Botox for headaches

[deleted993114]

What is the general experience/results with botox for cervicogenic headaches? Where do you inject?

Traditionally, I have injected in the occipital, temporalis, and frontal region with good results.

In the late 90s, Ferrante convinced us to do botox in the cervical paraspinous musculature and traps for patients with secondary myofascial pain from degeneration. As useful idiots, we did so, only to make patients worse by weakening the posterior musculature. Upon reconvening a year later, Ferrante reported that he had similar problems with botox in the neck, but good results for headache. It was pretty interesting, as it changed the way we practiced- we realized that strengthening the extensor groups in spondylosis was important in the PT realm and that weakening these groups made people worse. It was a good lesson.

Nonetheless, botox seems to work well for refractory headaches. Does anyone have experience to the contrary? Similar experiences?

PS- this is not running down Ferrante- he was faithfully promoting a treatment that he felt was helpful (and turned out to be so for headaches) and his efforts resulted in a paradigm shift in the treatment of neck pain. Sometimes things turn out that way.

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[Ferrismonk]

homepage

BOTOX® is a preventive migraine treatment for adults with Chronic Migraine, defined as 15+ headache days a month. See full Product, Safety Info & Boxed Warning.

www.botoxchronicmigraine.com

 

[Orin]

This isn't rocket science and I'm disappointed that someone thought this made sense. Step back and ask yourself how/why things work before you use them elsewhere. It might be hindsight being 20/20, but this shouldn't have been hard to foresee.

The purported mechanism of action here for Botox for chronic daily headache/migraines are different than just injecting it into a muscle for dystonia. Injecting botulinum toxin into the cervical paraspinal musculature is a setup for worsening cervicogenic headaches due to mechanical strain of the structures you assume are causing the pain. We should know this after seeing folks with cervical lamis or dropped heads after MBBs where aggressive muscle debridement/denervation led to no posterior spinal muscles to help and severe cervical kyphosis. Why would chemically denervation of those muscles be a good idea for long term efficacy?

If the headaches are purely occipital/cervical, the goal should be to inject low doses of botulinum toxin into the nerve endings that are "reporting" pain, without getting the neuromuscular junctions of muscles necessary to help maintain cervical alignment. There's a separate protocol from the Allergan that some folks use to better target the different head/neck pain patterns, but I would have to google the paper for it.

 

[deleted993114]

This isn't rocket science and I'm disappointed that someone thought this made sense. Step back and ask yourself how/why things work before you use them elsewhere. It might be hindsight being 20/20, but this shouldn't have been hard to foresee.

The purported mechanism of action here for Botox for chronic daily headache/migraines are different than just injecting it into a muscle for dystonia. Injecting botulinum toxin into the cervical paraspinal musculature is a setup for worsening cervicogenic headaches due to mechanical strain of the structures you assume are causing the pain. We should know this after seeing folks with cervical lamis or dropped heads after MBBs where aggressive muscle debridement/denervation led to no posterior spinal muscles to help and severe cervical kyphosis. Why would chemically denervation of those muscles be a good idea for long term efficacy?

If the headaches are purely occipital/cervical, the goal should be to inject low doses of botulinum toxin into the nerve endings that are "reporting" pain, without getting the neuromuscular junctions of muscles necessary to help maintain cervical alignment. There's a separate protocol from the Allergan that some folks use to better target the different head/neck pain patterns, but I would have to google the paper for it.

Hey- we were dummies then. I am the first to admit it. Also, with Ferrante promoting it, it seemed like a good idea at the time. There were a number of providers that tried this in good faith, only to have it fail. That failure was beneficial in altering the way we approach cervical spondylosis. Obviously, it was not an effective treatment and we know better now.

I have done a number of "stupid" things during the course of my career which we all thought at the time would be very beneficial. Unfortunately, many times this is how medicine advances- through errors.

It is not the first dumb thing I have done and will not be the last. If you never make mistakes, you are probably not attempting to "push out the envelope" hard enough; there needs to be a balance between enthusiasm and caution in any practice.

 

[Orin]

Hey- we were dummies then. I am the first to admit it. Also, with Ferrante promoting it, it seemed like a good idea at the time. There were a number of providers that tried this in good faith, only to have it fail. That failure was beneficial in altering the way we approach cervical spondylosis. Obviously, it was not an effective treatment and we know better now.

I have done a number of "stupid" things during the course of my career which we all thought at the time would be very beneficial. Unfortunately, many times this is how medicine advances- through errors.

It is not the first dumb thing I have done and will not be the last. If you never make mistakes, you are probably not attempting to "push out the envelope" hard enough; there needs to be a balance between enthusiasm and caution in any practice.

Yeah, I apologize as I was a little harsh. I agree wholeheartedly that stupidity leads to advances but we need to be more open about discussing the stupidity so we as a field can advance. Thank you for your contributions!

 

[deleted993114]

Yeah, I apologize as I was a little harsh. I agree wholeheartedly that stupidity leads to advances but we need to be more open about discussing the stupidity so we as a field can advance. Thank you for your contributions!

No offense taken at all. Medicine is very humbling and I can freely admit that I have done some dumb things through which I have learned. Currently, I think that pain management is more disciplined and evidence based (which makes me curious as to why PRP is so popular). Back then, we were a little more cavalier about treatments and were prone to medicine as practiced by "hero worship", in that there were guys like Racz, Sluyter, Bogduk, and April who were the leaders in the field and you basically trusted what they told you. First do the recommended procedures and hope that the science proves it right in a few years.

PS- I am never offended if called an idiot, as it can be true in many instances.

 

[ateria radicularis magna]

I thought botox can be useful only when you have wrinkles. I've never done botox for headaches. However, I went to a couple of Botox procedures and all was right after it. That's how I got rid of wrinkles and now I look and feel much better.

Whu

 

[SommeRiver]

I thought botox can be useful only when you have wrinkles. I've never done botox for headaches. However, I went to a couple of Botox procedures and all was right after it. That's how I got rid of wrinkles and now I look and feel much better.

Mmmhmmm

 

[10KHertz]

I perform a fair amount of Botox for cervicogenic headaches, migraines >15 episodes/month.
Results are commensurate with meta analysis literature worldwide, 50% success rate which is in conflict with every Botox rep...

The neurologists like the PREEMPT protocol which includes most posterior and frontal sites plus corrugators. My patients don’t love this frontal protocol so I avoid it mostly.

I don’t do Botox q 3 months like the neurologists in my region, maybe q 4-6months as needed.