Dr Chris Blatchley details the current treatment protocols for migraines and shares his approach to successful treatment with botulinum toxin
Migraines are very common, with more than 10% of women and 5% of men suffering from them worldwide.1 It is now established that botulinum toxin (BoTN-A) can be a very effective treatment, and it is well worth learning the injection protocol, which is not greatly different to standard aesthetic injection techniques.
In my experience, many aesthetic practitioners report having patients who find their intermittent, or episodic, migraines (as well as their headaches between attacks) disappear following BoTN-A treatments. Indeed, they are reminded that it’s time for another treatment when their headaches begin to return. Some sufferers have far more disabling migraines that aren’t adequately controlled by aesthetic doses. If the migraines become more frequent, they are described as chronic rather than episodic. The two groups are a continuum of the same ‘migraine mechanism’3 and there is no exact division between the two.1,3 As an aesthetic practitioner, it is not difficult to improve your injection protocols to help with these more severe migraines. If you do, you will have thankful, loyal patients who will likely refer your services and stay with you for life.
In this article I will give an overview of migraines and their standard drug treatment. These will normally be managed by the patient’s GP, but it is useful to know to further your knowledge on migraine management. I will then explain simply how you can improve your BoTN-A injection protocol. I find that at least 90% of patients will be very pleased with the results, though a few will require more extensive injections into the neck, and approximately one in 20 patients will report no benefit. This article will not cover the science behind how BoTN-A works; however references for further reading are included at the end of the article and readers are welcome to get in touch for more information.
The distinction between headaches and migraines is also not clear-cut, as they are both caused by the same migraine mechanism.3 However migraineurs will often describe their headaches as different to their migraines. Marked autonomic symptoms of photophobia, a need for quiet, and nausea and vomiting may be more disabling than the headache, and can often make them lose a couple of days a month. BoTN-A tends to reduce the frequency and intensity of the migraines, in particular the feeling that there is another migraine on its way. The headaches themselves will usually become less severe, which is of course pleasing to the patient. Generally, migraine treatment is seen as the specialist preserve of neurologists. Although there appears to be a certain complex mystique to the classification system of headaches, the basics relating to migraines, as described in the British Association for the Study of Headache (BASH) guidelines, are not difficult to understand. You should be able to help the patient understand their condition more, and not just administer the botulinum toxin.
Migraineurs will usually have a long history of headaches, and will have seen their GPs, and perhaps neurologists, so that the diagnosis is not in doubt. The hallmark of a migraine is a gradual onset of headache with associated autonomic symptoms of nausea and vomiting, avoidance of bright lights and strong sounds. Some will experience an aura of distorted vision or paraesthesia just before the migraine properly starts.1 Some patients will have been investigated with MRI scans, though this is not needed as the diagnosis is generally made from the patient’s history. If a patient reports a recent onset of headaches then this needs to be investigated to exclude other causes. However these patients are unlikely to present to you, and if in doubt then refer the patient to their GP.
The clinical aim is to control the symptoms of migraines and, secondly, reduce the frequency of future migraine attacks with as Dr Chris Blatchley details the current treatment protocols for migraines and shares his approach to successful treatment with botulinum toxin as little treatment as necessary. Unfortunately you cannot ‘cure’ the predisposition to migraines. BoTN-A is interesting because it is helping the understanding of how and why migraines start, and can be enormously effective. However it is not easily available on the NHS, and expense may be one reason why the NICE guidelines restrict its use.2 Other treatment strategies, described in the BASH guidelines and listed below, should not be forgotten.1
Lifestyle: patients can reduce their frequency and severity of attacks by adopting a healthy lifestyle – any consultation should include this advice. Eating breakfast immediately upon getting up, e.g. cereal/muesli, regular sleep, and avoiding alcohol are often very effective.1
Non-drug treatments: osteopathy is often tried, sometimes with good success. Following numerous conversations with neurologists, my opinion is that it works in a similar way to steroid injections in the neck (greater occipital nerve block) by reducing the inflammation around the bony attachment of the muscles in the base of the skull. Please read the BoTN-A section for more information.
