Botox

28 November 2013

Unusual Botox Treatment For Cluster Headache

This is Botox treatment like you’ve never seen before, and it could help patients with cluster headaches fight back.

Using Botox (botulinum toxin) for cluster isn’t new. Injections have been given to patients with varying success (take this study as an example).

But a unique treatment using Botox, if successful, could change the way we treat cluster in significant ways.

How it Works

Erling Tronvik and Dr. Daniel Bratbak at the Norwegian University of Science and Technology (NTNU) have developed a system designed to deliver botulinum toxin directly to the sphenopalatine ganglion, a bundle of nerve cells behind the nose. And the treatment doesn’t require surgery.

A press release from the NTNU explains:

The gear they have developed looks a pistol with a very thin barrel, just the thickness of a knitting needle. The barrel is inserted up through the nose of the patient, and by passing through a natural hole in the nasal wall, the mouth of the barrel comes to a bundle of nerves behind the sinuses.

The surgeon pulls the trigger of the pistol, which shoots a dose of Botox to the area around the nerve bundle. The whole process takes about a half-an-hour.

Could this non-surgical procedure actually fight cluster more directly and provide significant relief? And if it does, could it help patients with other types of headache as well?

Will it work?

This treatment is brand new, and patients are still being recruited for a trial. So we have to speculate – could it work?

The sphenopalatine ganglion has been a target for cluster research for a long time, because it is an important playing in a cluster attack. It’s also important in other types of chronic pain. Similar treatments are being used, such as the SphenoCath.

Although some patients have found relief through surgical treatments directed at the nerve cluster, these types of treatments haven’t yet found widespread acceptance.

It is true that Botox seems to impact pain messages sent through nerves. Could a more direct approach work better than traditional injections?

It doesn’t seem like Tronvik and Bratbak are sure, and it’s unclear why they have chosen this approach.

Dr. Alexander Mauskop from the New York Headache Clinic expressed his skepticism earlier this month, concluding,”Until we have some evidence that this treatment works we have to work with the standard approaches to cluster headaches, which include, occipital nerve blocks, oxygen, a course of steroid medications, sumatriptan (imitrex) injections, verapamil, lithium, and other drugs.“

As with any new treatment, we simply have to sit and wait. But we always hope that a new and unique treatment may help cluster headache patients, who suffer from one of the most intense pain disorders in existence.

6 November 2013

Migraine – Botox – And Funny Eyebrows

James Medications, Tips, Treatments 6

Have you ever wondered why some people who have had Botox (botulinum toxin A) treatment have strange looking eyebrows?

It’s called the Mephisto Sign, or perhaps Mr. Spock Eyebrows. Basically, one or both eyebrows arch, making the patient look – surprised, all the time. And they probably are.

This is a possible problem for migraine patients when they receive injections in the forehead. What happens is, the frontalis muscle of the forehead becomes hyperactive, causing the eyebrows to arch. You can see an example of the Mephisto sign from Botox here.

Fortunately, even if this happens it can usually be fixed. Another injection to the lateral-most point (the outer part) of the frontalis muscles should fix the problem, although you may still be waiting a few days.

Although a pretty minor problem compared to chronic migraine pain, the Mephisto sign can be a pretty annoying problem, as well as a dead giveaway that someone has had Botox treatment, for whatever reason.

It’s just another reminder that you need to make sure you’re going to a specialist experienced in Botox (or Dysport or Xeomin) migraine treatment. Make sure they keep a careful record of exactly where you have been injected each time. And do return to them if you have any problems with your treatment, including eyebrows that won’t behave.

Here’s some more information about How to be Safe with Botox (10 tips).

Also see A proposal to prevent the “mephisto sign” side effect of botulinum toxin type a injection in chronic migraine.

27 March 2013

How to be Safe with Botox (10 tips)

James Tips, Treatments 12

Although many people are injected with Botox (onabotulinumtoxinA) (botulinum toxin type A) and they never have any significant problems, there have been cases of severe health issues.

Only receive injections from a professional trained and experienced in using Botox for migraine. Many problems can be solved simply by visiting someone who knows what they’re doing.
Be sure the doctor knows your medical history. This includes your experience with migraine, any previous Botox treatments, previous surgeries, any medications you take (including sleeping pills, allergy medication, blood thinners, antibiotics and muscle relaxants) etc.
If you have infection, muscle weakness, or inflammation where you’re going to be injected – wait for another day.
Tell your doctor if you have experienced any side effects from a previous treatment.
Check the ingredients – if you have an allergy to any ingredients in the injections, don’t have the treatment.
Do not start any new medications without telling your doctor that you’ve had Botox treatments in the past.
After the treatment, tell your doctor immediately if you’re experiencing any of these side effects: itching or rashes, trouble breathing, trouble swallowing, drooping eyelids or drainage from your eyes, vision problems (double vision or blurred vision), heart problems or chest pain, muscle weakness or paralysis, loss of bladder control, trouble talking or hoarse voice. Note that some of these symptoms could appear several weeks after your treatment.
If you are pregnant, trying to get pregnant, or breastfeeding, discuss the risks with your doctor.
Be aware that Botox could cause migraine-related symptoms. These include headache, fatigue, anxiety, and pain in other parts of the body. Hopefully you won’t experience these symptoms. However, do discuss the pros and cons with an experienced doctor before starting treatment.
Botox should not be the first treatment you try for chronic migraine. Look at other options first – not only medications, but also non-drug treatments. If your doctor recommends Botox treatment when you’ve first been diagnosed, get suspicious and seek a second opinion

Please remember that these are not reasons why no one should ever try a Botox treatment. As with just about any treatment for migraine, there are pros and cons. Being aware of them helps you to have the safest and best options without making things worse.

