Why Try Botox?
Botox works in several ways to help improve the symptoms of migraines and chronic headaches. First, it weakens the muscles temporarily which are linked to triggering the headaches. There is also likely a direct effect on the nerve innervating those muscles, helping to reduce the incidence of headache triggering. Botox injection is a test to determine if those muscles and nerves are causing your pain, and a preview of what you might expect to experience from one or more of the surgical procedures discussed here in more detail.
Just as patients are the best judges of the severity of their head problems, patients are the best judges of the benefit of the Botox blocks. We attempt to objectively quantify the pre-treatment severity of head pain, as well as its response to our various treatments, but ultimately patients tell us when it's time to try Botox, when it's time to discuss surgical treatment, and whether or not we have been helpful to them.
How Does Botox Work?
Botox has been prominent in the media since the late ‘90's, most frequently for its ability to weaken small muscles of the face and neck that cause the wrinkles and furrows of aging. This drug is actually called a neurotoxin , indicating that it interferes with the normal function of the neuromuscular junction (connection between nerves and their associated muscles). Just as a local anesthetic such as Xylocaine interrupts pain signals going to the brain, Botox blocks transmission of the nerve impulse that causes a muscle to contract. Depending on the dose and distribution of Botox, the muscle is typically weakened or paralyzed for 2-3 months. A permanent loss of muscle function has never been reported, and the FDA has endorsed the safety of the drug by approving it for use in the muscles of the eye and many other parts of the body, and to treat wrinkles in the eyebrow region.
How Did Botox and Surgery Become Treatments for Migraine?
In the course of treating wrinkles physicians noticed a surprising extra benefit of the drug: Some patients whose brows were injected for wrinkles noted that their headaches disappeared! Based on these findings, further research has been done. In its simplest terms, decompressing these nerve branches by paralyzing muscles that were irritating them might be comparable to doing a carpal tunnel release, or for example loosening a tie that’s too tight. Some migraine headaches may be triggered by a simple mechanical problem, the compression of a nerve in the brow or posterior scalp.
A plastic surgeon in Cleveland, Dr. Bahman Guyuron, first published in 2000 his observation that a specific maneuver performed routinely in cosmetic surgery known as a “brow-lift” also appeared to improve or eliminate chronic headache problems in a large majority of his patients who had experienced head pain before their surgery ( Guyuron B, et al., Corrugator supercilii muscle resection and migraine headaches. Plast Reconstr Surg. 2000). These were not patients having surgery for headache; they were patients having brow-lifts to eliminate forehead wrinkles. Elimination of their head pain was an unexpected bonus. The muscles removed or weakened are the corrugatosr and procerus, and their treatment is most likely to be assist patients whose headache is primarily in the forehead region.
The Back of the Head: Another Source of Migraine?
Sometimes the trigger spot for a migraine is the back of the head. The major nerve in question in the back of the head is the greater occipital nerve. Other nerves that can be involved include the lesser occipital nerve and the third occipital nerve. The semispinalis capitis can compress these nerves are the only muscles which typically surround the nerves; using Botox to temporarily relax their compression of the occipital nerves is a specific test in helping to determine the cause of head pain in the back of the head, and elsewhere. If Botox is of significant help, its use may be repeated at intervals of 2-3 months or surgical removal of part of the semispinalis may give more permanent relief.
What are Possible Complications Of Botox Therapy?
One complication of Botox therapy in the brow region is unbalanced muscle weakening. This could alter the position of the brows or eyelids and make them asymmetrical. These changes are temporary, as Botox is always temporary, but could last several months and be distressing. These asymmetries are rare. If we block the small muscles of the brow, you will note smoothing of the forehead and mid-brow. Rarely, the Botox can migrate down toward the muscles controlling the upper eyelid, paralyzing them slightly and causing the upper lid to droop. Finally, the Botox may simply not help, which is upsetting but not itself a complication. Back to top
I understand why you would use Botox, but what are the nerve blocks for?
For patients who have nerve compression or nerve injury as the reason for their migraines/chronic headaches, we perform a trial of putting the nerve to sleep with a nerve block of local anesthetic (like the Novacaine used at the dentist’s office). If this results in a decrease or complete stopping of a patient’s migraines/chronic headaches, then we know there is a high likelihood that decompressing or resecting the nerve. So we use the nerve block as a DIAGNOSTIC test. It is not meant as a chronic treatment for migraines.
How long will the nerve block work for?
The type of nerve block we do uses a medication called Marcaine (generic name Bupivicaine). It typically wears off in 4-6 hours, but patients have had relief from headaches from anywhere from 3-14 days.
What are the complications of a nerve block?
There may be tenderness at the injection site for 24 hours. Bruising may sometimes occur, and we ask that you avoid taking aspirin or anti-inflammatory medications (Advil, Motrin) for 10 days prior to your visit. Tylenol, however, is safe to take, as it does not increase the risk of bleeding/bruising.
How is the surgery done?
Depending on the location/focus of your headaches, different approaches are used. For headaches focused in the brow/forehead region, the muscles known as the corrugator supercilli are gently removed. These are the muscles that assist in creating a “frowned” appearance, so one side effect of the surgery is fewer frown lines. Dr. Rosenberg also looks for other sites of compression or damage of the supraorbital or supratrochlear nerves, which may be related to the triggering migraine headaches.
For temporal headaches, Dr. Rosenberg locates the zygomaticotemporal nerves, which are resected and buried in the temporalis muscle.
For occipital headaches, a small incision is made over the back of the head, hidden within the hair. The greater occipital nerves, and in some cases the lesser and/or 3rd occipital nerve are located and decompressed.
All of these surgeries are similar to other peripheral nerves surgeries performed at the Institute of Peripheral Nerve Surgery. Dr. Rosenberg identifies injured or compressed nerves, using meticulous microsurgical technique, with the aim of restoring the patient back to normal function.
Why should I have surgery rather then get a nerve stimulator placed?
Some pain management centers place nerve stimulators into the nerves to control migraine headaches. That is about a $30,000 battery implanted in you with a couple feet of wires that get placed next to your nerves. It can confuse the nerve and minimize the pain. With placement of foreign material, such as the battery and wires, there is risk of the hardware getting infected. Also, patients can feel the batteries and sometimes find them uncomfortable. Also, nerve stimulators are not treating the cause of the problem but just fooling with the symptoms. It is certainly another option for pain control, and may end up being a treatment you seek, but may not be the best option for you.
How long is the recovery from migraine surgery?
Recovery from headache surgery with Dr. Rosenberg varies depending on the area which is being operated on. In the brow/forehead, swelling may persist from as little as 2 weeks to as long as 6 weeks, depending on the individual. Swelling from surgery in the temporal or occipital regions (side and back of the head) is much less noticeable since it is hidden by hair, typically. You may shower and wash hair two days after surgery and thereafter.. Pain medication is usually necessary for the first 3-5 days, due to incisional pain.
Are these procedures typically covered by Insurance?
The cutting-edge techniques in migraine/head pain management that we provide (Botox, nerve blocks and surgery) are not considered “covered services” by some insurance companies, and your insurance company may not provide any reimbursement for them. You may therefore be required to pay “out-of-pocket” for these procedures. We are happy to provide documentation of our evaluation and care to insurance companies, complete with diagnostic and treatment codes. However, if your insurance company denies coverage, the patient is responsible for payment. Office charges must be paid at the time of your visit, and surgical fees must be paid at least two weeks in advance of your surgery date.Back to top
