Botulinum Treatment Induced Dropped Head Syndrome in a Patient With Chronic Migraines and Multiple Sclerosis

Chronic migraine treatment typically is treated medically by use of medications, such as nonsteroidal anti-inflammatory drugs and triptans; however, for a subset of patients, botulinum toxin (or Botox) has effectively been shown to be an alternative medication.

Following Botox administration for chronic headaches, our patient developed unforeseen adverse effects and presented with severe neck stiffness, facial droop, and dysphagia, collectively known as dropped head syndrome, prompting them to seek emergency care. In order to counteract botulinum toxicity, we administered neostigmine, but unexpectedly induced cholinergic toxicity, which led to severe secretions and blurry vision. Glycopyrrolate was administered with responsive resolution of symptoms.

This case highlights the complexities of managing adverse reactions to Botox and raises considerations for alternative treatments, such as atropine, or concurrent neostigmine treatment with glycopyrrolate.