Skip to main content


Effect of Botulinum Toxin type-A (Botox®) on neck pain and craniocervical headaches caused by trapezius spasm in a child with generalised joint hypermobility resulting from Noonan's Syndrome


A twelve year old female with generalised joint hypermobility (Beighton 8/9) from Noonan's syndrome presented with chronic neck pain which caused frequent headaches. Touching the trapezeii reproduced the pain and range of movement at the cervical spine was decreased. She had been managed unsuccessfully with manual techniques, mobilisation, stretches and TENS over the prior twelve months. Poor sleep due to pain caused fatigue and decreased participation in school and physical activity.

Materials and methods

N of 1 trial design to investigate the efficacy of Botox® to reduce muscle spasm.

Baseline measures of weekly average pain (VAS), maximum pain (VAS), episodes of neck pain, episodes of headache and doses of paracetamol (acetaminophen) were obtained over 5 weeks. The intervention consisted of injecting 25 units of Botox® into each trapezius (total 50 units) over multiple sites. Outcome measures were recorded for seven weeks following treatment. Data was analysed using the c-statistic method in Excel®.


At six weeks average pain score decreased from a median of 48.5 to 20.0 (c-statistic p = 0.012). Maximum pain decreased from a median of 72.0 to 40.0 (c-statistic p = 0.009). Episodes of neck pain per week reduced from a median of 4 to 2 (c-statistic p = 0.009). No significant change was seen in the number of episodes of headaches per week, which reduced from 2 to 1 (p = 0.057). Analgesic requirement reduced from 4 paracetamol per week to 2 (c-statistic p = 0.012).


Botulinum toxin injections were an effective treatment.

Author information

Correspondence to LJ Tofts.

Rights and permissions

Open Access This article is published under license to BioMed Central Ltd. This is an Open Access article is distributed under the terms of the Creative Commons Attribution 2.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Reprints and Permissions

About this article


  • Paracetamol
  • Acetaminophen
  • Botulinum Toxin
  • Neck Pain
  • Poor Sleep