In Search of a Simpler Botox Treatment

Researchers are still interested in finding the “best” or more effective way to administer Botox, or onabotulinumtoxinA. There is a typical way of administering the Botox, but research has been limited into variations.

A typical procedure for chronic migraine would be 31 injections in 7 areas. But a study published last month in The Journal of Headache and Pain is opening the door to other options, and to a different understanding of how Botox works.

Muscles in the faceThe study included 63 patients with chronic migraine. The injections on the face and trapezius muscles used a “follow-the-pain” approach, with a fixed number of injections per muscle. The total Botox used was less than would be used in the more “traditional” treatment (in quotes, because all of this is still pretty new).

65.1% of patients experienced at least a 50% reduction in headache days. For over 70% of those, the improvement was greater – a 70% or greater reduction in headache days. Most patients were happy with the treatment.

That’s a significant improvement. Not only does this open up possibilities for a simpler treatment, it also raises questions about how the treatment works.

The researchers favoured “myofascial” sites of pain. If you’re familiar with myofascial trigger points, that’s what we’re talking about here. It could be that those trigger points play a role in migraine becoming chronic, and also in relieving chronic migraine.

A significant use of Botox is a mission to seek-out what areas of your face and neck are most related to migraine, or other types of headache. Research needs to continue to give us more information, and better treatment.

Read the study abstract here: OnabotulinumtoxinA injections in chronic migraine, targeted to sites of pericranial myofascial pain

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New Drug-free Device for Migraine Tested

A unique new device used to fight migraine is being tested, with promising results. The device is based on a common technique used for diagnosing certain brain problems; a technique which is increasingly being investigated for its therapeutic value.

The technique, known for this purpose as caloric vestibular stimulation (CVS), is also used as a test known as the caloric reflex test. This is used to test the vestibular system, using warm and cool air or water in the ear canal.

Caloric Vestibular Stimulation Device

A Caloric Vestibular Stimulation Device


It has been discovered that this test can actually provide some relief from certain conditions, particularly post-stroke conditions. Stroke is, of course, related to migraine, and often manifests similar symptoms. Could a CSV device actually decrease “migraine days”?

In this clinical trial, the answer was “yes”.

This trial was for patients with episodic migraine, averaging about seven or eight “migraine days” per month. Patients used the device themselves for 20 minutes per day over 3 months.

The device has aluminum earpieces inside padded headphones, which are controlled using a hand-held device. The earpieces deliver warm and cool currents to the ear canal.

Those using the actual CVS devices (there was a placebo group as well) experienced a significant drop in migraine days – 3.8 days per month. That’s almost down to half the migraine days per month. Patients also reported using less medication.

The researchers concluded:

The results from this randomized, double-blinded, placebo-controlled trial demonstrate that CVS treatment with a novel solid-state device significantly reduces the number of migraine days per month as well as the subjective headache pain scores and the need for migraine abortive prescription medications. Treatment can be administered in the home-setting with no technical expertise and modest training. Subjects demonstrated high rates of treatment adherence and also reported subjectively positive experiences with using the device. Together, these results indicate that CVS therapy addresses the existing need for new prophylactic therapies for episodic migraine. This approach appears to be both efficacious and very well tolerated, and further clinical testing is warranted. A second, expanded study is now underway. [source]

That second study is now recruiting participants (if you’re in the US or UK, you may be able to be a part of the study).

Study abstract: Preventing Episodic Migraine With Caloric Vestibular Stimulation: A Randomized Controlled Trial

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Adult and Pediatric Neurology Residents: Apply for this Training!

Adult and pediatric neurology residents in the USA in their first and second year can apply for this year’s American Headache Society Resident Education Program. The training will take place October 6-8 2017, but you only have 10 days to apply! All applications must be received no later than Friday, August 4th.

AHS Resident Education Program

This is a great opportunity to get a foundation in headache medicine that you will not get in your normal training. Apart from the formal sessions, you will have more informal times with headache experts, which will allow you to discuss cutting edge ideas and new treatments, as well as tested strategies for treating headache and migraine.

To apply, you must have a letter of support from your Program Director. But if you are accepted into the program, it will work like a scholarship. Your travel expenses will be paid for (the training will take place in Los Angeles), as well as food and accommodation. On top of the training, you will also get a complimentary one-year trainee membership to the American Headache Society.

More details about the program are here: AHS Resident Education Program. For more information on what you need to apply, see the American Headache Society Resident Education Program Application.

But remember, the application along with all supporting documents must be submitted no later than August 4th! Don’t miss this opportunity!

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10 Headache and Migraine News Highlights from the past 3 Months (July 2017 edition)

Hi everyone! It looks like our Facebook problem is resolved, although it’s taking a while for everyone to remember we’re here. 🙂

So, if you’ve missed some recent posts, here’s your chance to see what’s been most popular with visitors to this site. The most popular post is first. Also, the three posts in bold received the most “likes” on Facebook.

You can help remind people about the information that’s here – share a post that you think is useful!

