Although the quality of evidence is low due to variable study designs, botulinum toxin may be beneficial in the treatment of chronic tension-type headaches (CTTH) for specific patients with clear treatment goals, according to the results of a recent study.

The systematic review included prospective studies analyzing the efficacy of botulinum toxin in adult patients with CTTH. A total of 22 studies with varying designs and methods were included: 9 non‐randomized, uncontrolled studies; 8 randomized, placebo‐controlled, double‐blinded trials (RCT); 3 RCTs including a cross‐over, open-label period; 1 comparative, randomized, single‐blinded evaluation; and 1 retrospective study with prospective analysis of headache response to cosmetic botulinum toxin. Additionally, it was noted that the typical duration of each trial was <6 months and enrolled between 11 and 300 patients.

“Results were mixed, likely due to variable study design including toxin dosing, injection paradigms, duration/frequency of treatment and outcome measures,” the study authors reported. “However, while previous studies questioned the efficacy of botulinum toxin in the treatment of CTTH, we have found through our review that there could be benefit to the use of botulinum toxin use in CTTH with careful patient selection, specific injection paradigms and clear goals of treatment.” Benefits were observed in patients with muscle allodynia, in those who received retreatment every 3 months or fixed injection protocols, and possibly in those who received higher doses of botulinum toxin.

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Given the findings of this systematic review, the authors concluded that additional studies are needed to better understand the utility of botulinum toxin in CTTH. They added that “using the paradigm for botulinum toxin in chronic migraine may prove fruitful in treating CTTH.”


Freund B, Rao A. Efficacy of Botulinum Toxin in Tension-Type Headaches: A Systematic Review of the Literature. Pain Practice. 2019. DOI: