Early Use Of Botulinum Toxin In Headache
During the 1990s, there was increasing interest in treating tension-type headache with BT because of its muscle-paralytic actions. In the first publication on this topic in 1994, Sjaastads group in Norway reported a negative trial with BTA injected into the temporal muscles .
A case report in 1998 noted that frontal and periorbital headaches were relieved in a patient treated with BTA for blepharospasm , and in the same year, a publication on the use of BTA in tension-type headache reported it reduced the severity and frequency of migraine-type headaches .
In 1999, a case series from Germany reported that injections of BTA into the muscles of the head and neck alleviated tension-type headache , and a case series from Canada concluded that BTA used for wrinkles was helpful in reducing tension-type headache .
There was now so much interest in using one of the most potent poisons known to mankind to treat headache that the title of a paper in the Harvard Health Letter read Feed a cold, starve a fever, and poison a headache .
Interest in using BTA for migraine increased, and in 2000, Binder reported benefit for migraine in an open-label study . Allergan, which had obtained the rights to Oculinum from Scott in 1991 and rebranded it as Botox, launched a long-term clinical trials program for testing BTA in headache.
What Is Botox For Chronic Migraine Used For
Botox has been approved by the U.S. Food and Drug Administration as a preventative treatment for chronic migraine, which is characterized by headaches that occur at least 15 days per month and last four hours or more. Insurance companies usually require people to try other preventative medications before they will cover Botox for chronic migraine.
Blocking The Migraine Attack
The pathophysiology of migraine is complex and still not completely understood . An important feature in the genesis of a migraine attack in some patients may be the activation of C-fiber nociceptors in the dura. In migraine with aura, this activation may occur because of diffusion to the meninges of substances released from the cerebral cortex during spreading depression . When activated, these nerve endings release CGRP, which sensitizes the C-fiber nociceptors further and may activate adjacent A-delta pain fibers . Afferent activity from these two nerve fiber types flows to the trigeminocervical complex in the brainstem, where second order neurons in the trigeminal sensory pathways are activated. It has also been proposed that migraine headache pain may result from dysfunctional CGRP signaling in the trigeminal ganglion .
OBTA may interrupt this sequence of events by inhibiting the release of CGRP and other neuropeptides from the nociceptive C-fibers. This would not only prevent the C-fiber nociceptor from becoming sensitized but would also prevent the activation of nearby A-delta fibers by CGRP released from the C-fiber nerve terminals . Thus, the afferent flow into the TCC would be greatly reduced.
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You’ll Have To Get Dozens Of Shots
Though migraine symptoms vary from person to person, Botox for migraine is standardized. Every three months you’ll receive 31 shots totaling up to 155 units of Botox. This includes injections in specific spots in the forehead, temples, back of the head, neck, upper back, and shoulders.
If you’ve got a particular concern, like muscle spasticity or tightness in the shoulders, your provider may adjust the shot pattern to tackle that specific issue.
If Botox is working for you, there’s no known health risk associated with staying on it indefinitely, though it’s not approved for people who are pregnant or breastfeeding because of minimal studies in these groups.
Onabotulinumtoxina And The Cgrp Antagonists
With the advent of monoclonal antibodies directed against CGRP or its receptor , the landscape in chronic migraine prophylaxis has shifted. In many jurisdictions, the use of these newer therapies will also be limited by cost.
There have been no head-to-head trials between OBTA and the CGRP-As. The placebo controlled trials are not directly comparable, but in the pooled PREEMPT trial data, OBTA reduced headache hours per month by 39 h more than placebo at six months , compared, for example, to a reduction of 19 h per month more than placebo by erenumab at 3 months . OBTA was also being compared to a much larger placebo response. In the PREEMPT trials, the reduction in headache hours per month from baseline by placebo was 80, versus 55 in the erenumab study. Galcanezumab reduced headache hours per month by 23 and 18 hours more than placebo during the first three months of therapy in a chronic migraine study
Although follow up for several years of patients enrolled in an erenumab clinical trial has revealed no safety concerns , long-term safety remains an issue with the CGRP-As, as CRGP, which has many functions throughout the body, is blocked on a systemic level. In contrast, in the doses used in chronic migraine, OBTA has primarily local effects without concerns about systemic side effects.
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Botox For Migraines Side Effects:
In the clinical trials, it has been found that 26% people reported about the side-effects after completion of the first treatment, which reduced to 11% after completing the second treatment. Also, 9% pee reported that their headache worsened.
The side-effects are known to occur in the first few days after applying the injection, but they are not long-lasting.
