Migraine Treatments

Last updated on September 17th, 2021 at 06:46 am

YOGA AND MEDITATION FOR HEADACHE, MIGRAINE, AND PAIN.

@Neuralgroover

Yoga and meditation can help with fitness and mindfulness, but there are additional benefits. These activities can help you with migraines, headaches, and other types of pain. Yoga has the ability to help you:

  • Alleviate stress, which is a common source of headaches, migraines, and pain.
  • Sleep better, as sleep deprivation can cause or worsen headaches and migraines.
  • Support better posture, as poor posture is an agitator of migraines and headaches.
  • Reduce muscle tightness, as tension in your back, shoulders, and neck can be a contributor to migraines and headaches. Keep in mind that there is often an interconnection between neck and shoulder musculature and headaches. 70% of patients with migraine get neck pain and stiffness associated with their migraine attacks. Conversely, if there is significant tightness and spasm in these muscles, they can irritate the nerves in the back of the head (occipital nerves), and this can also contribute to headaches and migraines. So targeting these muscles to get them to relax can be very helpful.

 

There was a study published which looked at adding on yoga therapy in combination with standard migraine medical treatments. The study results concluded that yoga as an add-on therapy in migraine was superior to medical treatment alone. Therefore, it was suggested to integrate yoga as a cost-effective and safe intervention into the management of migraine. Other prospective randomized open label trials, systematic reviews, and meta-analyses have shown yoga to decrease headache frequency, headache pain intensity, and headache duration in both migraine and tension type headaches.

 

Tips for Starting Yoga To Improve Headaches, Migraines, and Pain

If you are thinking about starting yoga to improve your headaches, migraines, or pain, there are a few tips to keep in mind:

  • Always speak with your doctor before beginning to see if it is a good fit for you.
  • Consider a beginner’s class if you are new to yoga.
  • Check with the instructor to tell them about your headaches, migraines, or pain. They can recommend good poses or even modify certain poses so that they do not contribute to agitating your headaches or migraines.
  • Avoiding certain types of poses, like inversion, can reduce the likelihood of causing a headache.

 

 

Yoga Poses That Your Instructor Might Recommend To Reduce Headaches, Migraines, and Pain

There are a few poses that many yoga instructors might recommend if you suffer from headaches, migraines, or pain. These include:

  • Child’s pose: This pose can reduce tension in your upper body.
  • Cat and cow pose: This pose increases circulation, as well as reduces tension in your shoulders and back.
  • Seated forward fold: This pose opens up your shoulders and stretches out your back, a great way to relieve the tension in these areas of your body that causes headaches.
  • Legs up the wall: This pose helps blood flow towards your brain, which can help alleviate an existing headache.
  • Savasana: This pose uses the ground below your body to provide throughout and can increase oxygen to your brain, alleviating an existing headache or migraine.

Not only are the poses that go along with migraines beneficial, but some of the other techniques that go along with yoga, like breathing can help with headaches and migraines. Alternate nostril breathing is a common way to calm the mind and relieve stress. Yoga also helps tames the anxiety center of the brain, which is another way to relieve stress.

 

Meditation for Headaches, Migraines, and Pain

Meditation reduces stress and can possibly impact the severity of headaches and migraines. A recent study by the NIH was conducted that found several interesting results when meditation was used for headache and migraine sufferers:

  • The frequency and intensity of headaches and migraines could potentially decrease as a result of meditation.
  • People who practiced meditation had a decreased use of non-opioid medications over time.

The benefits of meditation for headaches and migraines include:

  • The ability to potentially lower stress levels, a key driver of headaches and migraines.
  • An improved pain tolerance with the onset of headaches and migraines.
  • A reduction in the frequency and intensity of headache, migraines, and other types of pain.
  • A better quality of life.

 

Meditation and migraine were studied in 92 patients and results were published. Over 30 days, the frequency of migraines decreased significantly. Medication usage was also significantly lower in the meditation group.

 

Different Types of Meditation Techniques To Try For Headaches, Migraines, and Pain

There are several different types of meditation techniques that you can try that can potentially help with stress reduction. These different techniques can also take your thoughts off of your headache, migraine, or pain.

Mindfulness Meditation

This type of meditation has its origins in Buddhism and is one of the most popular meditation techniques to try. When practicing mindfulness meditation, you will focus on your thoughts, as well as sensations, thoughts, and feelings.

