20 Sep 2013

Botox is famous for its cosmetic use by some doctors to reduce wrinkles.  Some observant doctors noticed that patients with chronic migraine headaches that received cosmetic Botox treatments had improvement in their headache symptoms.  Studies were done, showing that Botox does indeed reduce the frequency of migraine headaches.  In 2010, the FDA approved the use of Botox for chronic migraine headaches.  If effective, it is shown that repeating it every 3 months leads to greater improvement over time.  I have much experience in the use of Botox in the treatment of pain, especially for chronic migraine.  I find that it is often more effective than conventional headache medications, and with fewer side effects.

Candidates for Botox Migraine Therapy

I start every headache evaluation with a careful history and physical exam to rule out other causes of headache.  Some cases of “migraine” turn out to be different types of headaches, like tension or cluster headaches.  Other headaches can involve nerves like the Greater Occipital Nerve that radiate to the head, or even referred pain from the neck.  Overuse of medication, paradoxically, can also cause headaches that are similar to migraines.

Migraine headaches tend to have at least 2 of the following characteristics:

  • Headache on one side of the head
  • Headaches that feel like they are pulsating
  • Moderate or severe headache severity
  • Headaches that are worse with physical activity

And at least one of the following associated symptoms:

  • nausea or vomiting
  • sensitivity to light or sound

 Insurance Coverage for Botox

As a proven and established therapy for chronic migraine headaches, Medicare and insurance companies will pay for Botox treatments.  However, because of the cost, they will often require that other treatments have been tried first.  I find that many patients with chronic migraine headaches have already tried these medications at some point and already qualify.  If not, I can make recommendations about these other treatments as well.

How Does Botox Prevent Migraines?

The short answer is that we are not sure.  This is not uncommon in medicine: general anesthetic vapors were discovered in the early 1800’s and we still don’t know how they work!  It is believed that the Botox is transported by nerves from the head and face into the central nervous system, where it has its therapeutic effect.  The wrinkle-smoothing is a secondary effect and not related to the migraine treatment.

How is the Botox Injected?

The injection procedure is similar to that used for cosmetic Botox.  Using a very small needle, I carefully identify target muscles of the forehead, head, and neck, and inject very small amounts of medicine.  Taking my time to assure that it is done precisely, the procedure still only takes between 5 and 10 minutes.

How Much Improvement Can I Expect?

The effectiveness varies from person to person.  Two large studies have been published looking at Botox for chronic migraine treatment compared to placebo.  In these studies, 44-51% of participants reported that the number of days in a month with migraine headaches decreased by at least half.  The studies also found that the number of headaches per month continued to decrease month after month for at least a year.  In my experience, patients tend to report that headaches are less frequent, occur less often, and resolve more quickly.  Some patients respond very well, with reductions in headaches from every single day to zero or one headaches per month.

Is Botox Safe?

Botox is indeed a purified form of the botulinum toxin.  For medical use, incredibly small amounts are used for this reason.  When used correctly, serious side effects are rare.  More common are temporary increases in head or neck pain, or weakness of the neck or eyelids.  These reactions are rarely severe and resolve with time.


About Leo Lombardo, M.D.

Leo Lombardo, M.D. is a dual-board-certified pain physician and founder of Ventura Pain and Spine Physicians, a medical practice serving Ventura, Oxnard, Camarillo, and all of Ventura County.


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