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Botox and Insurance – is it driving you crazy?

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On the bright side, some people are being helped by Botox treatment for migraine.  And that’s great.

But the common complaints of cost and insurance complications continue to put a wrinkle in the treatment that’s been such a media darling.

Dr. Allan Block weighed in on the topic in Clinical Neurology News yesterday, explaining how these complications have brought his affair with Botox to an end.

You can read his article, Botox no longer worth the headaches, but here’s one comment he makes:

In the last 2 years, the process of getting it approved became increasingly difficult. Insurance companies put up more and more restrictions to a point that it became near impossible to get it covered. Between the paperwork and rising costs, I had more and more patients deciding to stop.

Have you given up on Botox – or avoided it altogether – because of the cost and/or insurance restrictions?  If you’re a doctor, what have you struggled with?  Are a million insurance exceptions going to be the death of this migraine treatment?

Stop Paying for Migraine Drugs – and Take Placebos?

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A study published this month is sparking debate about whether or not we should even bother paying for common migraine medications.  Does a “fake pill” work just as well as the real thing?

Headlines such as “Migraine sufferers benefit from placebos, study shows” may be sending the wrong message.  So – migraine is all in their heads after all?  People can just “think” their headaches away?

But if you know anything at all about the science of medicine, your reaction is more likely to be – this is news?  Really?!

Placebos usually refer to treatments that are thought to be “real” but aren’t.  In this case, there’s the common migraine medication rizatriptan and a pill that contains no medicine at all.

It’s no surprise at all that placebos help with a variety of very real conditions – including many pain issues, and even conditions such as congestive heart failure.  Well designed studies control for the placebo effect.  It’s nothing new at all.

There are positive and negative effects.  The nocebo effect happens when a treatment seems to harm someone when they think that it will.

In this particular study, it was found that rizatriptan did work better than a placebo.  However, if a patient thought that a placebo was rizatriptan, they did just as well as the patient who thought the rizatriptan was a placebo.  Positive and negative impact worked together to level the playing field.

This study certainly shows us again how powerful the placebo effect can be.  It does not, however, negate hundreds of studies showing that migraine treatments are usually more beneficial than a placebo.

It should also be noted that the study covered just 6 migraine attacks per person, and so does not say a lot about long term treatment.

What we do want to do is harness the power of the placebo effect.  In spite of the fact that most people want their doctors to tell the truth, the truth is that many, many doctors actually do prescribe placebos as if they are “real” medical treatments, knowing that the ruse will often help the patient.

On the more ethical side, most doctors do speak positively about a drug that should help you.  “Expecting the best” will increase your odds, no doubt.

So although there is no scientific reason to doubt the power of real migraine medications that have been carefully researched, there is also good reason to continue investigating placebos for all kinds of medical conditions.  We may not be able to think our way to a migraine cure, but being positive can make a huge difference.

Study abstract:  Altered Placebo and Drug Labeling Changes the Outcome of Episodic Migraine Attacks

FDA Attempts to Lower Acetaminophen / Paracetamol Intake

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Concerns about liver injury are prompting regulators in the US to encourage lower doses of paracetamol / acetaminophen.  In a statement last week, the FDA in the United States suggested that doctors stop prescribing dosages above a certain limit.

FDA - new recommendations for acetaminophen

That limit is 325mg per dosage unit, meaning that in certain cases doctors could prescribe up to 650mg in two tablets or capsules.

Concerns about acetaminophen are not new.  An overdose can cause liver damage that could be serious and even fatal.

Although most of the more serious dangers are minimized when following the instructions on the label, there have still been some issues:

  • When a patient takes paracetamol / acetaminophen in more than one product at the same time, such as in a “pain killer” and a “cold medication”.
  • When a patient takes Tylenol and alcohol at the same time.
  • When patients end up taking painkillers every other day or even more.

Although the new FDA recommendations don’t solve all these problems, they do help doctors, pharmacists, and patients take a second look at exactly what they are prescribing, dispensing and taking.

Remember, read the label, talk to your doctor, and remember that taking medications (even “mild” ones) is something to take seriously.

