BOTOX Ò FOR HEADACHE 

Migraine headache and associated headaches such as muscle contraction and chronic tension headache and neck pain are all potentially relieved with the use of BOTOX Ò. This medication was originally used to treat crossed eyes and later for conditions such as blepharospasm and torticollis (twisting necks) .  More recently, BOTOX Ò was used by cosmetic surgeons to produce minor paralysis of facial muscles around the eyes and smooth out wrinkles.  Many of the patients reported significant relief of a variety of types of headaches and various trials were instituted to prove that it works for the treatment of headache. 

Headaches are extremely common in the United States with an estimate of 30 million people affected such that they miss days from work or have chronic disability. 

BOTOX Ò (Botulinum Toxin Type A) for Headache 

Botulinum Toxin Type A is a new therapeutic option for the preventive treatment of migraine and chronic tension type headache.  It offers several advantages over current drug therapy.  Injections are given in doses up to 100-300 units every three to four months.  When it is effective, the need for daily medications or acute medicines for severe attacks are significantly reduced or entirely eliminated.  There are few side effects from the injections, except for minimal discomfort at the time of injection, including a sensation of pinprick and a little burning with minor bleeding which is likened to a mosquito bite.  Rarely drooping of the eyelid can occur. On rare occasions patients get aching in injected muscles, usually just a few days. I have now performed over 3000 patient injections in more than 700 patients with an 87% improvement rate. 
 

Mechanism of Action 

It is known that Botulinum toxin (BOTOX Ò) can partially paralyze muscles.  Patients with blepharospasm and torticollis (so-called cervical dystonia) have been treated and have had significant improvement in motor activity with reduction of either the blepharospasm or the torticollis.  What has been noted is that there is often a reduction in pain that is more significant than the motor effect and the pain effect lasts longer.  It is quite likely that small fibers containing pain-producing chemicals such as Substance P are affected by Botulinum toxin.  It is also likely that there are other mechanisms, not yet understood, for the effect of Botulinum injections.  None of these theories are yet proven. 

History 

In the early 1990's,  Dr. William Binder, an Otolaryngologist who used Botulinum toxin for cosmetic purposes in the muscles around the eye noted that a number of patients reported decreases in migraine headache.  Thereafter, gradually, the number of physicians using BOTOX Ò for headache has increased.  There is significant clinical evidence now that Botulinum toxin type A (BOTOX Ò) reduces the pain in migraine, muscle contraction headache, chronic tension headache and neck muscle spasm. 

Types of Injections

Muscles about the eyes and forehead are injected with small amounts of Botulinum toxin.  In our practice, usually the muscles between the eyebrows and above the eyes are injected with approximately 4 units in each of 4-6 different injections.  Thereafter, a series of three injections are made around the outside of the eye on the side.  Then injections are made into the temporal region and sometimes the jaw where the masseter muscle is located.  These are the only injections made in patients who only experience frontal pain with their headaches. 

On the other hand, many patients have headaches that involve the entire head, down the back of the neck, into the upper shoulders.  In this situation, an additional 50-100 units are injected, 25-35 units on each side, starting at the upper back of the neck and going down onto the shoulders.  The shoulder joint is not injected.  Sometimes if the pain or muscle spasm goes down between the shoulder blades we inject those muscles as well.

 Timing of Injection and Duration of Effect 

The majority of studies and treatment patterns to date have been based on earlier experiences with blepharospasm in which patients usually need to be reinjected every three months.  However, there are some unusual patients who need to have the blepharospasm muscles about the eye injected only once every two years.  After a patient receives a Botulinum toxin injection, there may be an immediate effect just from the use of needles into muscles.  In a Scandinavian study, it was found that dry needle injections into muscles such as trigger-point areas in fibromyalgia were significantly improved even though nothing was injected for a period of up to one week.  This may be the initial effect sometimes seen in migraine patients.  This effect is the exception rather than the rule.  Usually, patients do not begin to experience relief from their headache for two to three weeks.  Thereafter, however, the effect may increase and have a duration of three to four months.  

When a second injection is performed, the effect appears to last longer--up to four to six months. We speculate, based upon our experience and that of others, that after the third injection, the effect again may last four to six months.  Of course, additional information and patient experience is needed before there is definitive proof. 

Summary 

BOTOX Ò is a new treatment for migraine.  It works in chronic muscle tension-type headache in up to 87 percent.  It also is quite effective in some patients who are not responding to any migraine preventive therapy.  Our estimate of effect in this population is 75 percent.  Overall, this is believed to be an effective treatment.  In many instances this is a less expensive alternative than chronic daily therapy or frequent use of triptan medication.  Nonetheless, BOTOX Ò does not work in every patient and alternative therapies must be kept in mind.