1	BOTOX for Headache November 24, 2002
2	Purpose of Training Background Information Injection Technique Reimbursement Info Add to On-Line Database of “Injectors”
3	History
4	Some Published Uses of BOTOX^® Achalasia Blepharospasm Cervical Dystonia Essential Tremor Headache & Migraine Hemifacial Spasm Hyperhydrosis Myofascial Pain Occupational Dystonia Pain (muscle spasm) Spasmodic Dystonia Strabismus Spasticity Cerebral Palsy Multiple Sclerosis Stroke Traumatic Brain Injury Wrinkles
5	The Neuromuscular Junction
6	Botulinum Toxin Type A Mechanism of Action: Current Hypothesis
7	Botulinum Toxin Type A Mechanism Current Hypothesis
8	“NeuroCosmesis”
9	Serendipitous Discovery of Botulinum Toxin Type A for Treatment of Migraine Dr. William Binder, in 1992, injected botulinum toxin type A into patients’ foreheads to treat wrinkles Several months later, patients reported a lessening of migraine symptoms First correlation between use of botulinum toxin and reduction in headache severity
10	OBJECTIVES Where to Get Information BOTOX Therapy in 2002 Keys to SUCCESS !
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12	BOTOX Webpage
13	Patient Information
14	Reimbursement Page
15	Website for Botox Info http://imigraine.net/newrx/botox.shtml
16	Goals of Prevention: Criteria of Success Decrease frequency and intensity of headache Improve function and decrease disability Reduce use of other headache medications Increase efficacy of acute headache medications
17	Botulinum Toxin Type A: Hypothesis of Action Muscle Alpha motorneuron inhibition Gamma motorneuron inhibition Ia afferent reduction Nociceptors/pain pathway C and A delta fibers (group III and IV) Mechano- and chemonociceptors Substance P, CGRP, glutamate release
18	PREVENTIVE THERAPY BOTOX
19	Index Case: Botox RX Patient on Morphine q 3 hours Unemployed Continuous posterior headache Huge golf-ball sized muscle mass Tender
20	Index Case: Botox RX
21	Index Case: Botox RX
22	Index Case: Botox RX Patient now virtually without HA Employed No narcotics Neck mass-muscle spasm gone Injections q 3-4 months Third injection date: 10/20/2000
23	Frontal Headaches: Botox RX
24	Frontal Headaches: Botox RX
25	Frontal Headaches: Botox RX
26	BOTOX Technical Notes 2 cc Dilution Pressure over injection site Angle injection on forehead Perpendicular on neck muscles
27	Headaches: Botox RX 2 cc dilution & #30 needle
28	Botox®: Technical Notes 2 CC saline for dilution 20 G 2” needle to draw up toxin Change needle 30 G ½ inch needle Skin prep with isopropyl alcohol Swab stick for minor bleeding Finger pressure on all injections sites
29	Temporal Headaches
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31	Temporal Headaches Obicularis for “Crows Feet”
32	Temporal Headaches Avoid Veins
33	Temporal Headaches Press or Damp Minor Bleeding
34	Posterior Headaches: Botox RX
35	Posterior Headaches: Botox RX
36	BOTOX^® Injection Sites (Troost 2002); “no fixed site” Front: Mean total dose = 30 + 20 U Temporalis
37	BOTOX^® Injection Sites (Troost, 2002); site of pain Posterior: Mean Total Dose = 70 U + 30
38	Our Best Result: Botox®
39	Our Best Result: Botox®
40	Our Best Result: Botox®
41	Our Best Result: Botox®
42	Our Best Result: Botox®
43	The Scientific Basis of Migraine & Other Matters
44	Vanderbilt Cases Visiting Professor October 2000 Three patients with CDH injected October 27, 2000 2 of 3 without headache – Case 3: chronic encephalitis ? cause
45	Vanderbilt Patient 36 y.o housewife and caterer Moderate daily headache with Severe migraine episodes superimposed Two – three/week, multiple meds Incomplete relief with Triptans – had to cancel out on catering jobs
46	Vanderbilt Case Patient injected with 140 Units Injection date Oct 27, 2000
47	30 Units Frontalis and Temporalis
48	35 Units each trapezius
49	Additional 40 units in Rhomboids
50	The Trigger Point Manual
51	Anatomy of the Rhomboids
52	Results: Vanderbilt Patient 36 y.o. housewife and caterer injected Friday October 27, 2000 Back felt better that afternoon (“dry needle” or “acupuncture” effect) Severe Headache Tuesday in bed all day
