Treatment with botulinum toxin: An update

Table 1 Muscles and doses of botulinum neurotoxin more frequently used in the treatment of dystonias

	Muscles usually injected	Doses of botulinum toxin proposed
		A/Ona	A/Inco	A/Abo	B/Rima
Blepharospasm	orbicularis oculi	20 u/e	20 u/e	40 u/e	1250 u/e
Hemifacial spasm	orbicularis oculi	10-34 u	10-34 u	53-160 u	1250-9000 u
	corrugator
	frontalis
	zygomaticus major
	buccinator
	depressor anguli oris
	platysma
Cervical dystonia	sternocleidomastoid	100-300 u	100-300 u	500 u	2500-10000 u
	splenius capitis
	trapezius
	levator scapulae
	scalenii
	semispinalis
Writer´s cramp	flexor digitorum superficialis	Maximum of 160 u		Maximum of 250 u
	flexor digitorum profundus
	flexor pollicis longus
	lumbricales
	extensor pollicis longus
	extensor indicis
	extensor digitorum comunis
	flexor carpi radialis
	flexor carpi ulnaris
	Pronator teres
Spasmodic dysphonia	adductor spasmodic dysphonia:thyroarytenoid	Bilateral injection: 0.9 u/vf Unilateral injection: 1.5 u
	lateral cricoarytenoid
	interarytenoid
	supraglottic muscle complex
	abductor spasmodic dysphonia:posterior cricoarytenoid	3.75 u unilaterally, additionally 0.6-2.5 u in the contralateral muscle
Oromandibular dystonia	jaw-closing OMD:	masseter 25-50 u	25-50 u	100 u	2500 u
	masseter medial pterygoid temporalis
	jaw-opening OMD:	pterigoyds 15-30 u	15-30 u	30-60 u	1000 u
	lateral pterygoid
	submentalis complex
	deviating OMD:	temporalis 20-50 u	20-50 u	80-100 u
	contralateral lateral pterygoid
	tongue-protrusion lingual dystonia:	Intrinsin tongue muscles 10 u	10 u	30-40 u
	intrinsic tongue muscles

u: Units per session; u/e: Units per eye and per session; u/vf: Units per vocal fold and per session; OMD: Oromandibular dystonia.

Table 2 Method of injection of onabotulinumtoxinA for chronic migraine

Muscles injected	Injection sites (both sides)	Doses of A/Ona per muscle (both sides)
Frontalis	4	20 units
Corrugator	2	10 units
Procerus	1 (only one site in the midline of the forehead)	5 units
Temporalis	8	40 units
	Extra 2 optional sites	Extra 10 optional units
Occipitalis	6	30 units
	Extra 2 optional sites	Extra 10 optional units
Trapezius	6	30 units
	Extra 4 optional sites	Extra 20 optional units
Cervical paraspinal muscle group	4	20 units
Total sites range	31-39 total dose range	155-195 units

Adapted from the treatment paradigm based on the PREEMPT clinical program[132]: 155 units of onabotulinumtoxinA (A/Ona) every 12 wk administered to 31 injection sites across 7 specific head and neck muscle areas using a fixed-site, fixed-dose injection paradigm. Furthermore, up to 40 optional units could be administered using a “follow-the-pain” strategy. Each injection site = 0.1 mL = 5 units of A/Ona.