We are being asked increasingly about the relatively new injection treatments - Botox, and Greater Occipital Nerve blocks. For whom they are appropriate, these have changed headache treatment for the better. The problem of taking too many tablets has got a lot of press recently and patients are becoming more aware of how much is too much.
Migraine affects the head, so let’s treat the head, not the stomach!
To clear up any confusion here is brief round-up of what the two procedures entail with stories from two patients who have found them useful:
What? Botulinum toxin, of which Botox is the best known brand, is given as a series of tiny (0.1ml) injections under the skin or into the muscles of the forehead, above the ears, and into the neck and shoulders. For headache, the usual number of injections is 31 to 39.
Who? Botox, is licensed for the treatment of chronic migraine, i.e. in people who for 3 or more months have over 15 days of headache a month, of which at least 8 days are migraine (i.e. headache plus other features). The UK licence is restricted to people aged 18 to 65; and NHS use requires that medication overuse has been addressed, and three migraine prophylactics have failed. These restrictions need not apply to patients paying for their own Botox at the National Migraine Centre.
Why? A trial of almost 1400 chronic migraine patients proves benefit; probably by gradually blocking the action of pain nerves (C-fibres) which release chemicals that perpetuate and amplify chronic migraine pain.
When? The injections are normally repeated after 12 weeks. The effect usually lasts about three months, though once the vicious cycle of chronic migraine is interrupted, Botox treatment can cease. Two treatments, 12 weeks apart, are sufficient for many people; some need to continue treatment for longer.
How effective is it? Three out of four people with chronic migraine benefit after the first or second set of injections. The most typical response is conversion from chronic to episodic migraine, which then needs careful management to prevent recurrence of chronic migraine. Episodic migraine (i.e. fewer than 15 days headache each month) has not been shown to respond to Botox. There are other botulinum toxins available but these have not been found effective in any form of migraine, so are not approved by NICE or used at the NMC.
What are the side effects? Side effects are relatively uncommon and always get better naturally in a few days or weeks. Each of the following affects one in ten or twenty patients: worsening of migraine; neck pain and weakness; droopy eyelids or eyebrows. The injections sting slightly, and there can be a little bleeding from the injection sites. Very rarely, patients are allergic to botulinum toxin. People with nerve and muscle problems, other than migraine, may be oversensitive to botulinum toxin.
GREATER OCCIPITAL NERVE BLOCK
What? A greater occipital nerve (GON) block is an injection of local anaesthetic and depot steroid (i.e. it stays at the injection site) around the nerves which supply the scalp at the back of the head.
Who? Any form of headache may respond to greater occipital nerve block. If the nerve is blocked it cannot carry pain.
When? Benefit begins between an hour and a week after the injection. If you respond well, we may recommend additional injections when symptoms return. With some exceptions, in any given six-month period, we generally do not like to perform more than three nerve blocks.
Why? The steroid reduces inflammation and allows the local anaethetic to have a lasting effect. This may in turn reduce pain, and other symptoms caused by inflammation or irritation of the nerves and surrounding structures. Part of the benefit is from interrupting the feedback cycle of pain in the trigemino-vascular pathway. If migraine is like a faulty fire alarm, GON block is like putting a sock over the smoke detector.
How effective is it? In a trial at the Institute of Neurology in London involving 100 people with migraine and cluster headache just over half of patients found some pain relief, and 22% of these were pain free for between 20 and 90 days.
What are the side effects? Serious complications from this procedure are very rare. However, as with any injection, infection around the injection site could theoretically occur, as can bleeding. The most common side effect is pain which is temporary. The injection is just behind the ear, and you can hear it happening, which is disconcerting. There is often some swelling at the injection site, and a few hours on numbness at the back of the head. Twice Dr Elrington has had patients faint during the procedure – fortunately both had a good response.
Obviously here we are sharing the success stories with you. For a lot of people these treatments show little or no improvement but we feel it is important for those who feel they have 'tried everything' (a phrase we hear time and time again), that there are options.
The minimal risk of serious side-effects from these procedures compared to medication means that for many we think it is worth considering.
If you feel you have tried everything – make a list of exactly which drugs, at what dose, and for how long. Medication overuse (10-15+ days of acute or rescue mediation, with 15+ days of pain per month over at least 3 months) largely blocks response to other treatments and is a very common cause of treatment failure: previously disappointing medications can become effective a few weeks after addressing medication overuse.
Often doctors and patients do not use regular medication for long enough, or at sufficiently high doses. Never give up treating headache and migraine.
Both Botox, and nerve blocks are carried out at the NMC should you wish to try one of the treatments. Not all of our doctors administer them, so please discuss with reception if you are considering booking for a procedure.
Unfortunately we have to charge for these as the equipment and drugs required cost a significant amount more than an average consultation. We price them simply to cover our costs so they are more reasonable than at a private clinic.