Botox: Beyond Wrinkles, Relief from Chronic Migraine
When we hear 'Botox', we immediately think of reducing visible wrinkles and fine lines. However, its therapeutic use extends far beyond that, and now also serves as a preventative treatment for chronic migraines.
Botox or Anti-Wrinkle Injections have proven to be a game-changer in reducing the frequency and severity of migraine headaches. It provides a quality-of-life boost for many migraine sufferers by offering effective relief.
Botox, known scientifically as onabotulinumtoxinA, is a purified and diluted neurotoxin created by the Clostridium botulinum bacterium. Although it belongs to a family of toxins that can cause botulism, this refined version has medicinal and cosmetic applications.
Botox is famous for reducing fine lines and wrinkles by blocking nerve signals to muscles. Its role in treating chronic migraines is not completely deciphered, but it's widely acknowledged that it impacts the sensory nerves and migraine pain pathways.
When injected into specific areas on your face and neck, Botox can lessen the release of neurotransmitters like calcitonin gene-related peptides, brain chemicals related to migraine pain.
Gradually, Botox can recalibrate your brain's sensitivity, tempering its extreme reaction to migraine triggers.
Botox's Journey to Migraine Relief
Botox first debuted in the 1970s when ophthalmologists used it to treat eye disorders like blepharospasm and squint. Over the years, it has gained approval to treat more conditions including bladder incontinence, muscle contractions, and hyperhidrosis.
In 1998, a revelation came from an American plastic surgeon who reported that some of his patients noticed an improvement in their migraine headaches after receiving cosmetic Botox.
Spurred by these positive anecdotes, researchers initiated formal studies to evaluate the efficacy and safety of Botox for chronic migraine. The most impactful among these trials was the Phase 3 REsearch Evaluating Migraine Prophylaxis Therapy (PREEMPT) study.
The PREEMPT study engaged 1,384 individuals suffering from chronic migraines, to undergo double-blind, randomised, placebo-controlled clinical trials. The findings indicated that Botox reduced the number of migraine days and headache-related downtime.
Following the promising results of the PREEMPT study, the Food and Drug Administration (FDA) in America approved Botox for chronic migraine treatment in 2010, followed by TGA Australian approval in 2011.
The injection zones for migraine treatment differ from those for cosmetic use. A specific protocol for migraine Botox injection was meticulously developed over a decade, identifying the most effective placement and dosage. A typical treatment involves 31 injections on your forehead, back and side of your head, and neck, using a total of 155 units of Botox.
Botox, the brand name for onabotulinumtoxin A is manufactured by Allergan.
Additional Studies Supporting Botox Migraine Treatment
Additional scientific studies echo the findings of the PREEMPT study, reinforcing the effectiveness of Botox for chronic migraines. The COMPEL study, initiated in 2011, involved 716 patients who, on average, experienced 22 headache days per month. These patients received the previously mentioned, migraine botox treatment protocol (31 injections, 155 units), every 12 weeks for 2 years. At the conclusion of the study, a significant reduction in headache days was reported.
A 2019 study conducted here in Australia reviewed data from 211 patients across 7 private neurology clinics. This study revealed that 74% of patients experienced headache relief from Botox treatments, including fewer headache days and a reduction in pain medication usage.
Qualifying for Botox Migraine Treatment under the PBS
Botox is TGA-approved only for chronic migraines, and there is no supporting evidence for its use in treating episodic migraines or tension headaches.
In Australia, Botox for chronic migraine is available on the Pharmaceutical Benefits Scheme (PBS) administered by a neurologist trained in Botox injections. To qualify, you must meet all the following criteria:
- An average of 15+ headache days a month, with a minimum of 8 migraine days, continuously over a period of 6 months prior to starting treatment.
- You are unable to take a least 3 different preventative migraine medications (e.g. propranolol, amitriptyline, methysergide, pizotifen, cyproheptadine or topiramate).
- You are under supervision for headache medication overuse.
- Be 18 or older
- Currently being treated by a neurologist.
To continue Botox treatment on the PBS, a 50% or more reduction in the number of headache days per month must be achieved and maintained after two treatments (12 weeks apart).
Without PBS coverage, Botox treatment can be expensive. Prices per treatment can vary wildly and may reach a few hundred dollars. This treatment also requires a visit to a neurologist every 3 months.
What to expect during Botox Migraine Injections
Before your first injection, your neurologist will inform you of potential side effects and risks. This is an excellent opportunity to ask questions and verify that the established Botox protocol for chronic migraines is being followed.
The treatment involves injecting 0.1ml or 5 units of Botox in the designated areas and each injection may cause a small sting. As Botox comes in 100-unit vials, some neurologists may administer additional injections to areas where you typically experience migraine pain.
The procedure takes roughly 15–20 minutes, and there are no limitations on driving and other daily activities post-treatment.