For more, read about Botox headache injections here.
See what Allergan (the makers of Botox) has to say about Botox safety

13 October 2012

Botox: Benefits vs Cost vs Other Treatments

James Treatments 0

We’ve talked more than once about the complexities of using Botox for the treatment of chronic migraine disease. Whether or not Botox (onabotulinumtoxinA) will be helpful seems to depend on many factors – how experienced is the doctor? Where is Botox being injected? How often? And, of course, even if everything else is equal, every patient is still very different.

(Also see Botox for Migraine â€“ how does it actually work?)

Neurologist Dr. Stuart B. Black, member of the International Headache Society and founding member and director of the Dallas Headache Clinic, recently wrote about Botox. His article reminds us how much things have changed and how far we have to go.

Here are some of the challenges that he mentions (with some addition thoughts of my own):

The Cost: One treatment alone is $1,300-$1,500 in the United States. Worse, some doctors are charging significantly more than that.
Complete Treatment: Botox works best when it’s part of more comprehensive treatment for migraine, and not alone. That means you should be seeing a doctor who not only knows the details of your medical history, but also has training in a range of migraine treatments. If you go to a doctor who just knows Botox injection, you may not get the benefit you really need.
Insurance: I probably don’t need to explain this – many of you know how complicated it can be to get insurance coverage. An insurance company makes general rules for what it will cover – not rules that will be best for you. For example, take a look at Aetna’s policy. On the one hand, you could point out (as Dr. Black does) that none of the other treatments you’re supposed to try first are actually approved [by the FDA] for migraine. On the other hand, some would argue that there’s better evidence for a host of other treatments not even listed, and that there are many more you should try before spending so much on Botox.

Dr. Black also mentioned the changes that are being made in which injection sites should be used. I would add that this is still a huge issue for Botox. Although we continue to change how injections are done, based (hopefully) on the best evidence, we still know very little about how different types of migraine and different people may react to different injection sites. The time and cost involved in such research is staggering. But it leaves a lot of questions about how well Botox will work for you.

Read Dr. Black’s full article from Clinical Neurology: Weighing Botox’s Migraine Benefits Against Costs

30 April 2012

Chronic Daily Headache vs. Chronic Tension-Type Headache

James Information 4

Confused about the difference between chronic daily headache and chronic tension type headache? Let’s talk about it.

This month a report came out about the use of Botox for various headache disorders. The meta-analysis (a study of earlier studies) concluded that Botox had been helpful for "chronic daily headache" and "chronic migraines", but had not yet been proven useful for "episodic migraine" or "chronic tension-type headache".

Now of course this doesn’t prove too much – just that the studies so far seem to show that Botox is more useful for people with some diagnoses and not for people with other diagnoses. It could mean some have been studied more than others, or that we have not yet found the right type of Botox treatment, or it could mean that Botox simply isn’t useful in some conditions. We don’t really know.

But what stood out to me was the use of the term chronic daily headache. What does that term actually mean? And why is it different from chronic migraine or chronic tension-type headache?

Having not read the full study, I’m not sure how the authors are using the term, but I suspect from the abstract that they’re taking it from the studies they’re using. Which makes things even more tricky.

Chronic Daily Headache (CDH) is not really a specific term for a headache disorder, but a general term. This means that chronic migraine and chronic tension-type headache could both be called chronic daily headache.

CDH could be:

chronic cluster headache
chronic migraine
chronic paroxysmal hemicrania
chronic tension type headache
hemicrania continua
new daily-persistent headache
short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing

With all of these disorders, attacks come either constantly or at least 15 days a month. CDH are a huge problem. It has been estimated that up to 5% of the population have significant CDH symptoms. Most have chronic migraine.

Often CDH is related to the overuse of medication (such as triptans or acetaminophen / paracetamol, in which case you may be diagnosed with one of the above and medication-overuse headache, or it could be diagnosed as one or the other.

Because of the confusion over the terminology, or simply ignorance about the classifications, many patients are diagnosed with chronic tension type headache when they really have a different type of CDH.

Chronic Tension-Type Headache starts with episodic tension-type headache. In other words, first the patient has the occasional TTH, and later ends up with chronic TTH. Usually there’s pain on both sides of the head, feeling like a pressing or tightening. Physical activity probably won’t make it worse, but there is sometimes some mild sensitivity to light or noise, and possibly a little nausea (but not vomiting) – one, but not all three.

Chronic migraine, in contrast, usually starts with migraine attacks which eventually become chronic. The symptoms are migraine-like.

Now with both chronic migraine and chronic tension-type headache, your doctor will want to rule out other conditions. It is possible to have the symptoms of chronic TTH, and yet actually have a different diagnosis.

If you have been diagnosed with CDH, try to get a more specific diagnosis. Why? Because as research continues, there are treatments that will be more likely to help you depending on which type of chronic condition you have. The more you can narrow it down, the quicker you can get treatment that works.

For more of a breakdown of CDH types, see the National Headache Foundation’s topic sheet on Chronic Daily Headache.