Botox Treatment for Migraine

1. How I do I know if I have a migraine?
2. What are the different treatment options for migraine?
3. How does Botox help with migraines?
4. Who should not receive Botox injections?
5. Does it work straightaway?

How I do I know if I have a migraine?
Migraines are a type of headache disorders characterized by recurrent headaches that are typically described as throbbing or pounding over one side of the head. It is usually of moderate to severity intensity and can be accompanied by nausea, vomiting, sensitivity to light, sound and smell. Some patients with migraines also experience an aura. An aura refers to a sensory disturbance that occurs prior to the onset of the migraine. These may be experienced as visual disturbances (eg. tunnel vision, zig-zag lines across the visual field) or sensory disturbances (eg. tinging in the limbs or face). 

What are the different treatment options for migraine?
Migraines are commonly treated with a combination of lifestyle modification (eg. exercise, reduction of stress, diet) and medications. In general, medications used to treat migraine are classified into "abortive" and "preventive" medications.

Abortive medications are used to stop a migraine episode after it has occurred. It includes over-the-counter medications such as paracetamol and ibuprofen. However, if these medications do not help to abort your migraine attacks adequately, you may need prescription medications (eg. Cafergot / Triptans)

Preventive medications are used to prevent a migraine episode. Preventive medications are taken on a daily basis - it is recommended if your migraine episodes are severe or if they occur very frequently. Examples of preventive medications include Antihypertensives, Anticonvulsants, Antidepressants and Anti-CGRP medications. 

If these treatment options are not sufficiently effective, your doctor may recommend to you Botox Injections.

How does Botox help with migraines?
This treatment was first described by a Plastic surgeon Dr William J Binder in 1992. He noted that some of his patients who had Botox for aesthetic purposes reported a marked decrease in their migraine days. Following his discovery, several well-designed studies have confirmed his serendipitous findings, leading to an FDA approval for the use of Botox for migraine treatment since 2010.

Botox is now understood to reduce migraines via several mechanisms. These include:

1. Muscle relaxation
2. Reduce release of Nerve transmitters such as CGRP 
3. Interruption of pain signalling from sensory nerves of the face

Who should not receive Botox injections?
Certain individuals should avoid Botox injections for migraine prevention, including those with allergies to botulinum toxin or its components or patients with neuromuscular disorders (eg. Myasthenia Gravis).

If you have any of the following conditions, make sure that you inform your doctor as well:
1) Pregnant or breastfeeding women
2) Taking anticoagulant medications
3) Other muscular disorders (eg. ALS, swallowing or respiratory difficulties) 

Does it work straightaway?
After the injection, you will notice a difference in your migraine from the third day onwards. This will continue to improve and the peak onset of action is on the third week. Thereafter, you will find that the injection will continue to work up till the third or fourth month. If this treatment works for you, you will require repeated injected every 3 to 4 months. 

Dr Christopher Liu is a Pain Specialist based in Singapore with an interest in Headaches & Facial Pain disorders. He has lectured extensively on this topic.