Pain relief during the attack: NSAIDS such as ibuprofen are the mainstay of analgesia.1 Some patients report that they can abort attacks if taken early enough. Ensure that no over-the-counter medications containing codeine are being taken, or, at the most, only very occasionally. It is well recognised that if taken for more than 8-10 days a month, they can induce a medication-overuse headache, which presents as a chronic headache very similar to chronic migraine. It is very difficult to tell the difference and may be a reason why BoTN-A fails, but the opiates MUST be withdrawn.1 There is no clinical evidence that ‘cold turkey’ withdrawal is more effective than gradual withdrawal, which can take over a month. BoTN-A may help with this.
Nausea and vomiting: the autonomic effects of migraines produce gut statis, and domperidone is the antiemetic of choice for nausea and vomiting because it increases peristalsis to help ensure that it does not lie in the stomach unabsorbed. As such, it is very important for the patient to take the domperidone as early as possible before the gut statis take hold.1
Stopping the attack: triptans are the modern mainstay to stop a migraine. They cause constriction of the blood vessels and help reduce the pain produced by the dilation phase of the meningeal vessels and engorgement of the meninges. They should not be taken during the aura phase of the migraine, as this phase is caused by spasm of the vessels and so the effect of the triptan is wasted. It is a common mistake to take it too early and the triptan should be taken as the aura phase is resolving, just before or as the headache starts.3 Triptans should not be taken for more than 10-12 days a month, as they can also cause medication-overuse headache.1 Fortunately the withdrawal process from triptans is shorter than opiates.
Preventatives: Beta blockers, amitriptyline, anti-epileptics and other neuro-active drugs are used to suppress the underlying migraine process. However they are often associated with a lot of side effects, particularly tiredness, so they can be of limited use.1
Although it is not completely clear how BoTN-A works to help migraines, it can be very effective in preventing attacks if administered correctly. The latest theories are that it works by blocking free nerve endings in the fascia/muscle attachments, thus reducing the excitation of the trigemino-cervical tract in the brain stem.4 This is where the afferent fibres of the ophthalmic branch of the trigeminal nerve, from around the eye, and the greater occipital nerve, from the neck, overlap. This area acts as a relay station, sending signals to higher centres in the mid-brain where the migraine starts. Other precipitating factors include changes in estrogen level during the monthly cycle, bright or flashing lights, loud sounds, strong smells and starvation, each of which work separately and directly on the higher centres.5 It is unlikely that BoTN-A works purely by muscle relaxation, though this may help by reducing the free pain nerve ending stimulation in the associated fascial attachments. The value of BoTN-A is that it is not associated with the side effects of the usual preventative drugs, mentioned previously.
Amending your injection protocol for migraine treatments
Neurologists, especially in the UK, generally use the PREEMPT Protocol created by Allergan to treat migraines with botulinum toxin. In my opinion this protocol, which is now five years old, can be improved upon because it does not inject the corrugators effectively. This helps explain the general neurological view that BoTN-A is only effective against chronic and not episodic migraines. My experience is that if the corrugators are injected with 60U Botox/ Xeomin (3x the normal aesthetic dose) and 15-25U to the forehead, then, in the vast majority of cases, injections in the neck are unnecessary. This significantly keeps the costs down, because the PREMPT Protocol uses far more BoTN-A by including injections in the neck and temples. There is no reason why one cannot start by just injecting the glabella/forehead and add injections to the neck/temples later if necessary.
Of the three main forms of toxin, I use Xeomin/Bocouture 100U diluted with 2.5ml bacteriostatic saline, giving 20U per 0.5ml insulin syringe. You will need just under 100U to inject the glabella/forehead. The dosages will be the same for Botox/Vistabel. I have not used Dysport/Azzalure, but you would need to adjust the dose in the normal way. 1U Botox/Xeomin = 2.5U Disport. When injecting, hold the syringe at approximately 20 degrees to the skin, pointing medially towards the procerus, so that the tip of the needle is in the belly of the corrugator. Do not introduce the needle down vertically, since hitting the bone will blunt the needle and increases the chance of lid ptosis by puncturing extensions to the orbital septum.