It is important to note that Botox is not an instant remedy for migraines. It can take 2 to 3 treatments to achieve a noticeable reduction in the frequency or strength of your migraines. As treatments are on a 12-week cycle, it can take 6 to 9 months to notice a change. However, some patients have reported improvements after their first injection.
Many patients report that the effects of Botox start to dissipate at around 10 weeks, with the intensity and frequency of their migraines increasing as their next treatment date approaches.
It's important to note that you do not need to stop taking other preventative medications with Botox treatments, and you can continue to use abortive medications if necessary.
If you do not notice an improvement in your migraines after 3 treatments, Botox may not be the right treatment for you.
Understanding the Side Effects and Risks of Botox
Just like any prescription medicine, Botox comes with potential side effects and risks, although they are generally rare and transient.
The most prevalent side effect post-Botox injection is neck pain, experienced by approximately 9% of people in the PREEMPT study.
Around 5% of participants from the PREEMPT trials also reported experiencing a migraine following the treatment. However, these headaches and migraines are typically observed within the 1st month of treatment and tend to subside with subsequent injections.
Other possible side effects of Botox
- Droopy eyelids
- Bruising at the injection site
- Muscle weakness and pain
- Muscle spasms
- Frozen facial muscles
- Rashes and itchiness on the skin
- Respiratory tract infection
There are also rare but serious side effects, such as difficulties with breathing and swallowing.
It's important to note that Botox for chronic migraine is only approved for individuals aged 18 and above, and is not approved for use during pregnancy or breastfeeding.
Adding Botox to your Migraine Treatment Plan
Botox has been a trusted treatment option for different conditions for several decades and serves as a scientifically-backed alternative for those living with chronic migraines. Side effects are typically mild and infrequent, and for many, the biggest concern is just the needle.
Apart from the measurable benefits of Botox, such as the reduction in the strength and frequency of migraines, there are also many intangibles. You may now regain hours previously lost to migraines, allowing you to enjoy:
- More quality time with family and friends
- Less time off school or work
- The capacity to operate better during a migraine episode
- Mental clarity to take on more responsibilities at work
- The opportunity to follow a passion project.
Botox is not a fast answer for chronic migraines, and if it proves effective, you will need to continue treatment every 12 weeks for sustained benefits. Botox is not a cure, but it is an additional tool in your migraine treatment arsenal, alongside preventative measures, abortive treatments, and lifestyle changes.
If you are eligible for Botox via the PBS and willing to allocate more resources to treatment, Botox presents a promising remedy for chronic migraines, potentially restoring more migraine-free days to your life.
Sources & Studies
Allergan 2020, CONSUMER MEDICINE INFORMATION BOTOX ® Botulinum Toxin Type A, March, viewed 9 May 2023, <https://allergan-web-cdn-prod.azureedge.net/allerganaustralia/allerganaustralia/media/allergan-australia/products/pdfs/cmi/botox-50u-100u-200u_cmiv13_piv17_mar20_au.pdf>.
Australian Government Department of Health and Aged Care 2013, Pharmaceutical Benefits Scheme (PBS) | Botulinum Toxin Type A, injection, 100 units/vial, Botox® - July 2013, www.pbs.gov.au, Australian Government Department of Health and Aged Care, viewed 9 May 2023, <https://www.pbs.gov.au/pbs/industry/listing/elements/pbac-meetings/psd/2013-07/botulinum>.
Blumenfeld, AM, Stark, RJ, Freeman, MC, Orejudos, A & Manack Adams, A 2018, ‘Long-term study of the efficacy and safety of OnabotulinumtoxinA for the prevention of chronic migraine: COMPEL study’, The Journal of Headache and Pain, vol. 19, no. 1, viewed 9 May 2023, <https://thejournalofheadacheandpain.biomedcentral.com/articles/10.1186/s10194-018-0840-8>.
Dodick, DW, Turkel, CC, DeGryse, RE, Aurora, SK, Silberstein, SD, Lipton, RB, Diener, H-C, Brin, MF & PREEMPT Chronic Migraine Study Group 2010, ‘OnabotulinumtoxinA for treatment of chronic migraine: pooled results from the double-blind, randomized, placebo-controlled phases of the PREEMPT clinical program’, Headache, vol. 50, no. 6, pp. 921–936, viewed 9 May 2023, <https://www.ncbi.nlm.nih.gov/pubmed/20487038>.
Stark, C, Stark, R, Limberg, N, Rodrigues, J, Cordato, D, Schwartz, R & Jukic, R 2019, ‘Real-world effectiveness of onabotulinumtoxinA treatment for the prevention of headaches in adults with chronic migraine in Australia: a retrospective study’, The Journal of Headache and Pain, vol. 20, no. 1, viewed 9 May 2023, <https://thejournalofheadacheandpain.biomedcentral.com/articles/10.1186/s10194-019-1030-z>.