Before the advent of Botox in the treatment of head pain, I never agreed to see a patient in consultation regarding head pain until he/she had undergone complete evaluation by a neurologist or physical medicine specialist to rule out the possible problems noted above (tumors, etc.). Quite simply put, if you have a brain tumor, I'm not the one who will diagnose it, much-less treat it. As regards headache, my only expertise is to determine whether your pain seems related to a particular type of nerve compression syndrome caused by small muscles in the region of the brows and/or at the base of the skull, and to offer you treatment if this seems to be the case. That may seem to be specialization in the extreme, but, fortunately, recent clinical experience published in the peer-reviewed medical literature and the media, generally, strongly indicates that many patients with chronic head pain experience relief when specific muscles are weakened temporarily with Botox, and surgery offers a more-permanent solution for most of these patients. Success rates for migraine patients are approximately 80%.

Why Try Botox?

If your headache is caused by arthritis in your neck or a tumor or other abnormality inside of your skull, it shouldn't be improved by weakening the muscles of the brow or the back of the head with Botox. The opposite is also true: If weakening those muscles temporarily with Botox results in pain relief, it is logical to think that they play a significant role in your pain. Trying Botox for headache, then, can be viewed as a test to determine whether those muscles 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 Botox blocks afford them. 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 talk seriously about 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 nerves. 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. Botox actually inactivates the nerve-muscle junction, and the muscle fibers involved must grow new nerve connections before they can contract once again. 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 region of the brow.

How Did Botox and Surgery Become Treatments for Migraine?

In the course of treating wrinkles, muscle spasm after stroke, and other various problems, physicians began to note a surprising extra benefit of the drug: Some patients whose brows were injected for wrinkles noted that their headaches, often of many years' duration, had cleared spontaneously. Any good scientist knows that many health problems and outcomes are simply coincidental: they both may occur, but aren't related. However, the numbers of patients with forehead wrinkles who reported headache improvement began to increase, and the possibility became clearer: Perhaps weakening a few specific muscles containing branches of the nerve system registering pain in all parts of the head (the Trigeminal, or Fifth Cranial Nerve) somehow stabilized that system and caused it to quit signaling pain. In its simplest terms, decompressing these nerve branches by paralyzing muscles that were irritating them might be comparable to temporarily removing a “slipped disc” that was causing compression of a spinal nerve root. Some, if not most, headache might be a fairly simple mechanical problem, rather that a complex and often-mystical assortment of molecular and psychological interactions inside of the skull.

In 2000 A plastic surgeon in Cleveland, Dr. Bahman Guyuron, first published 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, Varghai A, Michelow BJ, Thomas T, Davis J. Corrugator supercilii muscle resection and migraine headaches. Plast Reconstr Surg. 2000 Aug;106(2):429-34). 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. Lots of things are done in the course of a brow lift, but the surgical maneuver which appears to be the most likely source of headache relief for these patients was removal of the same small muscles of the brow that are weakened temporarily by Botox when wrinkles are treated. These muscles, the corrugator and procerus, can be carefully removed using techniques designed to protect the small branches of the Trigeminal nerve that pass through them. For patients whose headache is primarily in the forehead region, the corrugator and procerus are the most likely candidates for this treatment.

What if My Head Pain Isn’t in My Forehead?

All headache and other head pain are not centered in the forehead; often they may occur in another quite-specific area, or may be generalized to involve the entire head and/or neck and shoulders. Is it possible for small muscles in the brow, or elsewhere on the outside of the skull, to cause pain at these various sites? The simple view is that this shouldn't happen, just as a problem with the brakes of your car would seem to be an unlikely source of engine trouble. However, the human nervous system is much more complex than your car, and the interrelationships between its parts are not all well-understood. This complexity is the primary reason for the ongoing debates and opposing theories regarding head pain and its treatment. Sometimes solid and well-meaning experts cannot even agree on how to name the specific type of headache or pain a patient is experiencing, much less offer a satisfying explanation or treatment. Botox and other forms of nerve blocks can serve as tests, temporarily turning off various nerve and muscle circuits to determine if and where nerves may be irritated.

