Botox: Helpful for Migraine Pain?

By Ellen Kuwana
Neuroscience for Kids Staff Writer
March 17, 2003
Updated: October 18, 2010

Botulinum toxin, which is more commonly known by its brand name "Botox," is a neurotoxin that is used in very dilute form to paralyze muscles temporarily -- not the first thing you might think of to inject into your face. Although it is only licensed for a few medical procedures, Botox has been used to treat more than 50 medical conditions such as excessive sweating. This drug, however, is gaining popularity as a cosmetic treatment for wrinkles on the face. In the United States, Botox was approved for treating wrinkles in 2002. Some people who had received Botox for cosmetic reasons reported that their headaches or migraines also improved. Intrigued, scientists set out to investigate.

The results from some preliminary studies are in:

  • Todd Troost, MD, at Wake Forest University has treated patients with Botox. These patients suffered from migraines, tension headaches or chronic daily headaches. Most of the patients had already tried up to three medicines for their headaches, with little effect. The patients received one to four Botox treatments spaced at three-month intervals. Among those patients who received four treatments, 92% reported an improvement; 84% of the patients reported improvement if they received fewer treatments. Troost emphasized that more than one treatment is often necessary to see any improvement.

  • Botox may be helpful in treating a "cluster headache," a type of headache that affects men more than women and strikes in a cycle of several headaches over the course of a few days. Out of seven patients whose headaches did not respond to other treatments, four patients found that Botox injections into the face or temple provided some relief from the cluster headaches. Three patients reported no effect.

  • A study by researchers at the St. Louis University School of Medicine found that Botox decreased the frequency of tension headaches for most patients for up to three months. Not only did the patients have fewer headaches, but they had less intense headaches. This study included 41 patients who reported having at least two tension headaches per week. Some of the patients received Botox and some received a placebo. Those getting the Botox received eight injections along the muscles of the forehead between the eyebrow and the hairline.

Perhaps the most well-known type of headache is a migraine. In the US, a migraine sufferer will typically experience one migraine per month, although about 4% of sufferers have a more chronic form, where they suffer from an attack each day. Migraines occur when there is an abnormality in the brain's blood supply system. Specifically, the blood vessels in the brain seem to overreact to certain "triggers." Triggers are highly personalized -- different people react to different triggers. Triggers for migraines can include:

  1. Certain foods (commonly chocolate, nuts, fermented or caffeinated foods, foods containing aspartame, MSG, or tyramine).
  2. Changes in barometric pressure, which happens before storms when the weather changes.
  3. Exposure to certain scents (chemicals, perfume).
  4. Blinking lights (such as headlights at night on a freeway).
  5. Changes in daily routine, such as sleeping more or less than normal.

The body reacts to these triggers by producing spasms in arteries at the base of the brain. These arteries close up, reducing blood flow to the brain. The neurotransmitter called serotonin is also released, which closes the arteries and contributes to decreased blood flow to the brain. Other arteries in the brain try to open more in response to this decreased blood flow situation, increasing the production of chemicals that cause inflammation and sensitivity to pain.

Migraines typically consist of three stages.

  1. Stage 1: Many migraines start with an aura, which happens 5 - 60 minutes before the headache, and includes visual, sensory, or motor disturbances. This "warning" of a coming headache occurs in about 20% of migraine sufferers.
  2. Stage 2: The headache phase is usually characterized by "throbbing" pain (in 85% of cases) that is unilateral, meaning only on one side of the head. Migraines are distinct from other types of headaches in that they are accompanied by other complaints such as sensitivity to light and sound and abdominal symptoms. Approximately 90% of people with migraines also suffer from nausea and about 33% will vomit when they get a headache. Other symptoms of a migraine may include blurry vision, nasal stuffiness, cramps, a stiff neck or tender scalp, and the inability to concentrate or even speak. Migraine sufferers also experience depression, intense fatigue, nervousness and anxiety. During a migraine, many people just want to be alone in a quiet, dark room.
  3. Stage 3: The termination period of a migraine is when the pain subsides. The migraine sufferer is left worn out and "not themselves" for up to 24 - 48 hours. This is often called a "migraine hangover."

There are many medications used to treat headaches, many of which fight the inflammation of the blood vessels. Antiseizure drugs are used because they stop the blood vessels from opening in response to a migraine. Antidepressant drugs are also commonly used. People who suffer from migraines not only endure a great deal of pain, they are never free from the fear that they will get a migraine. Drugs such as those mentioned above help, but rarely does one drug prevent all of the pain, and rarely does one drug remain effective over the many years one may suffer from migraines. People with migraines miss school or work, and may find it difficult to be social or outgoing while having a migraine. It takes a toll on one's daily life. Considering these factors, it's easy to understand why migraine sufferers are embracing a new therapy such as Botox injections -- even if Botox is not approved yet for the treatment of migraines.

There is still plenty to learn about Botox. For starters, no one completely understands how Botox works in treating headache pain. It may work by blocking the release of the neurotransmitter acetylcholine in the motor neurons. Acetylcholine is involved in muscle contraction. Botox is also thought to affect sensory nerves, thus blocking pain by this route also. Furthermore, the long-term effects of Botox use have not been studied. Over time, the body may develop immunity and the Botox may lose its effectiveness. Yet when you live with pain on a regular basis, any hope of relief is worth investigating. Scientists and migraine sufferers around the world are doing just that -- investigating, and hoping that this new treatment is as promising as it sounds.