Visualization Meditation

This type of meditation involves visualizing positive scenes and images and focusing on them. Another type of thing to focus on with visualization meditation is thoughts and scenes of where your headache, migraine, or pain has subsided.

Progressive Relaxation

This type of meditation is common to help you relax before you sleep and involves reducing tension in the body and promoting an overall sense of relaxation. This technique also involves “scanning” your body to isolate areas of pain and tension. When focusing on the head, shoulders, and neck, this technique can be particularly effective in reducing the intensity of headaches and migraines.

Movement Meditation

This technique involves changing your surroundings. You can take a walk, practice gardening, or even exercise while being aware of sensations and feelings within your body. Movement meditation can help reduce stress, which may in turn, alleviate the onset of headaches, migraines, and other types of pain.

 

 

Additional Benefits of Meditation

Meditation indirectly reduces the onset and severity of headaches, migraines, and other types of pain. However, there are several additional health benefits, over time, that come along with meditation practices:

  • Meditation has the power to reduce blood pressure, which can be a driver of headaches and other chronic diseases, like diabetes. High blood pressure is also the leading cause of stroke.
  • Anxiety is a condition that can be potentially alleviated by meditation.
  • Meditation can also increase feelings of self-worth, which can help overcome depression.
  • Sleep can be aided by meditation and improved sleep can also help reduce the onset of headaches, migraines, and pain.

 

 

Reducing Tension, Stress, and Anxiety

Overall, meditation and yoga are an array of techniques that you can use to reduce stress, tension, and anxiety in your body. These are things that can contribute to headaches. Yoga may help increase blood flow in the body, which can also help reduce headaches, migraines, and pain.

Overall, it is best to consult your doctor when considering treatments for headaches, as yoga is an advanced technique that you should work with an instructor on.

 

IF YOU HAVE HEADACHE, MIGRAINE, OR FACIAL PAIN AND ARE LOOKING FOR ANSWERS ON ANYTHING RELATED TO IT, A HEADACHE SPECIALIST IS HERE TO HELP, FOR FREE!

FIRST, LET’S DECIDE WHERE TO START:

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR THE LATEST INFORMATION, HOT TOPICS, AND TREATMENT TIPS, VISIT OUR FREE BLOG OF HOT TOPICS AND HEADACHE TIPS HERE. THIS IS WHERE I WRITE AND CONDENSE A BROAD VARIETY OF COMMON AND COMPLEX  MIGRAINE AND HEADACHE RELATED TOPICS INTO THE IMPORTANT FACTS AND HIGHLIGHTS YOU NEED TO KNOW, ALONG WITH PROVIDING FIRST HAND CLINICAL EXPERIENCE FROM THE PERSPECTIVE OF A HEADACHE SPECIALIST.

 

IF YOU DON’T HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR POSSIBLE TYPES OF HEADACHES OR FACIAL PAINS BASED ON YOUR SYMPTOMS, USE THE FREE HEADACHE AND FACIAL PAIN SYMPTOM CHECKER TOOL DEVELOPED BY A HEADACHE SPECIALIST NEUROLOGIST HERE!

 

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR FURTHER EDUCATION AND SELF-RESEARCH ON YOUR DIAGNOSIS, VISIT OUR FREE EDUCATION CENTER HERE.

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Last updated on November 18th, 2021 at 11:54 pm

HOME AND NATURAL REMEDIES FOR HEADACHES, MIGRAINES, AND PAIN.

@Neuralgroover

Staying Hydrated and Eating Healthy

Not drinking enough water (dehydration) is a common cause of headaches. Some studies indicate that there is a strong correlation between poor hydration and headaches. According to Science Direct, there are several different causes of headaches that are linked to lack of hydration and food or food additives. These include:

  • Skipping meals
  • Alcohol intake
  • Caffeine withdrawal
  • Excess salt (sodium) intake



According to the NIH, immediately hydrating can potentially eliminate your headache in as early as 30 minutes, if the cause is dehydration. Avoiding alcohol, eating right, and drinking plenty of water throughout the day is a great way to keep headaches from happening.

Certain types of foods can be headache triggers and avoiding these foods can help prevent headaches. Migraine is particularly susceptible to various food and food additive headache triggers. For example, aged cheese can be a headache trigger. Pickled food products, prepared food (like potato chips), canned soups, and others are also possible headache triggers. Other foods that cause headaches can be found in this article.

