Episode 8: Botox Injections for Chronic Migraines - It's Not Just for Wrinkles

Botox is best known as a cosmetic treatment, however in addition to cosmetic uses it has a wide range of medical applications.

In this episode, Dr Karmy explores the role of Botox therapeutic injections in managing chronic migraines—a condition that impacts millions worldwide and is often resistant to traditional medications.

Join Dr. Karmy as he breaks down the science behind Botox for migraine relief, discusses its pros and cons, and explains how it works as a powerful muscle relaxant to reduce pain and prevent attacks. 

Tune in to find out how well it works for chronic pain as well as other medical conditions.

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Chapters

• 1:37 Introduction to Botox Therapeutic Injections
• 3:24 Mechanism of Action
• 5:07 Advantages: Low Risk, Efficacy
• 6:12 Disadvantages: Frequency, Side Effects, Cost
• 10:50 Other Clinical Applications: Neurological Disorders (Cervical Dystonia, Cerebral Palsy), Bladder Spasms, Erectile Dysfunction and Hair Growth
• 14:15 Dr. Karmy's Parting Thoughts

Transcript

Dr Karmy: 0:00

The advantages is relatively low risk of side effects, and a relatively high response rate, at least when it comes to headaches. Generally speaking, 60 to 70 percent of patients who try Botox find that severity and frequency of headaches is reduced for about two to six months after each injection.

Raveena: 0:32

Welcome to Chronic Pain Chronicles with Dr. Karmy, where we navigate the intricate landscape of chronic pain management and explore the cutting edge treatments that can make a difference in your life. I'm Raveena, your host, here to guide you through today's discussion. In this episode, Dr. Karmy will be shedding light on Botox therapeutic injections, a treatment that has been gaining recognition for its effectiveness in managing chronic migraines. With migraines affecting millions of people worldwide, and often resistant to conventional medications, finding a viable alternative is crucial. Dr. Karmy will explain how Botox therapeutic injections work, discuss its pros and cons, and help you determine if this treatment might be the right option for you. As always, we are fortunate to have Dr. Karmy, a seasoned expert in chronic pain management, with over 20 years of medical experience, to share his invaluable knowledge with us.

