evaluate your symptoms and recommend any do’s and don’ts.

While rare, but Botox injections can cause some serious side effects. If you develop any severe side effects, you must call your doctor immediately. If the side effects appear to be life-threatening, do not waste time and contact your local medical emergency number immediately. Some of the side effects from Botox injections may include:

  • Allergic reaction
  • Spread of Botulinum’s toxic effects, which could potentially lead to life-threatening swallowing or breathing difficulties

Botox does have a boxed warning for this side effect.(13)

Does Botox Worsen Cervical Dystonia?

It is highly unlikely that Botox injections can worsen cervical dystonia. In a clinical trial, worsening of the symptoms was not reported as a side effect of Botox.(12) However, between the injections, you may find that your symptoms are coming back, especially if there is a long time between two doses.

In the trial, most people who received the Botox injections reported that their cervical dystonia symptoms returned to ‘pretreatment’ status within three months after taking the last dose. Botox treatment was found to be most effective at alleviating the symptoms of cervical dystonia six weeks after the injections were administered.

If the Botox injections do not seem to be working on easing your cervical dystonia symptoms, you should talk to your doctor, and they will work with you to determine the best treatment for your condition.

At the same time, though, using Botox for a long time can make it become less effective over time. If you continue to use Botox for a long time, it is possible that your immune system gets so used to recognizing Botox that it ultimately develops antibodies to fight against it.(14)

Antibodies are blood proteins that are produced by the body in response to a specific substance and then counteract it. As these antibodies learn to fight against Botox, this may leave the drug less effective at alleviating the symptoms of cervical dystonia. If this happens, it means that you are developing an immunity to Botox.

It remains unclear as to why some people’s bodies create these antibodies, but receiving Botox injections at higher doses or more frequently than usual can be some factors. Your doctor will try to reduce this risk of immunity to Botox by prescribing the lowest dose to treat the symptoms and also try to increase the waiting time between injections.

However, if Botox injections do not seem to be working on easing your symptoms of cervical dystonia, you should let your doctor know at the earliest so that they can make the necessary adjustments to your treatment plan as needed.

How Well Does Botox Work For Cervical Dystonia?

As mentioned above, a clinical study was carried out to determine the effectiveness of Botox injections as a potential treatment for cervical dystonia.(12)

Participants in the study were given either the Botox injection or a placebo was injected into the affected muscles. The research team wanted to determine if Botox was better at improving people’s scores on the Cervical Dystonia Severity Scale.(15,16) This is a 54-point scale. Having a higher score on this scale means you have more serious problems with your head position.

The research team discovered that people who received the Botox injections experienced a dramatic decrease in their scores as compared to people who got the placebo injections.

According to the guidelines issued by the American Academy of Neurology, Botox is recommended as the first-line treatment for cervical dystonia.(17) This is why doctors typically prescribe Botox as the first treatment for cervical dystonia.

The ultimate goal of treating cervical dystonia with Botox injections is to relieve the abnormal head positions and to ease neck pain.

Important Information to Consider Before Receiving Botox

Before you receive Botox, there are several essential facts you need to keep in mind. The drug might not be a safe option for everybody, especially if you have certain medical conditions or there are other factors that can affect your health. Some of these factors are mentioned below.

Botox comes with a boxed warning.(13) A boxed warning is the most serious type of warning given by the Food and Drug Administration that alerts doctors and patients about the effects of the drug that may prove to be dangerous. Sometimes, Botox may spread from where it was initially injected to other parts of the body. This can cause botulism, which is a serious condition that may cause the following symptoms:(18)

  • Difficulty breathing
  • Difficulty speaking
  • Difficulty swallowing
  • Lack of energy
  • Dropping eyelids
  • Blurry or double vision
  • Hoarse voice
  • Muscle weakness
  • Loss of control over your bladder

Botulism can occur within hours, days, or even weeks after getting a Botox injection. It is important to let your doctor know if you experience any of the above-mentioned symptoms while using Botox.

In some rare cases, difficulty swallowing or breathing can become life-threatening. People who already have trouble swallowing or breathing are at a higher risk of having these problems. Call your doctor or the local emergency number immediately if you experience problems with swallowing or breathing after getting a Botox injection.

Apart from the boxed warnings, Botox also has other warnings. These warnings are given for the following conditions:

  • If you have an infection in the area where you will receive the Botox injections, such as the neck.
  • If you have an upcoming surgery.
  • If you have had an allergic reaction to Botox or any of its ingredients in the past.
  • If you have a neuromuscular disorder, such as myasthenia gravis or amyotrophic lateral sclerosis (ALS).
  • If you are pregnant or breastfeeding.

