Botulinum Neurotoxin for Treating Blepharospasm, Cervical Dystonia, Adult Spasticity, and Headache: AAN Guideline

American Academy of Neurology (AAN) has released guidelines on Botulinum Neurotoxin for the Treatment of Blepharospasm, Cervical Dystonia, Adult Spasticity, and Headache in April 2016 and reaffirmed April 30, 2022. Endorsed by the American Association of Neuromuscular & Electrodiagnostic Medicine and the American Society of Plastic Surgeons.

Following are its major recommendations:

1. OnaBoNT-A and incoBoNT-A injections should be considered as treatment options for blepharospasm (Level B).

2. Weak Evidence AboBoNT-A may be considered as a treatment option for blepharospasm (Level C).

3. AboBoNT-A and rimaBoNT-B should be offered (Level A) as options for the treatment of CD.

4. OnaBoNT-A and incoBoNT-A should be considered (Level B) as options for the treatment of CD.

5. For focal manifestations of adult spasticity involving the upper limb, aboBoNT-A, incoBoNT-A, and onaBoNT-A should be offered (Level A) as treatment options.*

6. For focal manifestations of adult spasticity involving the upper limb, rimaBoNT-B should be considered (Level B) as a treatment option.* 

7. For focal manifestations of adult spasticity involving the lower limb that warrant treatment, onaBoNT-A and aboBoNT-A should be offered (Level A) as treatment options.*

8. There is insufficient evidence to support or refute a benefit of incoBoNT-A or rimaBoNT-B for treatment of adult lower limb spasticity (Level U). 

9. OnaBoNT-A should be considered as a treatment option before tizanidine (TZD) for treating adult upper extremity spasticity (Level B).

10. Both high-volume, low-potency injections of onaBoNT-A and endplate targeting of onaBoNT-A into proximal upper extremity muscles should be considered to enhance tone reduction in spasticity (Level B). 

11. OnaBoNT-A should be offered as a treatment option to patients with CM to increase the number of headache-free days (Level A).

12. OnaBoNT-A should be considered to reduce headache impact on health-related quality of life (Level B).

13. OnaBoNT-A should not be offered as a treatment for episodic migraine (Level A). Tension-type Headaches

14. No new studies were identified that would have changed the conclusion of the 2008 guideline.3 BoNT injection is probably ineffective for treating chronic tension-type headaches (two Class I studies) (Level B, as determined in 2008 guideline).

Reference:

David M. Simpson, Mark Hallett, Eric J. Ashman, Cynthia L. Comella, Mark W. Green, Gary S. Gronseth, Melissa J. Armstrong, David Gloss, Sonja Potrebic, Joseph Jankovic, Barbara P. Karp, Markus Naumann, Yuen T. So, Stuart A. Yablon Neurology May 2016, 86 (19) 1818-1826; DOI: 10.1212/WNL.0000000000002560