The following side-effects can occur when a person is administered with the Botox doses for a migraine:
Getting Botox Treatment Paid For By Insurance
In general, the FDA-recommended dosage of 155 units costs between $300 to $600 for each treatment. Because Botox is FDA approved for chronic migraine, its covered by most plans, including Medicare and Medicaid. Allergan offers a Botox Savings Card, which offers patients reduced fees.
Please note that before your insurance company will approve Botox as a treatment for your chronic migraine, you typically must have tried and failed to respond to two other preventative treatments. These might include anti-seizure medications, antidepressants, or blood pressure medications that are typically used to prevent migraine.
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How Well Does Botox Work For Migraines
Botox is a preventive medication that helps to stop a migraine headache before it starts. In studies, Botox was shown to prevent on average 8 to 9 headache days a month .
Botox is approved to be used in adults to prevent chronic migraine headaches that occur on 15 or more days per month and that last for at least 4 hours. At least 8 of the headache days must be associated with migraine.
Because Botox is an injection you receive every 12 weeks, you wont have to remember to take a daily pill for migraine prevention. You can combine Botox with oral medications for acute migraine treatment to help reduce pain once a headache has already begun, if approved by your doctor.
In studies, researchers found the most common side effect when Botox was used for migraine prevention was neck pain in 9% of patients . Other side effects included headache, droopy eyelid , and muscle stiffness or weakness.
Wheres My Nearest Chronic Migraine Specialist
Finding one whos right for you could be an important step in managing your treatment.
Please note: While we update our directory regularly, this list may not have current provider information. This is a list of physicians compiled by Allergan, an AbbVie company, known to have experience with BOTOX® in the past 5 years. The results shown may not be inclusive of all physicians who may have experience with BOTOX® or therapies like BOTOX® in your area. Please see the Terms and Conditions for additional details.
If you are a healthcare provider whose practice is currently being shown on Find a BOTOX® Specialist and you would like to opt out or update your profile information, please contact AcademyHelp@Allergan.com.
If you are a healthcare provider whose practice is not currently being shown on Find a BOTOX® Specialist and you would like to be included in appropriate search results, please contact AcademyHelp@Allergan.com for more information.
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What To Expect At The Clinic
You should bring along your headache diary to the clinic appointment. You should record how many days you have migraine and headache, as well as the number of days you use a pain relief treatment.
Many people are understandably anxious about having the 31 injections on their head, neck and shoulders. However, most are surprised at how well they tolerate these very small, superficial injections. The injections are placed with a very fine needle in the forehead, temple area, back of the head, upper neck and shoulders.
The actual injections can be done in 10-15 minutes. However, before the procedure is done, your nurse or doctor will take some time to look at your headache diary, discuss your headache pattern, explain the procedure and allow you time to ask questions.
For most people the injections are done while you are sitting . The injections might be uncomfortable and sting for a few seconds, but this settles quickly.
It is best to come without make-up but the skin will be cleaned prior to the injections, to reduce the chances of infection.
How Well Botox Works
Two clinical studies have demonstrated the effectiveness of Botox injections for preventing headaches in adults with chronic migraine.
These studies looked at adults with chronic migraine. The participants received injections of Botox or a placebo . They received injections in two sets, which were given 3 months apart.
Researchers compared the number of headache days that people had at the start of the study with how many they had after 6 months of treatment. The results showed that people who received Botox averaged fewer headache days than people who received a placebo.
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Does Insurance Cover Botox Injections
Insurance does not cover Botox injections when they are used for cosmetic purposes. However, if treating a medical condition such as chronic migraines, they will often cover the expense as long as certain criteria are met.
Typical criteria are the patient must have experienced 15 headaches a month with at least 8 of those headaches being migraines for at least 3 consecutive months. Botox can produce very harmful side effects if not administered properly so it must be done by a doctor specifically trained in use for migraines.
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Current Place In Therapy
Several treatment guidelines have recognized the role that OBTA can play in chronic migraine therapy. In 2016, the American Academy of Neurology recommended that OBTA should be offered as a treatment option to patients with CM to increase the number of headache-free days and should be considered to reduce headache impact on health-related QOL . In 2018, the European Headache Federation stated in its guideline: OnabotulinumtoxinA is recommended for treatment of patients with CM and considered an effective and well tolerated treatment. Quality of evidence: high. Strength of the recommendation: strong. Even though it was acknowledged that there is evidence that shorter disease duration may lead to a better response to OBTA, it still recommended, based purely on expert opinion, that patients should have failed at least two to three other migraine prophylactics unless contraindicated .
