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Relief for Chronic Migraine Patients May Come in the Form of Injections

For patients who suffer from chronic migraines, the pain is not only stressful and inconvenient, it can be debilitating. However, there is a treatment option to offer patients that can reduce the number of and intensity of migraines suffered.

Botox brand botulinum toxin was approved as a treatment for chronic migraines in 2010. A randomized placebo-controlled trial, PREEMPT, released earlier that year demonstrated the positive effect of botulinum toxin within a large population of chronic migraine sufferers. After six months, or two cycles of treatments, patients experienced eight fewer migraines per month, on average. After one year, the study showed even greater success with the treatment; 70 percent of patients regularly treated experienced at least 50% reduction in migraines.

Robertson_Eliza_whitCdHdSince the publication of the PREEMPT trial, the use of botulinum toxin for migraine has become a popular topic among physicians who treat chronic migraines. Although the specific reasons for why these injections reduce the occurrences and intensity of chronic migraines is not currently known, Eliza E. Robertson, M.D., Ph.D., Lexington Clinic neurologist, provided some insight into the matter.

“We know that the toxin inhibits the release of acetylcholine across the neuromuscular junction, thereby rendering flaccid paralysis of the target muscle,” Dr. Robertson said. “However, we think there may be an additional effect targeting pain-mediating neurotransmitters that are associated with migraines.”

This treatment is currently only recommended for patients who suffer from chronic migraines, defined with specific criteria, which includes at least 15 headache days per month. According to Dr. Robertson, the data from clinical trials only applies to this population, and not to those who suffer from occasional episodic migraines. She did add, however, that studies have been promising for chronic daily headaches.

For patients with chronic migraines who would like to explore the option of botulinum toxin injections as treatment, Dr. Robertson advises to recommend they first consult with a physician who currently performs this procedure to verify a diagnosis of chronic migraine and to ensure the patient’s insurance will cover the injections.

“Appropriate screening of patients for referral to a physician who performs the procedure should include establishing the diagnosis of chronic intractable migraine, that is, the patient experiences at least 15 headache days per month lasting at least four hours and has failed to improve with at least two prophylactic agents from different medication classes. Referral should be to a physician who performs the FDA-approved injection site protocol, which is 31 injections in seven muscles around the head, neck and shoulders,” Dr. Robertson said about the process.  “The protocol can be modified, if necessary, to each patient’s needs with subsequent injections based on tolerability and symptoms,” she added.

“While Botox, just one of the three types of botulinum toxin, funded the trials and obtained FDA approval for the treatment of chronic migraines, there are three forms of botulinum toxin type A: Botox, Dysport and Xeomin. Within my clinical experience, all three brands of the toxin work equally well in the treatment of chronic migraine.”

Regardless of which form of botulinum toxin is used, Dr. Robertson recommends the injections as a treatment option to chronic migraine patients because the positive effects of the treatment greatly outweigh the costs.

“The potential benefits of this type of treatment include a reduced number of migraines, increased hours of productivity, huge savings in cost, ER visits, and the avoidance of side effects from previously or too frequently used migraine medications.   Given the potential overall improvement in well-being and quality of life, botulinum toxin for chronic migraine is often the best option available,” Dr. Robertson said. “Besides, the procedure goes relatively fast and, for most, is well tolerated.”



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