Tics and Botox
While Botox injections are most notably known for their cosmetic use, they have also been used for medical purposes for several decades. Dr. Katie Kompoliti, M.D. explores the science behind using Botox injection to reduce tic symptoms. Dr. Kompoliti a former TAA Medical Advisory Board Member and is a Professor of Neurology at The Rush University Medical Center in Chicago.
Botulinum toxin injections have been successfully used to treat numerous movement disorders associated with muscle overactivity, presenting as either increased muscle tone, excessive muscle contraction or muscle spasms. Tics can be associated with excessive muscle spasms resulting in sustained or intermittent movements or vocalizations. Therefore, Botulinum toxin injections would be an appealing treatment modality for patients with focal tics, such as blinking, winking, head jerking, and vocalizations.
Botulinum toxin is a very potent neurotoxin that in essence weakens/paralyzes muscles. Currently, there are four products available for injection in the US: Botox, Xeomin, Dysport and Myobloc. The onset of the action following the injection is gradual, and its action can last up to 3 to 6 months. Botox injections have been used for medical purposes since the early 1980s. The first use was for Strabismus, an ophthalmological disorder. Since the late 1980s Botox injections have been used for movement disorders like Dystonia and other medical conditions like spasticity, drooling, excessive sweating, bladder control and gastrointestinal problems. For some of these disorders, like cervical dystonia, Botox injections are FDA approved, first line treatments. Therefore, neurologists have significant experience using Botox for medical purposes.
Botulinum toxin injections have been used for the treatment of tics. There is substantial anecdotal experience, a few uncontrolled studies and at least one well-designed, placebo controlled study that concluded that Botox can be a useful tool in treating both motor and vocal tics. However, Botox is a treatment that can only be used to target a specific area of the body. For example, if the patient has a single blinking tic, this could be a very beneficial treatment. Other areas that can be easily approached are shoulder, abdominal and neck tics. Botulinum toxin cannot be used to address the whole repertoire of an individual’s tics, because of technical and dose limitations. In treating refractory vocal tics, vocal cord injections have been used with variable success. Even when Botulinum toxin does not eliminate the vocal tic(s), it can sometimes be used to decrease the volume of the vocalization(s), albeit making the voice softer as well. When treating tics with Botox injections, it has been noted that there is also a decrease in the urge that precedes the tics.
The side effects from the injections are a result of weakening certain muscle groups, are dose dependent and when present they occur in the first few weeks following treatment. In the published series, side effects included neck weakness, swallowing difficulty, eyelid droopiness, low volume voice, and flu like symptoms lasting for a day, following the first injection. These were in the most part mild and lasted 1-3 weeks.
Administering Botox injections requires special expertise that is available only at specialized centers. Therefore, it is not always readily accessible to everyone. Finally, Botulinum toxin as a therapeutic option for tics is not FDA-approved. Coverage is variable, depending on insurance carrier and geographic location. The treating physician often needs to make a case of medical necessity. Although there are no data comparing medications, which are the standard of care for tic disorders, and Botulinum toxin injections for focal tics, if there is a single tic that is the most problematic and the muscles are accessible for injection, the side effect profile would favor Botulinum toxin injections over medications. But tics are usually multifocal and a systemic approach using medications is often needed.