Dr Karmy: 1:37

Hello, this is Dr. Karmy and today I am going to talk about Botox therapeutic injections for management of chronic migraines. Are you someone who has frequent and severe headaches and has tried multiple different medications, but unfortunately none of them work, or perhaps they do work, but only partly and your headaches are there every day and you're only allowed to take your medications three or four times per month. Perhaps you also tried nerve blocks at a pain clinic, but found that they only help for a day or two. What are your other options? One option is botox therapeutic injections. Botox therapeutic is identical to cosmetic botox that moviestars and housewives use for wrinkles. The only difference is that it is injected into different areas and also that the dose is higher. Botox incidentally is identical to botulinum toxin that causes botulism. The difference is essentially the dose. Like most things at very high doses, Botox can can be a poison but in low doses it is medicine. The dose of Botox administered for therapeutic purposes is about one hundredth of the dose that causes botulism. The mechanism of action of botulinum toxin, and Botox for that matter, is that it blocks the release of neurotransmitter called acetylcholine from motor neurons. Motor neurons are nerve cells which are responsible for controlling muscle movements. If you listen to my interview with Dr. Henry, you will know that neurotransmitters are a way for nerves to communicate with each other, but neurotransmitters are also a way for nerves to communicate with other tissues, such as muscles. If acetylcholine release is blocked, it causes for the muscles to relax. So in addition to treatment of muscle spasm, Botox can reduce release of neuropeptides from sensory neurons. Botox can reduce release of CGRP or calcitonin gene related peptide, as well as substance P, which we discussed in the previous podcast. So now that you understand how Botox works by blocking various neurotransmitters in neuropeptides, the question becomes what is it used for? And what are the pros and cons of using it? So, in terms of pros, the advantages is relatively low risk of side effects, and a relatively high response rate, at least when it comes to headaches. Generally speaking, 60 to 70 percent of patients who try Botox find that severity and frequency of headaches is reduced for about two to six months after each injection. Botox is not a cure, so whenever the effect wears off, typically Botox is repeated. I suppose an additional benefit is the cosmetic one, as some of the spots for injections used to treat headaches overlap with spots used for reducing forehead wrinkles. Patients will often also look better after their Botox injections. The only real limitation with Botox is that it is not advisable to administer it more frequently than every three months, because if you do, there's a risk to development of antibodies to Botox, which would cause the Botox to stop working. So if you're one of those patients that only gets two months of relief from Botox injections, often you have to supplement. with other approaches until it is time to do Botox again. In terms of side effects with Botox, I have seen one patient who developed fever and a rash. That's one patient in 20 years. Generally speaking, Botox is not recommended to pregnant women. Other contraindications include certain neurological disorders. Finally, the biggest problem with Botox isn't so much its effectiveness or the risks. The biggest problem with Botox is cost. A single vial of Botox costs 450 dollars and typically one needs two vials of Botox, which is 900 dollars in order to treat a headache. Sometimes, if patients are financially strapped, a single vial could be tried, and I have seen it being effective. However, in perfect world, two vials would be used. On top of that, there's also an injection fee, which is not covered by a drug plan. Having said all of that, the injection fee is a relatively small component of overall price, and the cost of Botox is the biggest component. If you have a drug plan, it will cover Botox under certain circumstances. Unfortunately, there's a lot of hoops to jump through to get the coverage. Typically, you had to have failed a number of less expensive tablets before you are eligible for Botox coverage. Also, you had to have had at least 15 headache days per month in order to be eligible. ODSP will also cover Botox sometimes with a special application. The other cons is has to do more with the very nature of Botox. Botox is a very powerful muscle relaxant. If one injects it incorrectly or with too high a dose, too close to eyebrows or into the neck, it can cause muscle weakness which can persist for one to two months. In the case of injecting it too close to eyebrows, it can cause eyelids to droop, because eyelid is a muscle. If you relax it, the eyelid starts to droop. And in the case of the neck, you could end up with, floppy neck that makes it difficult to keep your head upright. Also in the neck there are muscles responsible for swallowing and if the neck injections are too close to those muscles you may not be able to swallow for a month or two. Again, these risks are avoidable by starting with very low doses of Botox, by making sure you place your injections in the right places, and perhaps in some cases avoiding neck injections entirely. In addition to headaches, the botox is used for pain in other parts of the body. It is used for muscle pain in the neck, shoulders, and back. It is even on occasion used for tendons, nerves, and joints. The success rates tend to be lower than for headaches, and the duration of benefit tends to be shorter. But nevertheless, it is a treatment that can be helpful, especially if some of the other approaches more commonly used for back neck and shoulder pain have failed. In addition to avoiding injecting Botox into the neck, if at all possible, you try to avoid injecting Botox between shoulder blades because that can impact one's posture. There's also some discussion as to whether or not Botox can cause muscle atrophy over time if injected for months and years. Generally speaking, for most patients it is not an issue that they notice, but more of a theoretical issue. In addition to pain, Botox is used for a number of other indications, some of which are incidentally covered by OHIP. It is used for neurological condition caused cervical dystonia where neck is pushed to one side because of extreme muscle spasm. Botox is used to relax muscle in patients with cerebral palsy, or muscles in patients who had stroke, which often is associated with extreme muscle spasms in the paralyzed arm or leg. The doses for neurological disorders are typically much higher than the doses used for headaches and pain. And because of that, often EMG guidance or ultrasound guidance is used when administering these injections. Likelihood of post injection weakness with these procedures is much higher because, again, higher doses are used. Another indication for botox injections is bladder spasms. Urologists actually inject botox into the bladders of patients with overactive bladder. Again, it can work for a few months and then has to be repeated. Other more rare indications are erectile dysfunction and even hair growth. The uses for erectile dysfunction and hair growth are not well established with relatively little research to back them up, but nevertheless for individual patients they can be helpful. So what are my overall thoughts on Botox injections and chronic pain management? I think it is an excellent treatment for patients suffering from chronic migraines. It is also worth considering Botox injections for other areas in the body if more, common approaches such as nerve blocks, cortisone injections, platelet rich plasma injections, or radiofrequency ablation injections have not helped. The biggest barrier to wider Botox use is cost and I feel like I would use it a lot more frequently in my practice if the cost was not a barrier. Thank you.

. Raveena: 15:11

Thank you for listening to the eighth episode of Chronic Pain Chronicles with Dr. Karmy, where we explore chronic pain from a physician's point of view. In our upcoming episodes, we'll continue to delve into some of the most effective and widely used approaches to managing chronic pain, such as cortisone injections, radiofrequency ablation, and more. We'll also investigate the causes of chronic pain and where the field is heading in the future. Furthermore, Dr. Karmy will interview seasoned professionals and leading researchers in the field, sharing their insights and expertise in our discussions. I'm Raveena Aujla. Until next time, take care. Disclaimer, when it comes to your health, always consult with your own physician or healthcare provider for personalized advice and guidance. The information provided in this podcast is for educational and informational purposes only and should not be considered medical advice or a substitute for professional medical care.