Neurology and Neurosurgery


J. Ned Pruitt, MD

It is estimated that approximately 45 million Americans suffer from migraines. For many of these patients the migraines are managed with both preventative medications as well as acute medications when the migraines occur. Even then, many times a month a migraine causes one to two days or more of disability with each migraine event. For some patients migraines are so frequent that 15 to 25 days of each month are spent battling a migraine. Certainly, this disability is no less severe than other forms of disability and may last as long as 25 to 30 years. Most people with chronic migraines begin with episodic migraines. These patients may start out with just a few headaches and migraines each month. For some individuals the frequency and severity of their headaches and migraines gets worse over time. Many factors may influence this change in frequency including pregnancy, birth control, weight gain, stress and other health conditions such as hypertension. As the migraines become more frequent and there is less and less recovery time in between migraine attacks, an individual may go from a few headache days a month to one every few days. Eventually, he or she gets to the point where he or she has15 or more headache days a month. With each headache lasting 4 hours or more and 8 of those days associated with migraine, this, by definition, is a Chronic Migraine. Botox should be considered as a potential additional preventative medication for these patients with chronic migraine and experiencing more than 15 headache days per month. Chronic migraine sufferers have often been to many physicians and been on many different daily medications in an effort to decrease the number of migraines. In these cases, Botox can be a very helpful addition to management. A headache specialist should be able to sort through past and current medications for migraine management and determine the best preventative as well as acute migraine therapies.

Botulinum toxin or Botox was given FDA approval in 2010 for patients suffering from chronic migraine when these migraines are occurring more than 15 days per month. Botox can be used with other forms of preventative medications such as propranolol, amitriptyline, and topiramate. Botox can also be used in addition to standard medications for the acute treatment of a migraine attack such as sumatriptan (Imitrex), riztriptan (Maxalt) and zolmatriptan (Zomig) to name just a few. Botox was approved by the FDA because of its ability to lower the number of migraine days per month by approximately one third in patients who suffered from chronic migraine. Therefore, a patient suffering from 21 to 25 migraine headache days per month might expect a decrease in the number of migraine days to 14 to 18 days per month. Botox will not treat acute migraines and Botox will not stop migraines from occurring. Botox does not seem to be helpful in patients suffering from migraines less than 14 days per month.

Botox treatments occur every 12 weeks. During this time frame, patients keep close records of their migraine frequency with a headache calendar. This allows not only tracking of the number of migraines but will often help reveal patterns and triggers that aid in management. Patients often see a significant reduction in headache days after the first treatment. Some patients start to feel results as early as four weeks. Over the course of two treatment sessions, patients should notice a reduction in headache days. However, patients may not see a full effect on migraines until after their third series of Botox injections.

Botox injections are done using a standard FDA approved protocol, which includes small doses of the medication into superficial muscles of the forehead, bilateral temporal areas, upper cervical paraspinal and trapezius muscles (Figures 1-4). These injections are done with a fine needle and the procedure itself can take less than 15 minutes to accomplish. Because the injections are quite superficial, systemic side effects of the medication are extremely rare. However, occasionally after the forehead injections, patients may experience a temporary drooping of the eyelid and in very rare cases a temporary period of double vision. The most common adverse reactions reported by patients being treated for chronic migraine have been neck pain and headache. Although Botox therapy for chronic migraines involves specific injections in the forehead, temples, and upper neck, the effects of the botulinum toxin may spread from the area of injection to other areas of the body, causing symptoms similar to those of botulism poisoning. These symptoms can include swallowing and breathing problems. The FDA says it knows of no confirmed cases of the spread of the toxin when Botox has been used at the recommended dose to treat a variety of symptoms. These include chronic migraines, severe underarm sweating, or conditions such as blepharospasm, an involuntary muscle spasm in the muscles surrounding the eyes.