The Back of the Head: Another Source of Migraine?

Is it possible for a “pinched nerve” under the scalp in the back of the head to cause pain in the forehead, or throughout the entire head? The simple answer is, “Yes, probably so.” The nerve in question in the back of the head (the greater occipital nerve ) isn't a cranial nerve like the Trigeminal nerve, and it arises from the spinal cord. The Trigeminal nerve arises in the brain stem, which is closer to the brain, itself, and the two don't meet through most of their individual courses. This is like the brakes/engine trouble analogy discussed previously. However, there has been recent appreciation of a long-known detail of the neuroanatomy of the brain stem and upper spinal cord: the Trigeminal nerve starts in the brainstem, but then sweeps down inside the spinal cord, does a u-turn and goes back up the cord and into the brainstem once again before exiting to give off its many branches. This loop of the Trigeminal, called (going down) the descending tract and the secondary ascending tract (going back up) apparently intermingles with incoming fibers from the greater occipital nerves, and interaction between the two systems at that point seems quite likely. Stimulation or irritation of one system quite likely can affect the other. Thus, forehead pain may be caused by a pinched nerve at some location on the opposite side of the head.

Is this possible interaction between Trigeminal and greater occipital nerves just a theory? There are many theories in the neurosciences, and most of them are hard to prove. One fact lends strong support to the possibility, though: head pain at many different sites (all innervated by the Trigeminal system) has often been improved or eliminated by weakening the small muscles in the back of the head which envelop the occipital nerves . These muscles, the semispinalis capitus, 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 we might encounter in evaluating your head pain with Botox is that it simply might not help. If we can't help you, we can certainly put you in touch with other appropriate resources. Other complications of trying Botox in the brow region relate to the possibility of 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 situations. If we block the small muscles of the brow, you will note smoothing of the forehead and mid-brow. For most of us, this is a desired effect: we do not look as angry or worried. However, if you are in the media or another profession that requires unusual emotion and extreme facial expression, we should discuss alternative block techniques. Conversely, if you are a professional gambler a Botox block may be distinct advantage.

Botox and the FDA

The FDA position regarding the use of Botox in the diagnosis and treatment of headache is not clear at this time. This drug has been approved for use in many of the muscles controlling the movements of the eye, and for muscle spasm and imbalance in many other anatomical areas; it has also been approved for use to treat wrinkles in the forehead and brow. For many of these purposes, much higher doses of Botox are used routinely, when compared to the doses given in head pain management. In spite of these facts, we presently consider our Botox-related techniques to be an “off-label” use of the drug. This simply means that the manufacturer has not, as yet, obtained formal FDA approval for this particular use in a clear-cut way. Because we are research-oriented, and want you to be fully-informed of every aspect of your care by us, we have prepared a long and involved consent form that follows the format and detail suggested by our national board-certified association, the American Society of Plastic Surgeons. To put this form in perspective, remember that we wouldn't be troubling you with it at all if were using an identical amount of Botox to treat your wrinkles or muscle spasms in some other locations.

What’s Next?

If you've taken the time to read this far, you or someone you care about very much is significantly troubled by headache. Is Botox and/or surgery the answer? Possibly not, but, apparently, nothing else has worked very well either. Head pain can be a very difficult and disabling problem. Botox and the muscle-irritation theory that it involves may simply not be the answer, but if that is the case, you (or your loved one) will not find it difficult to determine. We can tell you if we might be of help, and you will be the first to know, within 5-7 days (the time it takes for Botox to work). If we haven't made a difference, we hope that you will agree that it was worth exploring. We think it's likely (statistically, and with good science) that we can be very helpful. We would consider it a privilege to care for you.