Botox | Headache NewsBlog

Neck weakness and tension-type headaches

By: Dr. Mauskop

13-05-2015

Tension headaches can be prevented, or at least made milder by strength training, according to a new Danish study just published in the journal of the International Headache Society, Cephalalgia.

Tension-type headache is the most common type of headaches and it is usually accompanied by increased muscle tenderness.

The researchers compared muscle strength in neck and shoulder muscles in 60 patients with tension-type headaches and 30 healthy controls, using rigorous strength measurement techniques. Patients were included if they had tension-type headaches on more than 8 days per month and had no more than 3 migraines a month. Compared to controls headache patients had significantly weaker muscle strength in neck extension, which helps keep the head straight. Headache patients also showed a tendency toward significantly lower muscle strength in shoulder muscles. Among the 60 headache patients, 25 had frequent headaches and 35 had chronic tension-type headaches (defined as occurring on 15 or more days each month).

The use of computers, laptops, tablets, and smart phones has increased in recent years and this may increase the time people are sitting with a forward leaning head posture, which contributes to neck muscle weakness.

Neck pain and tenderness is a common symptom in both tension-type and migraine headache sufferers.

This is not the first study to show that muscle strength and weakness were associated with tension-type headaches, but it is still not clear whether the muscle weakness is the cause or the effect of headaches. Neck and shoulder strengthening exercises have been shown to reduce neck pain in previous studies and in my experience strengthening neck muscles will often relieve not only tension-type headaches, but also migraines. So it is most likely that there is not a clear cause-and-effect relationship, but a vicious cycle of neck pain causing headaches and headaches causing worsening of neck pain and neck muscle weakness.

Physical therapy can help, but the mainstay of treatment is strengthening neck exercises. Here is a YouTube video showing how to do them. The exercise takes less than a minute, but needs to be repeated many times throughout the day (10 or more). Many people have difficulty remembering to do them, so using your cell phone alarm can help. Other treatment measures include being aware of your posture when sitting in front of a computer or when using your smart phone, wearing a head set if you spend long periods of time on the phone, doing yoga or other upper body exercises, in addition to the isometrics.

Sometimes pain medications or muscle relaxants are necessary, while for very severe pain, nerve blocks and trigger point injections can help. Persistent neck pain can respond to Botox injections. When treating chronic migraines with Botox, the standard protocol includes injections of neck and shoulder/upper back muscles. Here is a video of a typical Botox treatment procedure for chronic migraines.

New research on how Botox relieves chronic migraines and how to predict who will respond to Botox

By: Dr. Mauskop

09-05-2015

Botox, Migraine

While Botox (OnabotulinumtoxinA) has been shown to be effective in treating chronic migraines, its exact mechanism of action is not clear. Initially, we thought that it works by relaxing muscles in the forehead, temples and the back of the head and neck. However, this is not likely for several reasons. One reason is that some people have pain at the top of their heads, where there are no muscle, and injecting those areas leads relief of pain. Another reason is that Botox seems to be effective in relieving different nerve pains, such as that of shingles (post-herpetic neuralgia), trigeminal neuralgia, and other.

Botox blocks the release of acetylcholine, a neurotrasmitter that is normally released into the space between the nerve ending and the muscle (synapse), making the muscle contract. We also know that Botox blocks the release of other neurotransmitters, which may be responsible for its pain-relieving properties. One of these chemical messengers is CGRP (calcitonin gene-related peptide).

A study just published in the journal Pain by Spanish researchers showed that CGRP level is increased in blood of patients with chronic migraine even when they are not having a migraine attack. CGRP levels were determined in 83 patients with chronic migraines (average age 44 years; 94% females) before and 1 month after treatment with 155 to 195 units of Botox. CGRP levels after Botox treatment were significantly lower as compared with CGRP levels obtained before Botox treatment. Pretreatment CGRP levels in responders were significantly higher than those seen in nonresponders. One month after treatment, the CGRP levels did not change in nonresponders, but significantly decreased in responders. Demographic factors, clinical features, and comorbidities (co-existing medical conditions) were not different in responders as compared with those of nonresponders. The authors concluded that “These results confirmed that CGRP levels can be of help in predicting the response to Botox and suggest that the mechanism of action of Botox in chronic migraine is the reversal of sensitization as a result of the inhibition of CGRP release.”

Unfortunately, the test to measure CGRP levels is not yet available outside research laboratories and because this was a small study we do not know how accurate this test will be. It has to tells us with greater than 90% which migraine sufferer will respond. If it is less than 90% accurate, we’d be denying over 10% of patients a very effective and often life-altering treatment. Some studies also suggested that we can predict who will respond and who will not by the description of pain. That is, if the pain is squeezing, crushing from outside in, or involves the eye, then the chances of response are better than if the pain is exploding, or from inside out. The accuracy of this predictor is less than 70%, so it should not be used to screen for potential non-responders.

