Botox to Conquer Headaches
A Medical Breakthrough For Migraine Sufferers
By Slavina Gardella, M.D.
A Case Study: Christina

It is a busy afternoon in the office. The waiting area is crowded - patients sitting, reading quietly. The overhead call breaks the monotonous humming - my assistant Ana alerts me that there is an emergency for me. I walk briskly towards the exam room, open the door and there is my emergency. Her name is Christina, a young slim girl curled in a fetal position on the exam table, eyes closed, her hands pressing tensely on her temples. She is fighting a bad headache, the same headache that brought her to my office three times this month. Ana hands me the Imitrex injection; I inject the medication into her arm, and a few minutes later she slowly opens her eyes, her face visibly relieved. She sits up, finally able to talk. She turns to me with a host of questions:

"Do I have a brain tumor?"

"What is it that hurts?"

"Why does it hurt so much?"

"What triggers it?"

Christina does not have a brain tumor; her earlier MRT of the brain unequivocally proved so. Like a million others, she has a migraine headache - the second most common headache.

Demystifying the Migraine

Where exactly is the pain stemming from? It is not the brain or the skull that hurt. A widespread network of nerve endings in the muscles and the blood vessels is the culprit. Tensed muscles of the skull pressure the nerves; distended blood vessels irritate the nerve endings in the stretched walls. The result: a headache.

What are the causes? Much about the intricate mechanism of the headache is not understood, but certainly both genetic and environmental factors play roles. More to the point is the question, what are the triggers? The list is long and varies from patient to patient. Keeping a headache diary helps the migraneurs to identify their individual triggers. Well known ones include the following:

1. Hormonal changes in women - Commonly the worst migraine headaches occur around the time of a woman's menstrual period. Oral contraceptives may worsen the headache; conversely, some women find the "pill" beneficial. The same inconsistency applies to pregnancy and menopause stages of life, which are marked by significant hormonal fluctuations. While for the majority of women, pregnancy provides protection against their usual headaches, some may experience an exacerbation of them. Similarly, menopause may drastically reduce or conversely increase the occurrences of headaches; also at times menopause causes a transformation of the migraine headache into a different type of headache.

2. Stress is arguably the most common trigger factor. It is also the most difficult to control.

3. Food and drink - Numerous foods may aggravate the migraine headache: alcohol, especially red wine; beer; aged cheeses; overuse of caffeine (coffee, tea, soda, chocolate - all of them rich in caffeine); MSG, the key ingredient in some Asian foods; processed foods; salty foods; sweets; soy products; fava beans; hard sausages, smoked fish; aspartame (Nutrasweet, Equal).

4. Weather changes, especially fluctuations of barometric pressure, temperature, or humidity are well-recognized triggers.

5. Sensory stimuli such as bright light, sun glare, sounds, or unusual smells including pleasant scents or unpleasant odors.

6. Missing sleep or getting too much sleep.

7. Intense physical exertion.

Migraineurs are not created equal. Not all of them respond to the same triggers, while a trigger may not always induce a headache in the same patient. The interval between exposure to a trigger and the onset of a headache varies widely from hours to two days.

How do I know that my headache is a migraine, not a sinus headache?

Sinusitis rarely causes headaches in adults. It is uniformly associated with nasal discharge and fever. It ostensibly lacks symptoms such as nausea, vomiting, light, or loud sound sensitivity; also, there is no family history of headache.

If one gets what one thinks is a sinus headache it is imperative to be evaluated by a neurologist. Most commonly it turns out to be a different type of headache.


How do I know that my headache is a migraine and not a sinus headache?

Again, recurrent headaches require a visit to the neurologist's office. Based on a carefully obtained history and a focused neurological examination, the specialist will determine what kind of headache this is and will recommend further testing, the most frequent test being the MRI. This imaging test produces a very clear picture of the brain without the use of radiation. It will positively answer the question so frequently asked by headache sufferers
How do I treat my headache?

There are two approaches:

1. Abortive treatment - Its goal is to stop the migraine attack once it starts. To assure effectiveness, the medication should be taken early in the course of the headache. The most effective and specific anti-migraine medications are the ones of the Triptan family (Imitrex, Axert, Relpax, Frova, etc.). They can be combined with NSAID (Advil, Motrin, etc.) to augment their potency. Anti-nausea drugs may be needed as well.

2. Prophylactic treatment - The ambitious but attainable aim of this approach is to prevent the headache from occurring or significantly reduce the frequency and intensity of the attacks. To achieve this, a combination of medications, life style changes, relaxation techniques, and Botox treatments, can be employed.

Several groups of medicines, such as antidepressants, anticonvulsants, and calcium channel blockers, prescribed as a regular daily regimen, are recommended. Unfortunately, the pharmacotherapy of headaches is limited in its efficacy and has a potential for systemic side effects. Some supplements such as Magnesium, CoQ, and Vitamin B2 may play a role in lessening the pain and decreasing the frequency of the headaches.

Identifying and avoiding the triggers, reducing stress, implementing biofeedback and relaxation techniques (such as alternating contracting and relaxing muscles through the body), and acupuncture, have been proposed as adjunctive therapies and may prove helpful.

Lately, Botox has gained significant popularity. Like so many other success stories in the history of medicine, the discovery that Botox can be beneficial for the treatment of headaches happened serendipitously. It was observed that people using Botox for treatment of facial lines experienced marked improvement in their headaches, which lasted three to four months, the usual life span of the Botox. The intellectual curiosity of the scientists was fired up and numerous clinical studies were initiated, conducted, and completed. They confirmed the empiric observations. The current agreement is that Botox relaxes the muscles and prevents the release of chemicals from the muscles that may trigger the pain, thus preventing the attacks.

The procedure entails an injection in several sites, usually determined according to patients symptoms. The forehead and the temples are the standard sites. Since it is not uncommon for neck spasms to contribute to migraines and other types of headaches, muscles of the neck may also be injected. The needle used in the procedure is so fine that there is a minimal discomfort associated with the administration of the treatment. It only takes a few minutes.

Improvement is expected within one week. The really good news is that the effect lasts for three months. Subsequent treatment frequently prolongs the duration and enhances the effectiveness. The side effects are very infrequent, mild, and short lived. Cost may be a consideration, although many insurance companies authorize Botox when used for medical conditions.

Botox is the preferred treatment for many patients with migraines and tension-type headaches due to its high efficacy and low side-effect profile, especially in comparison to the other pharmeco therapies.

I look at Christina's face, her bright eyes smile trustingly at me. She says, "I am happy we've had this talk. We have a plan now."

"We do, Christina." I smile reassuringly back at her. It is the beginning of a partnership.