Living with Migraines

To gain a better insight into what it's like to live with migraines, I interviewed my friend Steve, a 40-year-old who has suffered from migraines for the past 15 years. He remembers having headaches as a kid. The headaches got better, but began again when he was in his mid-20s. Steve has been on pain medication for the past 14 years, similar to the pain killers you might get if you sprained your arm. He takes a high dose of this medicine, and it makes him slightly hyperactive. He says he's tried just about every medication there is for the pain including seizure medications and antidepressants.

Like many migraine sufferers, Steve is willing to try anything to reduce his pain. He has participated in research studies investigating the use of Botox for treating migraines. I tagged along with him when he received his first Botox injections. Steve said the shots were not very painful. He couldn't feel the liquid (Botox) being injected. After the shots, he had little red dots all over his forehead and neck.

The shots were all very superficial, meaning that the Botox was injected near the surface of the skin. Only a small amount of Botox is injected in each place. The doctor felt Steve's muscles to find the ones that were tight. These were the muscles that received Botox injections and included those in the forehead, temple, behind the ear, and along the neck and top of the shoulder area. Steve received a total of about 20 injections.

The doctor said that the Botox's effect should last about three months. Steve noticed a change in his migraines after he received the Botox treatment: the headaches were shorter, and less intense. "By the time I went to get my medicine, the headache was gone, then I got another one," Steve explained. This lasted about a week, then his headaches seemed to return to normal and he went back on his medication.

Steve explained to me that taking medication for headaches is tricky. If you take the medication too often, you can get "rebound headaches." But it's also hard to tell when an ordinary, bearable headache is going to turn into a nasty migraine. You don't want to take the medication too soon, in case the headache goes away or doesn't get worse, but you don't want to let the headache develop into a migraine! It's a balancing act between taking the medication in time, but not taking it too often. It is important to speak with a doctor concerning any medication you are taking.

Steve has an unusual trigger for his migraines: the weather. Whenever there is a change in weather (change in barometric pressure), he gets a migraine. He can be inside of a building and predict that a storm is coming because his head acts as a "storm sensor." Although this trigger is relatively rare, he also admits to drinking a lot of Coca-Cola. Caffeinated drinks are often a trigger, as is chocolate, which he sometimes eats.

Steve's migraines usually cycle four days on and three days off. Most people, he says, have a two or three day cycle. His migraines are unilateral, meaning they strike only one side. They usually start on the lower left side of his neck. If they start on the lower right side of his neck, they usually shift and end up on the left side by his ear. He knows a migraine is coming because there is "too much sound" and he becomes irritable. He also "loses vocabulary," finding it difficult to recall names or technical words he uses at work. He has to focus on what he's doing in order to be able to continue working. He says that his wife can tell when he's having a migraine just by looking at his eyes. They become almost squinty, and have a tired look. It's as if he can't open them all the way. He says he tries to relax the muscles in his face, which leaves him with sort of a dull, tired expression.

Steve describes living with migraines as "really annoying." It's not as if you get really excited when you don't have one -- it's more like you're just waiting for the next one to hit you. Having migraines, Steve explains, affects your whole life. It affects your family, your job, your social life.

He has tried self-meditation and biofeedback, but those alternative therapies did not work for him. Like many migraine sufferers, Steve takes an antidepressant in addition to the pain medication for the migraines. Antidepressants such as SSRIs (selective serotonin reuptake inhibitors) increase the action of the neurotransmitter serotonin in the brain. Steve describes the effect as taking some of the stress out of the equation, allowing him to be calmer about the pain.

Children's migraines are often difficult to diagnose because they may be shorter in duration. One child Steve knows will get a migraine for an hour, vomit, and then feel better. Steve sounds envious of this relatively simple solution to ending a migraine. If only his migraines were so easily banished. He describes them as "like an ache of someone grabbing inside my head." If he squeezes his head with his hands, he gets some temporary relief. For more permanent relief, it remains questionable whether Botox is the answer. Some researchers claim that more than one treatment is necessary for pain relief. For Steve, at least, the one injection provided only temporary relief. Time and more research are needed to develop better treatments -- and until then, migraine sufferers everywhere will do as they have always done -- wait for the pain to go away.

Did You Know?

  • Migraines affect approximately 28 million people in the U.S., most of them women (18% of women versus 6% of men). [Source: "More than a headache," by Julie L. McDowell, Modern Drug Discovery, The American Chemical Society, November 2002.]
  • Approximately 5% of the U.S. population has chronic daily headaches. [Source: "Botox may prevent headache pain," The BostonChannel.com, 2002.]
  • The use of Botox has increased from a $25 million business in 1993 to $440 million in 2002. [Source: "Wrinkles Gone? New Uses Studied for Botox," New York Times, March 2, 2003.]
  • The use of Botox for cosmetic purposes has increased by 1500% in the US from 1998-2002. [Source: "Very long term effects of Botox still unknown," British Medical Journal editorial, Volume 325, p. 1188.]
  • Two other medically used poisons are curare, a muscle relaxant used in surgery and physostigmine, which is used to treat glaucoma.

They said it!

"Lord, how my head aches! What a head have I! It beats as it would fall in twenty pieces."
--- William Shakespeare, Romeo and Juliet, act II, scene V, 1594

References:

  1. A good overview of the different types of headaches from the American Council for Headache Education
  2. FDA approves Botox to treat chronic migraine - October 15, 2010
  3. National Headache Foundation (includes information about an art contest for migraine sufferers, deadline May 23, 2003)
  4. National Institute of Neurological Disorders and Stroke page on headaches
  5. Printable Booklet on Headaches and Migraines from the National Institute of Neurological Disorders and Stroke

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