An interview with Dr. Craigan Griffin.

Q: Why is Botox used for treating headache?

A: The simple answer is that for many people it is a treatment that works for reducing headaches, particularly migraine headaches in people who have many disabling headaches each week.

Q: I thought botox was a toxin?

A: Botox is in fact a refined form of botulinum toxic which is the cause of botulism, a condition that can causes paralysis, which can be life threatening and usually requires hospitalization.

Q: Why would anyone want a toxin injected into their bodies?

A: Botox is like any medication, whether scientifically formulated or found in nature, where there is only value in the treatment if the potential for benefit is high and the potential risk is low.

Q: How is the risk of botox reduced enough to make it a safe treatment?

A: The key is location and dose. Botox works at the point where nerve meets muscle, blocking a certain amount of signal from the nerve to the muscle. A little bit in a specific muscle will relax that muscle. Too much will make a muscle weak. Too many weak muscles will cause problems with our ability to function, particularly if it effects activities such as walking, swallowing, or even breathing. But when the problem is too much muscle tension, relaxing the muscle a little bit can actually improve function.

Q: Has the FDA (Food and Drug Administration) approved botox for medical use in headache?

A: Originally it did for other conditions of uncontrolled muscle contraction, but not headache because there did not seem to be a consistent effect in reducing headaches. Even though the botox was carefully prepared, dosed, and administered, it needed to be proven to be helpful in treating the condition it is intended to treat. With careful experimentation, a very specific protocol was developed that safely and effectively reduced headache in people with chronic migraine headaches. Many insurances will now approve using botox as long as it is provided by a neurologist trained in the protocol for headache.

Q: Can anyone be treated with botox for headache?

A: If you have mild headaches, then a milder treatment is the right choice. If you have severe headaches, then a more aggressive treatment is needed. If you have very frequent and severe headaches, then seeing a neurologist is important for treatment that will not just treat the headache after it starts, but start a medication that will prevent the headaches from occurring. There are several medications of different types that will do this. If these common oral medications still don’t reduce the number of headaches, then it makes sense to look at other options, such as botox. The goal is to reduce the headaches from 3-5 days a week down to 3-5 headaches per month or less. If you only have 1-2 headaches a month, then there is no value in using botox.

Q: How does the risk of botox compare with other medications?

A: Medications have risk that varies with each medication, from mild side effects of dizziness or nausea, to more concerning side effects such as effects on heart, kidney and liver function. Really any medication can cause serious problems if taken improperly.

Q: What is involved with botox injections for headache?

A: The first step is to make sure there is no other cause for headache that needs to be treated, such as an infection, bleed, or tumor. Seeing a neurologist to get a history of symptoms, do a complete neurologic exam and then do imaging if needed is the first step. If the headache pattern is consistent with chronic and intractable migraine headache, then the next step is to discuss the best treatment options and try them out with proper guidance. If botox is selected as the best treatment, then insurance authorization is requested and an appointment is made for the injection. The injections include the muscles of the forehead, temple, back of the head and neck. Since some of the muscles are quite small and vital for facial movement, great care is taken with the dose and location of each injection. The protocol involves 31 injection sites, but slight adjustments are often needed to get the best response. The botox gradually wears off over 10 to 14 weeks, so the injections are usually scheduled for every 12 weeks. If there is no benefit after the second course of botox, then other types of treatment are needed. Often oral medication needs to be continued along with the botox.

Q: Apart from the type of headache, are there some people who can’t be treated with botox?

A: Yes, while they are rare there are some nerve and muscle neurologic conditions that would be worsened by using botox. This is another reason good reason to see a neurologist before deciding on treatment with botox.

Q: What are the type of side effects that you worry about with botox?

A: In general the breathing and swallowing problems that can occur with botox are more of a concern when we do injections in the muscles near the throat. Fortunately with headache treatment the closest we inject is the back of the neck. The only common side effects I have seen is occasional head heaviness and very rarely eyelid drooping. Since the botox gradually wears off, these symptoms rarely last more than 2-3 weeks and we can then adjust the dose at the next injection to avoid these problems.

Q: What is the likelihood of success in using botox for headaches?

A: In mild or tension type headaches, it is unlikely that botox will help. In more severe migraine headaches, particularly occurring 4-6 times a week, we often see a reduced intensity of the headaches. After a couple of injections we start to see a reduced frequency in the headaches, which is the primary goal, improving both function and quality of life. I have had some patient who for the first time in many years would have several weeks headache free. It is also common to see the headache become more frequent as the botox wears off.

Q: In patients who begin to have headache again at 8-10 weeks, can botox be given sooner?

A: In theory it could, but in practice we recommend not. If the botox is given too often, or if too high of dose is used, there can be atrophy of the muscles injected. In other conditions, such as cervical dystonia or limb spasticity higher doses and more frequent injections may be required because in those cases the muscles are often over-working or not working properly, so a different approach is needed. In headache, the muscles are normal and so needed to be gently treated with low doses of botox.