Also, continue reading below the list for some important reminders…

  1. New Migraine Medication Ready to Apply to the FDA for Release
  2. Migraines and Blue Light – Or Maybe Green Light…
  3. The Low Tyramine Diet for Migraine – Is it time to rethink it?
  4. Back to Sleep: Simple Lifestyle Changes to Fight Chronic Migraine
  5. Pulsed Shortwave (Electromagnetic) Therapy For Headache Pain
  6. New Device Approved by FDA to Fight Cluster Headache (video)
  7. Restless at Night? More Links to Migraine…
  8. Migraine because your Weight isn’t “Normal”?
  9. Warning Signs of Migraine in Children
  10. More Positive Results from the CGRP Migraine Treatments

Thanks for reading! Here are some important reminders. First, if you check the right sidebar on the Headache and Migraine News site, you’ll see a button you can press to ask your questions. This is a new experiment – so ask now and I’ll try to answer some of your questions here in the future.

Secondly, the fantastic Migraine Summit library is still available. For more information, whether you have already invested in this resource or not, see Get the Most out of Your Migraine Summit Library.

Finally, we have a new poll! Check out the right sidebar here and be heard!

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Could Stress Levels Predict Migraine Attacks?

A study published this month in the journal Headache is suggesting that daily stress could actually predict migraine attacks. Could this be a valid way to predict and even avoid migraine attacks?

The relationship between stress factors and headache and/or migraine is well known. However, concern has been expressed (by myself and others) about the way that this relationship is expressed and used in actual migraine treatment.

Could stress predict migraine?The study is Forecasting Individual Headache Attacks Using Perceived Stress (abstract), based on over four and a half years of information from 95 migraine patients. The patients filled out a daily “stress diary” known as the Daily Stress Inventory (DSI). The DSI is designed especially to measure the common daily stressors we all face.

The study authors, who have studied the link between stress and chronic headache before, believe that stress “let-down” is a major factor when it comes to headache and migraine. In other words, they believe that when you have a lot of stress, after that stress is gone you may experience a “let-down” migraine attack.

The authors were generally encouraged by the results, indeed seeing a connection between stress (or, more accurately, stress let-down) and migraine symptoms.

The authors also point out the benefit of being able to predict a migraine attack – the ability to stop an attack before it starts with treatment.

Up to this point, there would be few people who would disagree. Yes, migraine attacks and stress are related. Yes, being able to predict an attack is very valuable.

However . . .

But bear with me. Headlines such as “Today’s Stress Level Predicts Tomorrow’s Migraine Risk” are going to give you quite a false impression of this study and its implications.

First, the authors admit that this is only the first step in an attempt to create a good predictive model (“The stress model in this analysis should be viewed as representing a first step in the new venture of forecasting headache attacks and not a final model for widespread clinical use.”). In other words, no, they have not created a model that will always or even mostly predict an attack. In fact, they found about a 25% success rate in predicting attacks. This is, as they say, “better than chance”. In other words, it’s significant, it shows a connection, but having a 1 in 4 chance of being right is not a great model of prediction. (They use the illustration of a weather forecast – to say that it will rain tomorrow, and being right only 25% of the time, is not very useful!)

Second, there are a number of reasons why stresses one day could lead to a migraine attack the next day. For example:

  • Did the stressful events cause you to lose sleep? In that case, did the stress trigger the attack, or did the lack of sleep?
  • Had the migraine attack actually already started? If there were early non-headache symptoms, such as irritability or fatigue the day before, that could lead to stress. But the stress would actually be a result of the migraine attack, not a cause.
  • There are a lot of things that can cause stress. Did a lack of sleep lead to stressful situations in the first place? Are you always stressed when you’re at that weekly meeting – when you also drink too much coffee? Does the commute mean not only stress, but missing that healthy mid-day meal? In other words, there are hundreds of factors that could be involved, beyond just stress.

For every stress-let-down headache, we’re also seeing a let-down day with no headache. Why is that?

This is not so much a criticism of the study, but a caution against how we interpret it. This study does not show that stress is the cause of migraine attacks, or even the sole trigger. In fact, in most cases, it may not be a trigger at all.

Why is this important? Let’s use a simplistic example. Emily finds that weekly meeting very stressful. It usually causes her to be late to lunch, and she drinks too much coffee during the meeting.

She has migraine attacks, and the doctor blames it on stress. Sure, she could skip the meeting (could that have career consequences?). It might help. But what if she could just drink one less coffee, and bring a healthy snack?

Do not believe the idea that stress=migraine attacks. Many people with very stressful lives have no more headaches than the rest of us.

Besides, we have a lot less control over stress than we do over other things – bringing along that healthy snack, getting to bed at a regular time, exercising regularly, and getting good migraine treatment. In fact, a life without stress would not be very good for you.

Of course this is a complex issue. But again, taking a complex issue and over-simplifying it by saying,”Migraines? It’s just stress.” is not helpful for the patient.

Studies like this are helpful as we continue to try to understand the physiology of migraine. But let’s not be fooled by the headlines.

The full study is available here: Forecasting Individual Headache Attacks Using Perceived Stress

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