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May 10, 2016; 86 (19) Special Article

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

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
First published April 18, 2016, DOI: https://doi.org/10.1212/WNL.0000000000002560
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Abstract

Objective: To update the 2008 American Academy of Neurology (AAN) guidelines regarding botulinum neurotoxin for blepharospasm, cervical dystonia (CD), headache, and adult spasticity.

Methods: We searched the literature for relevant articles and classified them using 2004 AAN criteria.

Results and recommendations: Blepharospasm: OnabotulinumtoxinA (onaBoNT-A) and incobotulinumtoxinA (incoBoNT-A) are probably effective and should be considered (Level B). AbobotulinumtoxinA (aboBoNT-A) is possibly effective and may be considered (Level C). CD: AboBoNT-A and rimabotulinumtoxinB (rimaBoNT-B) are established as effective and should be offered (Level A), and onaBoNT-A and incoBoNT-A are probably effective and should be considered (Level B). Adult spasticity: AboBoNT-A, incoBoNT-A, and onaBoNT-A are established as effective and should be offered (Level A), and rimaBoNT-B is probably effective and should be considered (Level B), for upper limb spasticity. AboBoNT-A and onaBoNT-A are established as effective and should be offered (Level A) for lower-limb spasticity. Headache: OnaBoNT-A is established as effective and should be offered to increase headache-free days (Level A) and is probably effective and should be considered to improve health-related quality of life (Level B) in chronic migraine. OnaBoNT-A is established as ineffective and should not be offered for episodic migraine (Level A) and is probably ineffective for chronic tension-type headaches (Level B).

GLOSSARY

AAN=
American Academy of Neurology;
aboBoNT-A=
abobotulinumtoxinA;
AE=
adverse event;
BDI=
Blepharospasm Disability Index;
BoNT=
botulinum neurotoxin;
CD=
cervical dystonia;
CI=
confidence interval;
CM=
chronic migraine;
DAS=
Disability Assessment Scale;
EM=
episodic migraine;
incoBoNT-A=
incobotulinumtoxinA;
onaBoNT-A=
onabotulinumtoxinA;
QOL=
quality of life;
RD=
risk difference;
rimaBoNT-B=
rimabotulinumtoxinB;
RMT=
randomized, masked trials;
TWSTRS=
Toronto Western Spasmodic Torticollis Rating Scale;
TZD=
tizanidine

Footnotes

  • Approved by the Guideline Development Subcommittee on November 16, 2013; by the Practice Committee on February 27, 2015; and by the AAN Institute Board of Directors on January 19, 2016.

  • Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Supplemental data at Neurology.org

  • Received June 8, 2015.
  • Accepted in final form December 21, 2015.
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