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OnabotulinumtoxinA injections: treatment of reversible cerebral vasoconstriction syndrome chronic daily headaches
  1. Ricardo Senno1,2,
  2. Ethan Schonfeld3 and
  3. Charulatha Nagar4,5
  1. 1 Medicine, Chicago Medical School, Rosalind Franklin University, North Chicago, Illinois, USA
  2. 2 Sennogroup Wellness & Rehabilitation, Northbrook, Illinois, USA
  3. 3 Department of Humanities and Sciences, Stanford University, Stanford, California, USA
  4. 4 Neurology, Northwestern Medical Group, Glenview, Illinois, USA
  5. 5 Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
  1. Correspondence to Ethan Schonfeld, eschon22{at}


Reversible cerebral vasoconstriction syndrome (RCVS) is a rare condition characterised by repetitive, multifocal, vasofluctuations of cerebral arteries. A key symptom is chronic, disabling ‘thunderclap’ headaches, which are extremely difficult to treat as established medications may exacerbate the pathophysiology of RCVS. OnabotulinumtoxinA (OBT-A) injections are used for the prophylaxis of chronic daily headaches (CDH). The mechanism of action of OBT-A significantly differs from oral headache treatments. Thus, OBT-A may be an effective, safe treatment of RCVS-CDH. A 51-year-old woman with RCVS-CDH presented to outpatient clinic. This case report describes the first, believed, documented treatment of RCVS-CDH by OBT-A injections. In 2018, the consented patient received a total of 200 units of OBT-A, 155 units to the 31 approved U.S. Food and Drug Administration (FDA) sites and 45 units injected into the bilateral occipital belly of occipitofrontalis muscles. The patient reported 3 months of excellent pain relief (60% reduction). Three rounds of OBT-A injection, each 3 months apart, resulted in 80% reduction. OBT-A injections may prove a successful, novel treatment for RCVS-CDH.

  • botulinum toxin
  • contraindications and precautions
  • neurology (drugs and medicines)
  • headache (including migraines)
  • vasculitis

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  • Contributors RS was responsible for conceptualisation, investigation, supervision, methodology, writing, reviewing, formal analysis, data curation, editing and was the attending physician. ES was responsible for investigation, writing, reviewing, data curation by interview and medical chart review, formal analysis, writing initial draft, literature review and editing. CN was responsible for investigation, formal analysis, editing and was the attending physician.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Obtained.