In general, OBTA is better tolerated than the oral migraine preventive drugs. A randomized double-blind trial comparing OBTA to topiramate in patients with chronic migraine in 2009 demonstrated the superior tolerability of OBTA. In the OBTA group, 7.7% discontinued because of adverse events, compared to 24.1% in the topiramate group . In 2019, OBTA was compared with topiramate in a randomized parallel group open-label study. Only 1% of subjects in the OBTA group withdrew because of adverse events, compared to 42% in the topiramate group .
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Botox For Chronic Migraines
Botox for Chronic Migraines has been developed over the last decade, and is now defined as a successful treatment option for those suffering from fifteen or more migraine days per month. In clinical trials of Botox treatment for migraines, over 1,000 patients were studied, suffering from on average 20 migraine days per month, 18 of which were defined as moderate-to-severe headache days.
Through this randomized study, patients who received Botox injections experienced on average 8 fewer headache days per month after 6 months of continued treatment . After a full year of Botox treatment for migraines, 70% of those treated with Botox injections reported fewer than half of the migraine days per month that they initially experienced at the start of the study.
Botox treatment of chronic migraines is a proven method to provide migraine sufferers with fewer migraine attacks and many more pain-free days.
How Do I Access Botox
Botox is only available on the NHS for people with chronic migraine who have tried at least three other preventive treatments. It is currently only available via a specialist such as a headache specialist or consultant neurologist.
If you think you are eligible for Botox and would like to considered for treatment you can ask for a referral to a specialist. The specialist will assess your history and symptoms to make sure Botox is an appropriate treatment option for you. You should be asked to keep a headache diary to monitor the effectiveness of the treatment.
If Botox doesnt work for you or stops working your specialist will discuss other treatment options with you.
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Who Is Not A Good Candidate For Botox Treatment
There are some people who should not get Botox for migraine attacks or for any other reason.
You arent a good candidate for Botox if any of the following apply to you:
- known sensitivity or allergy to botulinum toxin
- signs of infection at or near the injection site
- neurological conditions that make you more prone to muscle weakness, such as amyotrophic lateral sclerosis or myasthenia gravis
- youre pregnant or breastfeeding
What You Need To Know About Migraine And Botox
Weve all heard of Botox, responsible for generations of smooth foreheads in Hollywood. But Botox has also brought relief to many people who suffer from chronic medical conditions. In 2010, Botox was approved for use with chronic migraine, and many patients are reporting success. What do you need to know before considering it?
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History Of Botulinum Toxin
The scientific history of BT began in 1820 when Justinus Kerner published a description of botulism. Professor van Ermengem at the University of Ghent isolated the causative organism in 1897 and named it Bacillus botulinum, a name later changed to Clostridium botulinum .
The clinical use of BT began when Alan Scott used it in strabismus in 1977. He obtained FDA approval in 1989 for BTA to treat strabismus, blepharospasm, and hemifacial spasm . Over 150 years had gone by from the time of Kerners observations to the clinical use of BT.
Side Effects And Warnings
Botox can produce side effects. It should always be injected by a trained professional. If your anatomy is asymmetric, or if the dose you receive is not exactly equal on your left and right sides, you may develop a slightly lopsided facial appearance for a few months until the medication starts to wear off.
Other side effects that can occur include:
- Muscle weakness
- Neck stiffness
- Neck pain or soreness
Technically, Botox is a toxin, not an infection. But some people develop an immunity to the toxin, making it ineffective. You can develop this reaction whether you are getting Botox for muscle disease, cosmetic reasons, or migraine prevention.
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How Long Does It Take For Botox To Work
Some patients may see improvements in their headache frequency in the first 4 weeks, but most patients who see improvements will notice them after the second injection at 12 weeks.
In 24-week long studies, patients continued to see reductions in their number of headache days on most days over the 24-week period. Botox also lowered the total length of time of headaches on days when they occurred over the study period, when compared to placebo.
Botox is not recommended for the preventive treatment of episodic migraine.
Summary Of Possible Side Effects:
- A temporary worsening of your migraine for some days or a migraine attack on the day of treatment. These should be treated with your usual medication.
- The skin is cleaned before the injections are done but as with all injections, infection, bleeding, tenderness, and bruising are possible where the injections are placed. This will usually be minor and last no more than a few days.
- Drooping of the eyelid or brow. It is important not to rub the areas where the injections were done for the first 24 hours. Cleaning the forehead, washing the hair, applying make-up is best avoided until the drug is fully absorbed during that first day.
- Minor changes to expression lines in the forehead are possible.
- Weakness and pain in the neck and shoulders which can last a few weeks. If this happens you should let your clinic know and they may avoid injecting those areas in future treatment sessions.
- If you have found no benefit after the second treatment, a third treatment may be given, or an alternative will be considered.
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