Botox and Headache Prevention

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Many of my headache patients ask if Botox would help their headaches. This newsletter will focus on Botox and its role in headache prevention. A patient testimonial will be included. I hope this newsletter will help you decide if Botox makes sense for you.

What is Botox?
Botox is Botulinum Toxin Type A. It is a neurotoxin used for greater than 20 years and is currently FDA approved for eye muscle conditions such as strabismus and blepharospasm and for a neck problem called cervical dystonia. The mechanism of action for these conditions is related to the muscle relaxing properties of Botox. It is not yet FDA approved for migraine or headache prevention; however recent clinical trials show promising results. Two recently completed clinical trials were done exploring the use of Botox for adults suffering from “chronic migraine”, i.e. headaches and/or migraine occurring on 15 or more days/month. The results of these 2 studies showed a decrease in the number of headache and migraine days. Additionally, the quality of life in patients receiving Botox in the studies improved significantly compared to patients receiving placebo injections.

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How is Botox injected for headache prevention?
Typically 100 units of Botox are injected in multiple sites over the forehead; around the eyes; the temples; the back of the neck and the upper back. The Botox comes in a 100 unit vial and I mix it with a saline solution prior to injection, yielding a concentration of 2.5 units per .1 cc. Then, I fill 5 small syringes, each containing 20 units of Botox. Very small 30 gauge needles are attached to the syringes and then the Botox is injected. There are certain fixed sites and amounts that I use for every headache patient and these include the forehead; the eye and the temples. The fixed sites require 65 units of Botox. With the remaining 35 units, I can “follow the pain” of where my patients experience most of their pain relative to their headaches and tailor the remaining Botox injections accordingly.

The vial of Botox is mixed fresh for each injection visit. There is no “sharing” of Botox with other patients. Each patient pays for and receives the equivalent of 1 full vial of Botox (100 units). Studies indicate that larger amounts (100-300 units) are required for headache prevention in contrast to cosmetic uses of Botox which often require much less quantity.

What are the risks of Botox injection?
The risks are minimal and include bruising, swelling and pain at the site of injection. There is a very slight risk of eyelid dropping which is reversible. An ice pack is applied prior to the forehead and facial injections which can lessen injection pain and prevent bruising and swelling.

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How soon does it work?
From my experience, many patients feel almost immediate relief from the muscle tenderness part of their headaches, including the forehead, neck and upper back areas. This is due to the muscle relaxing characteristics of Botox. However, true migraine prevention results are not often evident for 2 weeks. The accepted theory on why Botox works to prevent migraine is that it prevents the release of some of the inflammatory agents that cause migraine such as CGRP and substance P.

How long does it last?
Most patients experience 12-14 weeks of benefit after Botox injection. Many comment they can tell when it starts wearing off by an increase in headache.

What is the cost?
Currently we charge a total of $825.00 for Botox injection. This fee includes 1 full vial of Botox (100 units); all related supplies such as needles and syringes; and the procedure cost. The time for the procedure is 30 minutes. In most cases, you can return to work after your injection.

Our policy is to offer insurance billing for Botox; however, we cannot guarantee it will be covered since it is not FDA-approved for headache prevention and is considered “experimental” and “off-label” by most insurance companies.

Patient Testimonial (a quote from one of Dr. Hutchinson’s patients)
“I am really pleased with the results! I felt a “softening” of the muscle tension in my forehead and the back of my neck right away and that has continued over the past week. As you indicated, it appears that the injections take some time to fully work. My forehead today feels better than it did over the weekend, and my shoulders and neck have not been as tense either. I am very satisfied with the results and feel that Botox can be another “weapon” in my arsenal to prevent migraines.”

How do I know if I am a good candidate for Botox for headache prevention?
If you are currently frustrated with your headaches, then Botox is a strong consideration. It is especially helpful, in my opinion, for those patients who have a muscle tension component to their headache, e.g. a lot of forehead/scalp or neck muscle tightness and tenderness. Also, based on the recent studies by Allergan (the maker of Botox), those with more frequent headaches, especially more than 15 days/month, would be good candidates for Botox injection for headache prevention.

Please call our office 949-861-8717 and set up an office visit to evaluate whether you would be a good candidate for Botox. I will review your current headache management as well as the pattern of your headaches and give you my opinion. If Botox makes sense, it can be ordered and the injections given 1-2 weeks later.

Susan Hutchinson, MD Director-Orange County Migraine & Headache Center