Treatment of Migraines with Botox

By Dr. Scott W. Mosser

The use of Botox® treatments to relax or eradicate wrinkles and frown lines on the forehead and around the eyes is currently the most popular non-cosmetic procedure in the United States, Europe and many other countries. Although used since the 1980s by dermatologists and in the cosmetic industry, the US FDA approved the use of Botox® for cosmetic purposes in 2002 and since then, its popularity has soared.

Botox® is a highly purified form of botulinum toxin Type A, which is produced by the bacteria clostridium botulinum. When injected directly into overactive muscles, Botox® inhibits the release of acetylcholine, a neurotransmitter that causes muscles to contract. The result is inhibition, or relaxation, of the muscles. This form of botulinum toxin A was developed by a doctor in San Francisco and licensed by Allergan, Inc. in 1989 for commercial use. According to Allergan, almost 3.3 billion Botox® cosmetic procedures were performed in 2005 alone.

The Positive Side Effect

At the beginning of 2001 it was first reported that patients who were incidentally migraine sufferers and had undergone Botox® Cosmetic treatments were experiencing relief from migraine symptoms and having fewer attacks. This serendipitous discovery has led to further research and clinical trials with the aim of earning FDA approval to use Botox® in the prophylactic treatment of migraine headaches.

This is good news for the more than twenty-five million Americans who suffer from migraine headaches that cause debilitating pain and suffering and billions of dollars in lost productivity each year. Many things trigger migraine headaches, including stress, changes in hormone levels, diet, and weather conditions. Although more women than men suffer migraine attacks, this disorder strikes all, including young children. There is generally a genetic tendency or sensitivity to conditions that trigger attacks, and not all treatments are effective for all sufferers.

Research on migraine patients who received Botox® injections has shown as much as an 80-90% effectiveness in relieving “imploding” type migraines, which are headaches characterized by pain moving from the outside of the head inward with a “squeezing” or “crushing” sensation. The Botox® injected around the eyes and forehead works on the same nerves that become inflamed during a migraine attack and cause acute pain. An estimated one-third of migraine sufferers have these “imploding” types of headaches.

Specifically, there are several nerves that supply sensation to the skin around the forehead, eyes and scalp that may also play a role in the pain component experienced during a migraine attack. These three important nerve areas are (a) the supratrochlear and supraorbital nerves, located in the inner upper eye area, which supply sensation to the central, right and left forehead areas; (b) the zygomaticotemporal nerve, located outside the orbit, just in front of the hairline outside the brow, which supplies sensation to the temple area; and (c) the greater occipital nerve, located in the back of the neck, which supplies sensation to the back of the scalp.

What these nerves share in common is that the intense pain migraine patients experience may be distributed along some or all of these nerves in the same manner as the normal sensory distribution of such nerves. The sensations also all travel through muscles on the way to the surface of the skin, a trait that is not very common in other nerves of the body.

Although the specific mechanism is still not clearly understood, when you treat the muscles around those peripheral nerves with Botox®, the pain portion of the migraine attack is inhibited, relieved or even eradicated.

The Actual Botox® Procedure

The typical Botox® cosmetic injection procedure takes approximately 10 minutes.
No anesthesia is required, although the area to be treated may be numbed with a cold pack or anesthetic cream prior to injecting.

Several tiny injections of Botox® are made directly into the muscles that cause the moderate to severe frown lines between the brows or into other muscle locations which the surgeon has determined beforehand. If the treatment is specifically for relief from migraine pain, the procedure may be more extensive and take longer, depending on the number of areas to be injected.

Discomfort is usually minimal and brief, the most common side effects following injection being temporary eyelid droop or a slight nausea.

You may see a marked improvement within days and improvement may continue for as long as a month; the effects generally last up to four months or longer. The number of injections, the extent of the areas injected and each patient’s specific skin type all determine the degree and length of effectiveness.

As with all medical procedures of this type, anybody who is considering Botox® treatments should choose a physician who is trained and qualified in facial plastic surgery. The human face has a complex anatomy and the surgeon must be familiar with the physiology and function of the more than 40 muscles present in the face.

An Exciting Application

The vast majority of my patients who seek Botox® treatments or who undergo Botox® injection therapy on a regular basis in my San Francisco clinic are interested in the cosmetic effects of the treatments; in eradicating squint and frown lines and wrinkles, and in achieving a smoother, younger facial appearance. Treatment time is quick and easy with a low risk of side effects, provided of course, that it is performed by a skilled and experienced Board-Certified Plastic Surgeon. Patient satisfaction with results is high.

The innovative use of Botox® treatments specifically to relieve migraine pain is of special interest to me because it is closely related to some of my own research. In my anatomical study of the greater occipital nerve* I was able to contribute to the medical knowledge used in treating this nerve. A protocol for doing surgery on the greater occipital nerve was made possible as a result of the findings from my study.

Anyone who suffers from migraine pain and is not finding relief from the standard drug treatments, or who has other health considerations which make the traditional treatments ineffective or prohibited, owes it to herself or himself to investigate the possibility of Botox® therapy. When balanced again the cost of long-term traditional pain control drugs and the work time lost due to physical incapacity, the cost of Botox® treatments, which can relieve symptoms sometimes for as long as six months or more, is not prohibitive.

Botox® injections have been found to not be effective in all types of migraine, but have achieved remarkable results in some types.

With my San Francisco and Bay Area patients who seek treatment to relieve migraine pain I consult with the primary physician treating their migraine symptoms to determine what type of migraine headaches they experience and which nerve areas are the most affected. A full medical history and a candid discussion of the options ensure the best approach to achieve effective – and often life-changing – results.

*Mosser, SW, Guyuron, B, Janis, J, Rohrich, R. The Anatomy of the Greater Occipital Nerve: Implications on the Etiology of Migraine Headaches. Plast. Recon. Surg 113(2):693-7.

Copyright © 2006 by Dr. Scott W. Mosser. This article may not be copied or reproduced in any form without the written permission of Dr. Scott Mosser. Internet links to the sub-page containing this article are permitted.