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Botox For Migraines

Botox for migraines is one of the newer advances to come along within the last five years. Many people are familiar with Botox and usually the first question I get is..can you get rid of my wrinkles too?? Well..yes and no. Wrinkles in forhead, yes, around the eyes, you have to see the plastic surgeon for that one!

Botox for migraines is a form of botulism toxin that is extremely diluted. The injections are given in small amounts and placed just under the skin, near the nerves that cause pain. The main mechanism of action is to bind to nerve tissue and block certain impulses along the nerve, thereby causing paralysis of the muscle in that area.

It is sometimes used for neck spasms known as dystonias, torticollis or "wry neck". It has been on the market since the 1980's and some neurologists who were involved in the original clinical trials have been using it since then with sucess.

I should note that if you are in the upstate New York area, we are also doing Botox for migraine at The Dent Headache Center. I have been doing this treatment since 2005 and at this point have done thousands of injections of botox for migraines.

The use of botulinum toxin for headache was first discovered in the 1980's at the University of California in San Francisco. The dermatologists were using about 80 units of Botox and noticed when placed in the face (for wrinkles!) many women noticed their migraines disappeared. It took almost 20 years to get clinical trials completed but when accomplished, Allergan, the makers of Botox applied to the FDA for the indication for "chronic migraine prevention". This is important as you must have 15 migraine days a month or more inorder to get Botox. Note, I said 15 days..not 15 migraines. A migraine can last several days right?

The large PREEMPT trial, sponsored by Allergan the makers of botulinumtoxinA showed that the intensity of migraines was significantly improved in the Botox arm of the trial vs placebo. There was also a significant reduction in the number of headache days. The total length of the trial was 32 weeks. After the first 16 weeks, placebl patients were switched to the Botox arm, and they too saw significant improvement at this point.

Another study by Dodick, et. al., demonstrated similar results with patients once again having a significant decrease in the frequency of headache days per month.

botox for migraines



The picture above approximates where the injections are placed (in the green circles) and they are always placed on both sides of the head, no matter on which side your headaches are frequent. We also put several injections in the neck at the base of the skull and across the trapezius muscle. After all, you would look pretty funny with lines on one side of your forehead and not the other, right?

Injections are not placed past the midline of the eyebrow as that would paralyze the eyebrow (for a few months) and you would not be able to raise them.

Side effects of Botox for migraines include irritation at the injection site which may last a few days, and a minute amount of blood at the injection site. If given in the neck, weakness of neck muscles may be noticed but it is usually not severe. Approximately 8-9% of the time, patients will see spasming in the neck after the injections. This is treated with anti-spasmotics until the Botox wears off. Subsequent injections are not placed in the neck anymore and patients still see relief from migraine when the injections are just in the head.

Some people get slight elevation of the eyelids. This is due to the fact that Botox paralyzes the muscled in the center of the forehead. The brain responds by lifting the eyebrows to try and compensate. Rarely when used for headache, it may travel around the orbits and cause one or both eyelids to lower a bit (ptosis). I did see this happen with one patient...but it stopped traveling at her crow's feet! They disappeared and she was delighted. I tried to tell her this may not happen again but she didn't care..she was happy.

The sucess rate with Botox for migraine has been reported to be as high as 75%, but clinically we see about a 50-60% success rate.

Injections are given every 3-4 months depending on the patient and how soon the first set begins to wear off.

Botox does not cure headaches or a migraine cure! Like many other medications for headache, Botox offers another medium for headache management. If sucessful, Botox for migraines may allow you to reduce, and perhaps eliminate, your other headache medications. Talk to your insurance company to see if you are covered. If you can prove that you meet the criteria, you may get your injections covered.

Botox is now approved for use in chronic migraine and has received the indication for this treatment from the FDA. This means more than 15 days per month that are migraine days (yes menstrual migraine days count!). If you are interested, please contact your provider. If you live in NY State, you can reach our clinic at (716)250-2000 and ask to make an appointment with me or Dr. Mechtler to talk about this new treatment. Almost all insurance plans in our area are now paying for botox for migraines.

References:
1. Aurora SK, Dodick DW, Turkel CC, et al; PREEMPT 1 Chronic Migraine Study Group. OnabotulinumtoxinA for treatment of chronic migraine: Results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 1 trial. Cephalalgia. 2010;30(7):793-803.
2. Dodick, D.W., Mauskop, A., et.al., Botulinum Toxin Type A for the prophylaxis of chronic daily headache: Subgroup analysis of patients not receiving other prophylactic medications: A randomized double-blind, placebo-controlled study. Headache. 2005:316-324

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