53	Results: Vanderbilt Patient Continued No headaches since! No Medication Had menstrual cycle and no headache! First time in years Catered party for 68. No headache Next: follow and reinjection, 3 months
54	Post-traumatic: Nail-in-the Eye Headache 37 yo business woman Auto accident October 1998 Momentary unconsciousness Rupture of breast implants No prior headache history Severe unresponsive headaches since
55	Nail-in-the Eye Headache
56	Post-traumatic Headache Headache Types: (1) Sharp Nail stabbing into L eye (2) Left occipital pressure to L eye -> vomiting (3) Lancinating Deep L jaw pain cycling over eight hours (4) L anterior neck pain twisting neck R
57	Post-traumatic Headache Additional Complaints: Off balance – generally dizzy Depression Sharp focal pains at base of neck Muffled popping sensation in ear
58	Post-traumatic Headache Prior Treatments Five epidurals Non-steroidals Calcium channel blockers Beta-blockers Anti-depressants Physical therapy
59	Post-traumatic Headache Current Meds Paxil 20-40mg /day Elavil 25 mg/d Neurontin 1500 mg/d Zomig prn Compazine prn
60	Post-Traumatic Headache Patient Patient injected with 160 units Injection date November 1, 2000
61	10 Units Frontalis, 30 Units Left Temporalis
62	35 Units each trapezius
63	Additional 40 units in Rhomboids
64	Results: Post Traumatic Headache Patient Dramatic improvement starting 3 weeks post injection. Neck and facial pains disappeared Balance improved Lower back pain persists Reinjections April 5, July 2001, Nov 2001, February 2002 No pain meds
65	November 2001
66	If at first…… 72 y.o male with chronic daily headaches for 10 years Left temporal location Negative Temporal artery biopsy No medication helps – latest failure: Topamax Negative work-up
67	If at first…… Headaches described as 8/10 Gradually increasing throughout day Examination normal Hot shower at 3:00 AM “takes my mind off it” 3 Tylenol / week Requests BOTOX
68	If at first……
69	If at first… you don’t succeed TRY AGAIN!
70	Measures of Preventive Drug Efficacy Verbal reports, patient diaries Frequency Intensity Headache Impact Questionnaire Migraine Disability Assessment (MIDAS) score
71	More Keys to Success that will differentiate YOU From many other physicians
72	History & Physical Examination
73	Historical BOTOX^® Injection Paradigms for Headache Fixed Site Injection sites pre-determined, same for everyone in study Follow the Pain Injections given into regions where patients report pain or tenderness
74	The KEY Not Fixed site Not “Follow the Pain” Individualized Examination Find the MUSCLE SPASM Combined Approach
75	Patient Care Considerations Avoid the orbit Ptosis Avoid periosteum Potentially painful Palpate for superficial temporal vessels Avoid intra-arterial injection
76	Principles: BOTOX Individualized Palpate muscle spasm ( “trigger point “ ) Gravity effect Onset of benefit 2-4 weeks Increased duration with repeat
77	Injection Site: Trapezius
78	Cross section: Neck Muscles
79	Palpation / Injection Technique
80	Levator Scapulae
81	Palpation of Levator Scapulae
82	Injection of Levator Scapulae
83	Palpate the neck and shoulders
84	Our Technique: BOTOX November, 2002 Individualized; large men take MORE History and Physical Separate Visit Frontal HA Only: 30-60 Units Posterior HA Only: 70-100 Units Front and Back: 100-160 Units Upper back injections 40-60Units
85	Rating Scale
86	Our Experience: BOTOX Intractable headache 1457 Patient Injections (as of 11/24/02) 471 Patients Frontal Headache : 75% better CDH: Posterior-Neck HA: 87% better Side Effects, minor bleeding, rare burning, aching sensation
87	Results: Chronic Migraine
88	Summary Botulinum toxin type A is a new, well-tolerated therapy Evidence is beginning to support the use of botulinum toxin type A in the overall management of patients with headache
89	Conclusions: BOTOX Safe Effective No Side Effects Better for posterior headaches Consider as first line therapy for Chronic Migraine
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91	Questions ?
92	Bye