Read the full recommendation from the FDA here:  Acetaminophen Prescription Combination Drug Products with more than 325 mg: FDA Statement – Recommendation to Discontinue Prescribing and Dispensing

The Hidden Ingredient in Your Painkillers

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Concerns about hidden ingredients in medications and supplements are not new.  But researchers at the University of Dundee and University College in London are so concerned about one particular ingredient that they’re saying the public “should be warned about the potential dangers”, and the tablets “should be prescribed with caution only if the perceived benefits outweigh the risks.”

That ingredient?  Sodium.

Yes, sodium – as in, salt.

Sodium - hidden in your painkillers?

But at such high levels that it could cause some serious risks.

When it comes to ibuprofen medications, as an example, there are already concerns about increased risk of heart disease.  Since migraine patients are already at an increased risk of heart disease, they need to be cautious about how much they take.

But it turns out that there’s another reason to be concerned particularly about those versions of these medications that are soluble or “effervescent”.  Taking the maximum dose of some of these may mean you’re over your daily limit of salt, even if you don’t eat anything else all day!  And it’s often these versions that are recommended for migraine, because they’re “fast acting”.

This particular study compared patients who had taken high-sodium versions of medications such as ibuprofen, aspirin, and acetaminophen / paracetamol with those who took the same medications, but versions that were sodium-free.

The sodium did make a significant difference.  The report in the British Medical Journal explains (emphasis mine):

Overall, the researchers found that patients taking the sodium-containing effervescent, dispersible and soluble medications had a 16% increased risk of a heart attack, stroke or vascular death compared with other patients taking the non-sodium versions of those exact medications.

Patients taking the sodium-containing drugs were also seven times more likely to develop high blood pressure and overall death rates were also 28% higher in this group.  These events are largely driven by an increased risk of hypertension and stroke.

Of course it’s no secret that patients should take these medications with caution, and not use them frequently and especially not long-term.  At least, it shouldn’t be a secret.

But researchers are encouraging doctors to watch patients closely when they feel that these medications must be prescribed.  And they’re also calling for better labelling on medications containing sodium.

As for patients, researchers have this recommendation:

It’s an avoidable risk and it’s a cardiovascular risk which is the commonest cause of death in Britain. If you take these drugs every day it would be better for your health to take the normal versions, not the soluble ones.

For more information:

Question: If someone has Allodynia, can they take Imitrex?

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The short answer is “yes”.  But, of course, you didn’t come here for a short answer, did you? 🙂

Years ago, many doctors became concerned that triptans such as Imitrex (sumatriptan) would not work as well once the patient developed allodynia.  (By the way, the allodynia here that we’re talking about is sensitivity/pain when the skin is touched – see My Hair Hurts! Migraine and Allodynia)  In fact, it was soon repeated over and over that triptans need to be taken early in a migraine attack (for example before allodynia hits) in order to be most effective.

Imitrex and allodynia

Now, taking medication earlier in the attack (as opposed to taking the same dose later in the attack) does seem to work better for a number of reasons.  Quite simply, as migraine triggers more and more severe symptoms, you can end up with a vicious circle of pain that is very hard to stop.

However, the relationship between triptans and allodynia may not be so simple.  For example, even if allodynia has already hit, if you take a triptan early in the attack it can still be effective (see Difference in Triptan Effect in Patients With Migraine and Early Allodynia)

Allodynia is something to be concerned about.  Not only can it be uncomfortable or even disabling, it may be a predictor of chronic migraine.  Plus, the frequent use of triptans can cause all kinds of problems, including medication-overuse headache.

So if someone has allodynia, can they take Imitrex?  Yes, they can, but:

  • They should talk it over with a doctor who knows their symptoms and medical history.
  • It’s possible that another medication may work better for them, especially if allodynia is a major symptom.
  • If they are taking Imitrex or another triptan several days a month or more, they need to seriously look at other treatment options.
  • As with many migraine abortives, it’s still recommended that you try to take something early in the attack rather than several hours later.  This applies whether you suffer from allodynia or not.

Take treatment seriously – it will help you avoid many more problems in future years.

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The articles on Headache and Migraine News are © 2004-2025 J. Cottrill.
Every effort is made to ensure the accuracy of each article, and to point you to further sources of information. However, this site is for informational purposes only and should never replace a visit to your doctor.