Botox for Migraine headache symptoms

Botox (onabotulinumtoxinA)

This famous dermatology, beauty assisting, facial line erasing drug also works for migraine headache and has an indication from the FDA for migraine prevention for patients with chronic migraine (15 headache days a month, 8 of which have migraine features).

Description

Botox is botulinum toxin, a neurotoxin produced by the bacteria that causes botulism.  The toxin is purified and used in tiny doses in specific areas to block motor muscle contractions.  It wears off after about 3 months.  It is common knowledge that plastic surgeons in Hollywood inject movie stars with Botox and in that circumstance the toxin paralyzes the facial muscles and eliminates frowns and lines.  So, it has been known that the Botox toxin would block efferent (motor) nerve transmission but how it helped migraine has not been understood.  Recent articles have discussed that Botox will block the release of a common neurotoxin, generated during the migraine process, CGRP, and this helps migraine.  

Dose

The migraine dose is 155 units IM divided into 31 sites, give every 12 weeks.

Botox dosing by muscle for Chronic migraine

Frontalis                    20 units in 4 sites

Corrugator                 10 units in 2 sites

Procerus                    5 units in 1 site

Occipitalis                 30 units in 6 sites

Temporalis                40 units in 8 sites

Cervical Paraspinal   20 units in 4 sites

Patients describe the injections as like tiny pin pricks as the needle is going a shallow distance into muscles in the face, jaw, and back of head.  The drug works best if given in the protocol as described above.  Sometimes no migraine relief works on the first or even second try, so it is recommended that the patient try it three times.

It is uncertain whether Botox is effective for headache prevention in patients with migraine who have 14 or fewer headache days per month (episodic migraine). 

Side effects

There may be problems swallowing, speaking, or breathing.  The toxin effects may appear in areas away from the injection site and may cause all over muscle weakness, double vision, blurred vision, drooped eyelids, hoarseness, change or loss of voice, or unclear speech.

Cost

Most insurance companies cover most of Botox therapy.  Patients should talk to an insurance supervisor about coverage.

Effectiveness

Allergan, the maker of Botox, says that “some patients in company sponsored trials experienced a 50% reduction or more in headache days per month after two cycles of Botox, and more than 2 out of 3 patients showed some improvement.”

However, an April 24, 2012 article in the Journal of the American Medical Association headlined that Botox injections are only modestly effective for preventing migraines in the most frequent suffers.  The researchers looked at 27 trials comparing Botox to placebo and four other studies comparing Botox to other migraine treatments.  Botox treatment given to patients with at least 15 headaches a month prevented about 2 headaches a month.  The researchers felt that Botox was no more effective than commonly used migraine preventive drugs, didn’t work for Chronic Tension Type Headache, nor for patients with less than 14 migraines a month.  There also is a high placebo response with Botox use.

Satnam Niijar MD, a headache specialist at Johns Hopkins University School of Medicine said “the research analysis will surprise few clinicians working in the field.  This review emphasizes that most patients experience modest benefits, but we already knew that."

Problem

80-90% of patients with chronic migraine are overtreating with over the counter analgesics, caffeine, opioids, or butalbitol and that is called medication overuse headache.  See the article at categories-medication overuse headache.  When I see these patients for a second opinion, and they are already on Botox, but they're not doing well, I discover that they many have not been educated regarding how too much medication can cause headache.  A recent patient was getting Botox and taking hydrocodone from the same doctor.  In my opinion patients should be educated about medication overuse headache and detoxed before Botox is ever considered.  Most of these patients pass into episodic headache and do well.

For good migraine treatment consider: 

Do the migraine lifestyle.

Get on a migraine preventive drug.

Limit all headache medication to no more that 2 days a week, except maybe DHE.  Don't take opioid narcotics or butalbital.