Botox against migraine

Botox as a migraine drug

Prevent migraine with Botox

The “wrinkle killer” Botox as a migraine medication: What may sound amazing to some is reality, at least for chronic migraine. Botulinum toxin, which is well known in this field, has long been used not only for cosmetic purposes, but also to treat various neurological conditions. These initially included spasms and dystonias, from whose pharmacological research cosmetic Botox originally emerged as a “chance find.” And for more than ten years, migraine has been one of them. This is because Botox was officially approved for migraine back in 2011. More precisely: approved for the treatment of chronic migraine. In this article I would like to explain the therapy with Botox against migraine in more detail.

These are the topics:

When Botox is used as a migraine medication, it is injected into the back of the head and neck, next to the forehead and temples.
Relieve migraine headaches or reduce their occurrence

Prevent migraine with Botox

For Botox to work against migraines and effectively reduce headaches, preventive treatment is needed. In the case of an acute attack, it is too late. This is because the toxin needs a few days to take effect. With success, the attacks occur less often or the migraine headaches are not as severe. Ideally, both are achieved and Botox relieves migraines in terms of both frequency and intensity.

Remedy for migraine headache

Botox, as mentioned at the beginning, has been approved as a therapy for chronic migraine since 2011. Before that, there was no drug for the specific prophylaxis of chronic migraine. Only the drug topiramate was considered for this purpose. However, its effect is limited in chronic migraine. In addition, severe side effects are possible, including central nervous disorders.

Since the end of 2018, the monoclonal antibody “ Erenumab ” has been available, which is intended to reduce the frequency of attacks. Unlike Botox, the active ingredient, also known as the “migraine shot” or by its trade name “Aimovig,” specifically attacks the CGRP receptor which is centrally involved in migraine.

CGRP is a neurotransmitter that is released in increased amounts during migraine. In studies, erenumab had a comparable effect to Botox in migraine. However, because erenumab is the first agent to directly block the CGRP receptor, the long-term consequences of such a blockade are still uncertain. In this respect, this is an advantage of Botox, which is considered to be thoroughly researched.

In addition to the above-mentioned therapies for prophylaxis, there are, of course, the well-known drugs for the acute treatment of migraine, especially triptans and ergotamines, which are not the subject of this article. Given the failure of both Botox and other agents in episodic migraine, they represent an important treatment option for sufferers.

Botox only for chronic migraine

Unfortunately, Botox only works for chronic migraines. And only in the case of chronic course there is a prospect of getting the costs for Botox against migraine reimbursed by the health insurance. Chronic migraine is when headaches occur for more than 3 months on at least 15 days per month.

Chronic migraine affects about 1-2% of the population. It is associated with much greater impairment of quality of life compared to episodic migraine. In my practice, several patients have Botox injections for their migraines, although they are not reimbursed by the insurance companies. But the gain in quality of life is worth it to them.

Migraine prophylaxis for several months

How well does Botox work against migraine?

Unclear how Botox attenuates migraines

In most cases I see in my practice, Botox can improve migraines both by frequency of occurrence and severity of attacks. Exactly how Botox reduces migraines, however, is unclear in detail. A direct, pain-inhibiting effect of Botox has not yet been demonstrated in animals or humans.

However, the lack of knowledge also comes from the fact that it is not yet known exactly how migraine actually develops. In the past, it was believed that the attacks originated from a malfunction of the blood vessels in the brain. The vessels would constrict and the brain would be undersupplied as a result. And that would cause the headaches.

According to this theory, Botox relieves migraines by relaxing muscles, as in wrinkle therapy. This would relieve the pressure on the vessels and migraine attacks would become less frequent. So much for the theory. However, this is now considered to be disproved.

Does Botox relieve migraines by inhibiting neurotransmitters?

Today, it is more likely that migraine is triggered by overactivity of nerve cells in the brainstem. This overactivity causes important nerves in the face to send pain impulses to the brain. Messenger substances play an important role in this process, transmitting signals between the cells. And that could be the very lever that Botox uses to reduce migraines. This is because Botox has long been known to inhibit the release of neurotransmitters. The best-known such messenger is acetylcholine . Botox prevents the release of acetylcholine and thus interrupts the transmission of stimuli between nerves and muscles. Studies indicate that Botox inhibits other neurotransmitters besides acetylcholine. Some of them are involved in pain stimulation, including. Glutamate , Substance P , CGRP and neurokinin A . Inhibition of these neurotransmitters is thought to reduce pain sensitivity. And that could be the mechanism by which Botox is able to relieve migraines. But it is not proven. Thus, it is still not clear how exactly Botox works against migraine.

Relief already after the first treatment

If the migraine responds to Botox, then the effect occurs after the first treatment. And then increases with further treatments. Studies on the efficacy of Botox for migraine show a steady reduction in headaches with repeated therapy. In this study, half of the patients showed a 50% reduction in days with attacks after the first treatment. After a second and third treatment, the percentage of patients increased from 50% to 60%. Another study also showed steady improvement in patients who were injected with Botox for migraine every 3 months for 2 years. From the 2nd year onwards, a flattening out usually follows and the effect does not improve further.

