CLINICS 2011;66(6):1089-1094 Moreover, through a peripheral mechanism it can inhibit the sensitization of central trigeminovascular neurons.60 Thus, Bot-A has more than one effect with regard to headache, migraine and chronic neuropathic pain control. Recently, Bot-A has been used for the treatment of tinnitus.61,62 A crossover double-blind study of the effect of Bot-A showed that it had little effect on tinnitus.62 One group was first injected with Bot-A and four months later with saline injections into three sites around the ear: 1 cm above the pinna, 1 cm behind (at a ‘‘2 o’clock’’ position), and 1 cm behind auricle (at a ‘‘5 o’clock’’ position). The second group was first injected with a placebo and, four months later, with Bot-A. Seven participants reported a decrease in their tinnitus after the Bot-A injection, and two improved after the placebo. When tinnitus was analyzed through the global clinical impression of the patient (i.e. ‘‘better’’, ‘‘worse’’ or ‘‘the same’’), the effects of Bot-A were significantly better than the placebo (p,0.05), when comparing pre-treatment and 4 months after injection (p = 0.04). Such results suggest that the Bot-A can play a role in tinnitus management by reducing peripheral inputs from the cervical, temporal, frontal and periauricular muscles. A similar study showed that, out of 26 participants, 7 improved, 13 worsened and 16 were unchanged.61 When treatment with the botulinum toxin is being considered, potentially serious side-effects, such as changing cardiac reflexes, should be considered.63 Eighty percent of people treated with the botulinum toxin reported abnormalities in their electrocardiograms. The fact that the treatment is likely to demand repetition for long periods is a disadvantage that – when used for the treatment of other disorders such as hemifacial spasm – has made many people discontinue treatment.64 CONCLUSION Studies have been pointing towards a high prevalence of somatosensory tinnitus among tinnitus patients. Thus, professionals involved with providing treatment for patients with tinnitus must differentiate this specific subgroup from the conventional ones. Investigating the presence of somatosensory tinnitus by means of a specific protocol and choosing adequate therapeutic options that will target auditory pathways and musculoskeletal dis- orders may increase the possibility of satisfactory results. REFERENCES 1. Jastreboff PJ, Sasaki CT. An animal model of tinnitus: a decade of development. Am J Otol. 1994;15:9–11. 2. Seidman MD, Jacobson GP. Update on tinnitus. Otolaryngol Clin North Am. 1996;29:455–65. 3. 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