Video of Botox injections for chronic migraine with TMJ

By: Dr. Mauskop

01-05-2015

Botox, injections, Migraine, TMJ

The FDA-approved protocol for Botox injections for chronic migraines calls for 31 injections with 155 units of Botox. This is the protocol we teach young doctors and new injectors.

However, just like with any other medication, doctors are allowed to go “off label”, meaning that we can inject Botox for headache types and pain conditions other than chronic migraine (in which case insurance will usually not pay) and we can also adjust the number of injection sites and the total dose of Botox when treating patients with chronic migraines. I have a fair number of patients who need up to 200 units and on a very rare occasion even 300. The maximum dose allowed during a single treatment is 400 units, which is usually needed when injecting large muscles in arms and legs, like in cerebral palsy or spasticity due to strokes.

This YouTube video shows injections for chronic migraines with additional injections into the masseter muscles (at the corner of the jaw) to treat TMJ syndrome, which is also called temporomandibular disorder. Injections of the temporalis muscles in the temples, which are also involved in chewing and which are always injected for chronic migraines, also helps relieve TMJ syndrome.

Don’t take migraine drugs Depakote and Topamax when pregnant

By: Dr. Mauskop

10-02-2015

Alternative Therapies, Botox, Headache medications

Epilepsy drugs Depakote and Topamax are two of only four drugs approved by the FDA for the prevention of episodic migraines (the other two are blood pressure medications in the beta blocker family, propranolol and timolol, while Botox is the only drug approved for the preventive treatment of chronic migraines). However, these two drugs are contraindicated in pregnancy. Considering that the majority of migraine sufferers are young women, this is a topic that needs to be revisited regularly, especially when additional data appears.

A new study just published in the journal Neurology followed children in the British National Health Service whose mothers suffered from epilepsy and who were taking Depakote (valproate) or Tegretol (Carbamazepine) or Lamictal (lamotrigine). Only Depakote caused a significant drop in IQ in children whose mother was taking more than 800 mg of Depakote a day. Children whose mother took less than 800 mg (the usual dose for migraines is 500 mg, but sometimes 1,000 mg is needed) did not have a lower IQ, but had impaired verbal abilities and a 6-fold increase in needing educational intervention.

Unfortunately, Tegretol and Lamictal are not effective for the prevention of migraine headaches, while Topamax which is effective, can cause birth defects. Neurontin (gabapentin) is a relatively benign medication, which is safe in pregnancy and it is somewhat effective in the prevention of migraines, including chronic migraines.

Ideally, all drugs should be avoided in pregnancy. We usually advise non-drug approaches, including regular sleep, healthy diet, exercise, biofeedback or meditation, and magnesium supplementation. If this is insufficient, we usually recommend Botox if migraines remain frequent (they often improve in pregnancy). Botox is not approved for use in pregnant women, but considering that it acts locally on nerve endings with very little of it getting into the blood stream, it is most likely safer than any drug that is ingested.

Bell’s palsy (facial paralysis) is twice as common in migraine sufferers

By: Dr. Mauskop

29-12-2014

Botox, Brain disorders, Science of Migraine

A report by Taiwanese doctors just published in the journal Neurology suggests that having migraine headaches may double the risk of Bell’s palsy.

Several medical conditions, such as asthma, anxiety, depression, irritable bowel syndrome, epilepsy, and other occur with higher frequency in migraineurs, but until now, no one suspected an association between migraines and Bell’s palsy.

The researchers compared two groups of 136,704 people aged 18 years and older – one group with migraine and the other without. They followed these two groups for an average of 3 years.

During that time, 671 people in the migraine group and 365 of the non-migraine group developed Bell’s palsy.

This association persisted even after other factors such as sex, high blood pressure, and diabetes were taken into account.

The authors speculated that the inflammation and the blood vessel problems seen in both conditions may explain this association.

This study appears to be of purely academic interest since we do not know how to prevent Bell’s palsy. However, I decided to write about it because a couple of my colleagues (one in our office and at least one other on a doctors’ discussion board) reported seeing Bell’s palsy soon after administering Botox injections for chronic migraines. This report by Taiwanese doctors suggests that Bell’s palsy might have been not due to Botox, but rather a coincidence since Bell’s palsy is more common in migraine sufferers.

Treating chronic migraines with Botox is cost-effective

By: Dr. Mauskop

22-12-2014

Botox, New treatments

Cost is the only major issue with Botox injections, which is the only FDA-approved treatment for chronic migraines and which is now covered by almost all insurance companies. It is very safe and highly effective, relieving headaches in 70% of migraine sufferers. A study just published in the journal Headache suggests that Botox may be not only clinically effective, but also cost-effective.

Researchers from the Renown Neurosciences Institute in Reno, Nevada analyzed data from 230 chronic migraine sufferers who did not respond to two or more prophylactic drugs and were given Botox injections. Botox was given twice, three months apart. Compared with the 6 months before Botox, there were 55% fewer emergency room visits, 59% fewer urgent care visits, and 57% fewer admissions to the hospital. In those 6 months the savings amounted to half of the cost of Botox treatments. Considering that improvement tends to get more pronounced with each subsequent Botox treatment, it is very likely that the costs savings would grow with additional treatments.