Reduction of attacks and pain by one third

These studies also demonstrated that even patients who continued to experience frequent migraines despite Botox nonetheless experienced relief. Because of the Botox, headaches were not as bad as before. In practice, the aim of Botox for migraine is therefore to reduce either the frequency of attacks or the intensity of headaches. And best of all, of course, both. In both cases, the reduction by one third is usually taken as a measure of therapeutic success.

Termination if no success after third treatment

If none of these goals can be achieved in a patient after the third treatment at the latest, then Botox will foreseeably not be able to relieve migraine and the therapy should be terminated. At this point, the treatment has usually already cost over 2,000 euros, and further injections of Botox seem pointless. Simply because of the high cost of Botox for migraine, I then advise patients against further attempts. In addition, of course, there are the many injections and the associated risks, which should not be accepted if success is unlikely.

Multiple Botox injections needed for migraines

How does the treatment proceed?

Every successful treatment begins with a detailed consultation. Also and especially with Botox for migraine. Because there are a number of contraindications that must be excluded. Possible side effects must also be addressed. This is because Botox is injected in relatively high doses for migraine, which can be unpleasant in individual cases. Short-term nausea and headaches are possible, also dizziness.

From an aesthetic point of view, Botox injections into the forehead, as provided for migraine, can cause drooping eyebrows (a so-called “brow ptosis”). I do try to prevent this with my patients. But it cannot be ruled out completely. Brow ptosis can affect the appearance quite significantly and can also be psychologically stressful.

And finally: Botox is not always successful against migraine. It is therefore important to bring the patient’s expectations down to a realistic level so that he or she does not experience a possible therapy failure as too bitter a disappointment.

Cost of Botox for migraine

The cost of treatment must also be discussed. Even the minimal protocol for migraine, in which 155 units of Botox are injected, costs around €600 (guideline) per session. With an initial frequency of one treatment per quarter, the costs quickly add up to €2,000. And since costs for Botox against migraine are only reimbursed by health insurance if conventional therapies were demonstrably unsuccessful, patients often have to bear them themselves. It is essential to make this clear in advance.

Migraine medication and Botox

Furthermore, it must be clarified whether another medication for migraine is being taken in addition to Botox. If the existing medication helps at least partially, then it can be maintained for the time being. After successful first or second treatment with Botox, discontinuation should then be considered. In such cases, it is recommended to continue the medication with the same dose during the treatment in order to assess the effect of Botox against migraine in isolation.

Dosage and injection regimen of Botox for migraine

Once all these questions have been answered satisfactorily, then nothing stands in the way of the actual therapy. The dosage of the toxin per treatment is between 155 and 195 so-called “Allergan units” (AE). The first treatment is carried out regularly with 155 AU, distributed over the following 4 zones and 31 injection points:

Botox against migraine – injection scheme
(forehead, 7 points)
Botox against migraine – injection scheme
(lateral right, 4 points)
Botox against migraine – injection scheme
(lateral left, 4 points)
Botox against migraine – injection scheme
(Back of the head and neck, 16 points)

If there is no success after the initial treatment with this dose, the dose is increased to 195 AU in a second session. The additional units of Botox are then injected into the zones where the patient is most violently plagued by migraines.

What should be considered with Botox as a migraine medication?

Risks and side effects

Side effects

Common side effects of Botox for migraines include neck pain, headache, nausea, and dizziness. All symptoms are short-lived and usually pass after 1-2 days. Short-term redness occurs at the injection sites, which disappears within a few minutes. Small hematomas are possible if the needle pierces a blood vessel. They usually pass after 2-3 days.

Due to the rather high dose injected into the forehead, eyebrows may droop(ptosis). I try to avoid this in my patients by selecting the injection sites specifically depending on the musculature and, as a first step, possibly also setting the dose lower than intended.

Contraindications

There are some contraindications to Botox that need to be considered. These include:

Neuromuscular transmission diseases, such as myasthenia gravis and Lambert-Eaton syndrome.

The presence of dysphagia or chronic respiratory distress.

Acute infections and inflammations

Taking medications that affect muscular transmission and certain antibiotics(amynoglycoside antibiotics, spectinomycin).

Hypersensitivity to one of the components of the Botox preparation used.

Pregnancy and lactation

Prices of Botox treatment for migraine (guidelines)

How much does Botox for migraine cost?

The cost of a treatment with Botox against migraine according to the standard scheme (155 Allergan units) in my practice in Munich is about 620 € as a guideline. The large regimen of 195 units, according to which Botox is injected against migraine when the standard regimen does not produce the desired effect, incurs costs of around €820 (guideline value). Please note that individual billing is always done according to the German Medical Fee Schedule (GOÄ) and may deviate from the stated guideline values.

In order for the health insurance to cover the costs of Botox for migraine, a chronic migraine according to the criteria outlined in the text above must be present in any case. Furthermore, therapy with conventional drugs, such as metoprolol, flunarizine, or topiramate must have been previously attempted without success. Unsuccessful means that either the desired effect was not achieved or the drug was not tolerated. I recommend that my patients check with their health insurance company in advance to see if the costs will be covered.

Attractive at every age

LIPS and SKIN Aesthetic Medicine

Eva Maria Strobl, MD
Herzog-Heinrich-Strasse 34
80336 Munich