Conclusion

Cervical dystonia is a rare condition in which the neck muscles can involuntarily contract or spasm into abnormal positions. The condition can be painful, and there is no cure for it as of yet. Botox injections are the first line of treatment for cervical dystonia. The primary treatment for getting relief from pain is to have the Botox injections in the neck muscles every 11 to 12 weeks. Botox helps immobilize the nerves in the neck muscles, thus relieving the pain and other symptoms.

If you want to learn more about using Botox to treat cervical dystonia, you should talk with your doctor, who can advise you on whether Botox injections would be the right treatment for you.

References:

  1. Chan, J., Brin, M.F. and Fahn, S., 1991. Idiopathic cervical dystonia: clinical characteristics. Movement disorders: official journal of the Movement Disorder Society, 6(2), pp.119-126.
  2. Jankovic, J., Leder, S., Warner, D. and Schwartz, K., 1991. Cervical dystonia: clinical findings and associated movement disorders. Neurology, 41(7), pp.1088-1088.
  3. Dauer, W.T., Burke, R.E., Greene, P. and Fahn, S., 1998. Current concepts on the clinical features, aetiology and management of idiopathic cervical dystonia. Brain: a journal of neurology, 121(4), pp.547-560.
  4. Velickovic, M., Benabou, R. and Brin, M.F., 2001. Cervical dystonia. Drugs, 61(13), pp.1921-1943.
  5. Defazio, G., Jankovic, J., Giel, J.L. and Papapetropoulos, S., 2013. Descriptive epidemiology of cervical dystonia. Tremor and Other Hyperkinetic Movements, 3.
  6. Putkonen, A., 2015. Recovery From Cervical Dystonia With Topiramate. Journal of Medical Cases, 6(8), pp.373-375.
  7. Putkonen, A., 2015. Recovery From Cervical Dystonia With Topiramate. Journal of Medical Cases, 6(8), pp.373-375.
  8. Brin, M.F., 2009. Basic and clinical aspects of BOTOX®. Toxicon, 54(5), pp.676-682.
  9. Paton, W.D., Vizi, E.S. and Zar, M.A., 1971. The mechanism of acetylcholine release from parasympathetic nerves. The Journal of physiology, 215(3), pp.819-848.
  10. Odergren, T., Hjaltason, H., Kaakkola, S., Solders, G., Hanko, J., Fehling, C., Marttila, R.J., Lundh, H., Gedin, S., Westergren, I. and Richardson, A., 1998. A double blind, randomised, parallel group study to investigate the dose equivalence of Dysport® and Botox® in the treatment of cervical dystonia. Journal of Neurology, Neurosurgery & Psychiatry, 64(1), pp.6-12.
  11. Benecke, R., Jost, W.H., Kanovsky, P., Ruzicka, E., Comes, G. and Grafe, S., 2005. A new botulinum toxin type A free of complexing proteins for treatment of cervical dystonia. Neurology, 64(11), pp.1949-1951.
  12. Accessdata.fda.gov. 2021. [online] Available at: > [Accessed 29 March 2021].
  13. Fda.gov. 2021. [online] Available at: [Accessed 30 March 2021].
  14. Suchard, M., 2015. Immunosenescence: ageing of the immune system. SA Pharmaceutical Journal, 82(8), pp.28-31.
  15. O’Brien, C., Brashear, A., Cullis, P., Truong, D., Molho, E., Jenkins, S., Wojcieszek, J., O’Neil, T., Factor, S. and Seeberger, L., 2001. Cervical dystonia severity scale reliability study. Movement disorders: official journal of the Movement Disorder Society, 16(6), pp.1086-1090.
  16. Jost, W.H., Hefter, H., Stenner, A. and Reichel, G., 2013. Rating scales for cervical dystonia: a critical evaluation of tools for outcome assessment of botulinum toxin therapy. Journal of neural transmission, 120(3), pp.487-496.
  17. Simpson, D.M., Hallett, M., Ashman, E.J., Comella, C.L., Green, M.W., Gronseth, G.S., Armstrong, M.J., Gloss, D., Potrebic, S., Jankovic, J. and Karp, B.P., 2016. Practice guideline update summary: Botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology, 86(19), pp.1818-1826.
  18. Davletov, B., Bajohrs, M. and Binz, T., 2005. Beyond BOTOX: advantages and limitations of individual botulinum neurotoxins. Trends in neurosciences, 28(8), pp.446-452.

Also Read: