Is Botox Right For Me and My Migraine?
VVartanian on 11 Nov 2013 at 9:00am
Those who suffer from chronic migraines know that staving off headache pain is no small project. Pain prevention often involves a process of trial-and-error to settle on the right mix of medication and lifestyle change (like less stress and more sleep). And even with those things in place, there's still no guarantee that you'll be 100% headache free. Migraines are notoriously tricky to treat.
But, this is where Botox comes into the picture -- it's FDA-approved for prevention of chronic migraine and many insurance carriers cover it if other migraine meds aren't working.
So, we wanted to drill down and get a few facts straight before you submit to those 31 (albeit tiny) injections every three months. How does Botox work to prevent pain? Exactly how does it stack up against other migraine meds? And, since it's an extra added bonus -- will it do anything for the worry lines snaking across your forehead? Read on for more insight into this migraine-mitigating injectible:
How did physicians find that Botox could assist your aging (and aching) head?
A "serendipitous discovery" was made in the 1990's when LA-based cosmetic surgeon, Dr. William Binder, started noticing patients who de-wrinkled with Botox were also walking away with less headache pain. Botox was officially FDA-approved for chronic migraine (i.e., headaches that occur more than 15 days monthly) in 2010.
"Who would have thought that it turned out to be our best migraine prevention treatment with probably the least amount of side effects and the highest rate of effectiveness?" says Chicago-based headache expert Dr. Larry Robbins,"It works in about 60% of people -- which doesn't sound great, but in comparison to other headache drugs, it's twice as effective."
“After the FDA approval of Botox for chronic migraine in 2010, I went from treating three patients a year to three patients a day,” adds Dr. Emily Rubenstein Engel, Associate Director of the Dalessio Headache Center at Scripps in San Diego. “It’s really a great treatment; you could say it’s as if we’ve found The Holy Grail of headache medicine,” she says.
What is Botox and is it safe?
Botox is made from a toxin produced by a bacterium called Clostridium botulinum. It’s the same toxin that causes botulism -- a rare food borne illness that causes paralysis. The drug works by dampening signals from the nerves to the muscles – so the injected muscle relaxes and is unable to contract.
“If you had a can of peas and left it out in the heat and botulinum toxin accumulated in the can for a few days – it would be 25,000 stronger that what Botox is. It’s the same toxin – but it’s an incredibly tiny amount of the toxin. Used in low doses – it’s generally safe,” says Dr. Robbins.
But, for those that feel injecting a paralyzing toxin directly into your forehead still doesn’t sound exactly, well, risk-free... Dr. Robbins further elaborates that, “The negative side effects of Botox [a purified and diluted form of botulinum toxin A] have been extremely tiny and much lower than any of the medications that are usually used for headache.”
So, what about those side effects?
Now that we've hit highlights -- what are the downsides? Likely, it’s a bit of bleeding or bruising around the injection site. Occasionally, consequences such as droopy eyelid or other facial weakness can occur -- sometimes due to incorrectly placed injections, but this is always reversible and wears off within a couple of months.
This (fairly) spotless side effect profile also explains why five million people worldwide have used Botox for migraine in the last 16 years. Especially if you consider the slew of side effects that may occur with commonly used migraine medications -- see below for a more detailed comparison.
Says Dr. Engel, “Botox serves as a terrific preventative medication for migraines without having systemic side effects, and it’s shown to be safe. As far as has been documented, there’s never been a serious outcome from Botox in all the people who have gotten it for migraine or cosmetic use. This is reassuring in comparison to the other preventive headache meds which not infrequently, have at least minor side effects – and occasionally, severe side effects.”
Exactly how does Botox work for migraines?
Many theories abound in regards to how Botox vanquishes migraine misery -– but it’s thought the “muscle relaxing” benefit is only a minor player. The leading hypothesis is that Botox quiets down chemicals that cause inflammation and migraine pain – although researchers are still trying to pin down precisely how this works.
Says Dr. Engel, "They did an interesting study where they pre-treated with Botox on one side of the forehead – and not on the other. Then, they gave the patients capsaicin injections, a chemical extracted from peppers which can cause skin inflammation.
And, what they found was really significant — patients only got wheals (or red bumps) on the side that was not treated with Botox. This may be further proof that Botox can inhibit inflammation and the chemicals that cause pain."
What is the procedure like?
First off, you need a formal diagnosis of chronic migraine (more than 15 migraines a month) from a neurologist or headache specialist. And, if you want your insurance to cover the treatment – you have to have already tried and “failed” two to three migraine-preventing drugs like Elavil (amitriptyline), Topamax (topiramate), Inderal (propanolol) or Depakote (valproic acid).
“Failing” means that your headaches are still sidelining you on Saturdays or you can’t tolerate the medication's side effects (e.g., Topamax is causing cognitive problems, anxiety or intolerable tingling in your hands and feet).
So, an “F” on your medication scorecard means you’re a likely candidate for the FDA–approved protocol for Botox -- which is a series of 31 injections (which are speedy and might sting a little) in the forehead, temples, back of the head, neck and shoulders.
What sort of result should I expect?
Dr. Engel says it may take up to two weeks to kick in, although some patients may notice a difference after a few days. “Overall, it has a cumulative effect,” she says, “with each treatment patients do better but it tends to wear off around three months.”
And, what happens when you’re due for you next dose? “Expect to see a re-emergence of more frequent headaches,” says Dr. Engel, “It tends to be a consistent pattern where many patients get wear off before their next dosage – so some insurance companies are allowing us to reinject at 10 weeks instead of 12."
All that said, Dr. Robbins (who has injected Botox over 6,000 times in an estimated 1,600 patients) cautions that there’s a chance a patient will respond beautifully to Botox-- but then the drug will loose its steam.
“In 60% of people who respond really well to the drug— about 20% of the time the drug will stop working. So, we’ll do something else for awhile and often come back to the Botox.”
Will I see any cosmetic benefit?
Although your neurologist’s intention is not to erase evidence of sunscreen-free summers (and migraine injection sites are not chosen for aesthetic effect) – you still may see some forehead smoothing and the disappearance of those angry 11’s between your eyebrows.
Conversely, Dr. Robbins often has headache patients who do not want any hint of cosmetic effect -- “Some people do not want to look “Botoxed” or artificial in any way, so we just avoid the forehead completely,” he says.
Can I go to a plastic surgeon to get this done?
Despite the fact is nothing inherently wrong about a trained physician (i.e., a plastic surgeon) injecting Botox for headache – Robbins says, overall, it’s probably better to see a headache specialist or neurologist for your Botox and migraine management.
“Botox is really only 10% of what we deal with in treating headache patients – just because a patient is on Botox doesn’t mean they don’t need [another drug] for daily prevention of migraines. There’s also the non-medical aspect of treatment like lifestyle changes [like decreasing stress, eating healthy, getting exercise like yoga] that we talk about. It helps to see someone who deals with that all day long.”
“The expectation of Botox is not that it will make your migraines go away – but that it will decrease your headache days from twenty to two. You still need someone with experience in migraine to help you with the occasional headache and to monitor your progress,” says Dr. Engel.