Obviously, besides saving money, Botox provides a significant improvement in the quality of people’s lives, which is much harder to measure. At our Center we give Botox to more than a quarter of our patients and see a dramatic improvement in the majority. Botox is not only much more effective for chronic migraines, but it is also much safer than any oral medication.

Botox relieves new daily persistent headaches.

By: Dr. Mauskop

15-08-2014

Botox, Chronic migraine, Headaches

A report from the Cleveland Clinic and Case Western Reserve describes 22 patients with new daily persistent headaches (NDPH) who were treated with Botox injections.

NDPH is a condition in which the headache begins suddenly without an obvious trigger and persists continuously without a break. Because NDPH is relatively uncommon, there have been no large studies of this condition. Patients with NDPH usually do not exhibit symptoms of migraine, such as throbbing pain, nausea, sensitivity to light, noise or physical activity. Because of its sudden onset, we suspect that these headaches may be the result of a viral or another type of infection. There are no treatments that consistently relieve these headaches, but we usually try all of the drugs and approaches we use in migraines.

A group of doctors from Cleveland, Ohio discovered that while Botox seems to help, only 32% of patients with NDPH showed improvement, confirming the refractory nature of this type of headaches. Twenty one of the 22 patients underwent more than one treatment with Botox and most were given a standard migraine treatment protocol with 155 units injected into 31 sites. The improvement was modest but it did result in headache-free days, which were not observed prior to this treatment. The disability improved slightly and when the improvement did occur, it lasted about 8 weeks. Some of our chronic migraine patients also require Botox injections every 8 to 10 weeks, instead of the usual 12. Considering that we do not have any better treatments, Botox should be offered to patients with NDPH.

Botox helps post-traumatic headaches.

By: Dr. Mauskop

04-08-2014

Botox, Headaches

Botox is FDA-approved only for chronic migraine headaches, however, it is being used “off-label” for other types of headaches as well. We find that frequent episodic migraines, cluster headaches, numular, and cervicogenic (neck-related) headaches improve with Botox. In our practice, post-traumatic headaches also seem to respond to Botox.

A report by neurologists from Stony Brook University describes five patients suffering from post-traumatic headaches, who responded to Botox. These patients sustained a traumatic brain injury and had suffered from post-traumatic headaches for years, despite trials of various prophylactic medications. After treatment with Botox, all of their five patients had greater than 50% improvement of their disability as measured by the MIDAS (MIgraine Disability Assessment Scale) questionnaire.

This is not a surprising observation because in many patients with a traumatic brain injury headaches have migraine features, suggesting similar underlying mechanisms. People with a family history of migraines who sustain a head injury seem to be more likely to develop post-traumatic headaches than those without such family history, which also suggests a link with migraines. Some patients with post-traumatic headaches and especially those with overt whiplash injury (almost all head injuries, to a varying degree, involve a whiplash neck injury) may respond to Botox because Botox relaxes tight muscles. We no longer think that this is the reason Botox helps migraines because there is evidence that in migraines Botox works by blocking sensory nerve endings rather than by relaxing muscles.

Because of the cost, insurance companies are often unwilling to pay for Botox to treat anything but chronic migraines. However, headaches that begin after a head injury and are accompanied by some migraine features can be correctly classified as post-traumatic chronic migraines, thus avoiding difficulties with the insurance companies.

Predicting response to Botox in chronic migraine.

By: Dr. Mauskop

08-07-2014

Botox, Chronic migraine, New treatments

Botox is a very effective treatment for chronic migraines and possibly other types of headaches and pain. However, Botox is an expensive and somewhat unpleasant treatment. Even though Botox helps a high percentage of patients (about 70%) it would be useful if we could predict who is going to respond and who is not.

One of the predictors seems to be the directionality of pain. That is, if patients with migraine who have constricting (imploding) pain or pain localized to the eye seem to respond better than those who have pain that seems to be pushing from inside out (exploding). This is not a very reliable predictor because some people have difficulty categorizing their pain in that way and because even if they do describe it clearly one way or another, this predictor is far from 100% accurate.

In a study just published in the journal Headache a group of Spanish neurologists claim that they have found a predictor with 95% accuracy. They measured blood levels of calcitonin gene-related peptide (CGRP) and found that those with levels of CGRP above a certain number were 28 times more likely to respond to Botox than those with levels below that level.

CGRP has been shown to be very involved in the process of migraine and several drugs and antibodies which block the CGRP receptor appear to be very promising (see my recent blog post on such antibodies). So, it is not very surprising that this correlation between the response to Botox and blood level of CGRP was found. However, this finding needs to be confirmed in a larger group of patients (this study involved 81 patients) and this test needs to become available commercially since now it can be done only in research laboratories.