Botox for Migraine Headaches or Tension Headaches

Since the 1990s, there have been increasing literature that documents the efficacy of botulinum toxin type A (Botox) for the treatment of a variety of pain states including migraine and tension type headaches. Even though Botox is most well-known for causing a muscle paralysis by preventing the release of acetylcholine from nerve endings resulting in wrinkle reduction and resolution of muscle spasticity (blepharospasm, spasmodic dysphonia, etc), it also reduces the release of a variety of pain neuropeptides as well as blocking the feedback loop transmission of pain sensation.

For tension type headaches where persistently chronic muscle contraction contributes to the headache, a partial paralysis of the muscle in the region of the pain does much to alleviate the headache.

Not All Migraine Headaches Respond Equally Well to Botox!

Certain migraine headache types respond better than others. For those whose headaches are described as imploding (vise-like, squeezing, crushing, etc) have a much higher response rate to Botox injections (>80%) than those headaches described as exploding in nature (15%). Headaches due to muscle spasms (especially in the neck region) respond well to Botox too as well as most types of tension headaches.

However, headaches in certain areas do not respond well to botox including top of head (upper side, upper back, and very top), temple, cheeks, between eyes, and behind ear.

Areas that do generally respond well to botox injections include forehead, neck, and in front of ears.

The temple areas have mixed results (some patients respond well, whereas others do not).

Where and How are the Injections Performed?

Generally speaking, the injections are performed not only in the distribution of one's headaches on one side, but also on the opposite side even if there is no pain (fixed-site strategy). Why? Well, experience has shown that injecting only on the side where the headaches are located will result in the appearance of migraine headaches on the opposite side. Injecting both sides prevents this switch from happening.

There are 4 general regions that are injected: glabellar (right above and between the eyebrows), forehead, temples, and upper neck. Each region requires anywhere from 4 - 5 injections on average to as many as 10 injections with each injection containing 2.5 - 5.0 Units of Botox. Most patients require injections to more than one region.

After injection, there is a SLOW reduction in the severity and frequency of migraine headache attacks resulting in decreased need for medications (if at all) over time. As such, it may be up to 2 months before the benefit of Botox may be realized by the patient. Repeat injections are required every 3-4 months to maintain the benefits as Botox wears off by than. Although the maximum benefits occur when used prophylactically (treatment to prevent future attacks), it can also be used in the acute setting, though not as successfully.

Click here to read the consent you will be asked to sign before every injection session.

Who Qualifies for Botox Injections?

Contraindications... You are NOT a candidate if you suffer from:

Neuromuscular Disorders (ie, Myasthenia Gravis)
Myopathic Disorders (ie, amyotrophic lateral sclerosis)
Pregnant

If you have none of the contraindications, the next steps to take are:

Full neurologic workup by a neurologist required (please have your neurologist fax a summary report to us)
Failure or minimal responsiveness or unacceptable side effects with standard migraine headache medications as prescribed by your neurologist OR
Financially speaking, cheaper to obtain Botox injections than continue with medications. See next section regarding this.

Does Insurance Cover Botox Injections for Headaches?

Unfortunately, very few insurance companies cover Botox for headaches in spite of the extensive literature that supports its use. As such, in our office, we will require pre-payment before treatment. One can than submit the receipt to your insurance company for reimbursement if possible.

HOWEVER, if headaches are triggered by muscle spasms, most insurance companies will cover Botox injections for these spasms. Determination of whether these spasms are present or not is done by your neurologist.

Financial Assistance

Reimbursement assistance for those who are uninsured or otherwise unable to afford BOTOX can be found here (http://www.botoxpatientassistance.com). Or call 1-800-44-BOTOX, option 6. The form you will be required to complete can be downloaded here.

If migraine headaches are affecting your quality of life, please contact our office for an appointment with Dr. Chang.

References

Botulinum toxin type A (BOTOX) for treatment of migraine headaches: An open-label study. Otolaryngology—Head & Neck Surgery. 123(6):669-676, 2000. Link
Treatment of migraine headache with botulinum toxin type A. Facial Plast Surg Clin N Am. 11(4):465-475, 2003. Link
Procedures for administering botulinum toxin type A for migraine and tension-type headache. Headache. 43(8):884-891. Link
Exploding vs. imploding headache in migraine prophylaxis with Botulinum Toxin A. Pain. 125(3):286-295. Link

Any information provided on this Web site should not be considered medical advice or a substitute for a consultation with a physician. If you have a medical problem, contact your local physician for diagnosis and treatment. Advertisements present are clearly labelled and in no way support the website or influence the contents.

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