Sleep is another way to alleviate headaches. For people who get less than six hours of sleep, they are more likely to have a headache. In a recent study, 85% of migraine sufferers chose sleep to relieve their headache while 75% reported that their headache forced them to get rest because of their headache.

Hot and Cold Compresses

For any type of headache that has radiating pain, you can place a cold compress on the area where the pain started. The cold temperature will help numb the pain, and this tends to be especially helpful for migraine. For tension headaches, studies have shown that a hot compress can work fairly well. If you have a tension headache, the hot compress can be placed on the neck or shoulders to release tension in your muscles. There are other conservative treatments on how to treat headaches without medication discussed here.

 

Essential Oils For Headaches and Migraines

Essential oils are another type of remedy for headaches. These essential oils are made from the bark, flowers, leaves, stems, and roots of plants. Some of the more popular types of essential oils for alleviating headaches include peppermint essential oil, rosemary essential oil, chamomile essential oil, eucalyptus essential oil, and lavender essential oil. Some of these oils can be used in an aromatherapy format and others can be applied topically. Here are some of the benefits of these essential oils for headaches:

  • Peppermint essential oil: Peppermint essential oil can relax muscles, ease pain, and alleviate tension and migraine headaches. This essential oil is typically applied topically.
  • Rosemary essential oil: Rosemary essential oil can reduce insomnia and relax muscles, as well as help with headaches. This essential oil can be applied topically or used via a diffuser.
  • Chamomile essential oil: Chamomile essential oil is commonly used for reducing stress and tension. It is a great aid for reducing tension headaches.
  • Eucalyptus essential oil: Eucalyptus essential oil is great for clearing sinus headaches and can be highly effective when used with other essential oils, like peppermint.
  • Lavender essential oil: Lavender essential oils are great for reducing stress and helping with overall relaxation. Commonly used via aromatherapy, lavender essential oil is great for reducing migraine severity.

Teas Can Help Alleviate Headaches, Migraines, and Pain

Herbal teas, without caffeine, can help alleviate the severity of headaches, migraines, and pain. These teas can help add water to the diet. Ginger, for example, is an herb for tea that works particularly well with alleviating migraines, and especially the nausea associated with migraines. Some studies indicate that ginger can alleviate headaches and migraines particularly quickly. Ginger can potentially help alleviate symptoms as soon as two hours after use. Other types of herbal teas include peppermint, chamomile, and lavender.




Vitamins and Minerals That Can Help With Headaches, Migraines, and Pain

Vitamins and minerals, like Vitamins B, E, and magnesium can help with headaches. Natural migraine preventive supplements including vitamins, minerals, and herbal supplements are detailed further here. By adding these vitamins and minerals to your diet, you can help relieve headaches over time.

  • Vitamin B: Vitamins B6 and B12 are available as supplements and can play a role in general nerve and neurological health, although excess B6 can also cause neuropathy, so should not be used in excess. Vitamin B2 is the B vitamin which has good evidence for preventing migraine headaches.
  • Vitamin E: This vitamin may play a role in relieving headaches and migraines associated with the menstrual cycle.
  • Magnesium: Increasing the amount of magnesium in your diet can work particularly well if you experience migraine headaches, and has shown benefit in some patients with cluster headache and tension type headache.

Relaxation Techniques That Can Help Reduce the Severity of Headaches, Migraines, and Pain

Different types of relaxation techniques, such as breathing can help alleviate headaches. These relaxation techniques work best when you are alone.

  • Breathing Techniques: Deep breathing, visualized breathing, and rhythmic breathing are all activities that one can do to reduce stress and cope with migraines or headaches.
  • Visualized Breathing: Visualized breathing involves imagining the air moving in and out of you and each breath gets rid of a little bit more tension.
  • Progressive Muscle Relaxation: This involves taking note of the different areas of your body that hurt and relaxing them gradually. Rotating your head slowly and removing tension from your neck and shoulder muscles can help alleviate any headache or migraine symptoms.
  • Meditation, Yoga, and Mental Imagery Relaxation: These are different techniques, but they all have one thing in common. They make you pause any activity that is causing you stress and focus on yourself. Mental imagery relaxation involves focusing on peaceful images in your mind. Yoga helps calm the mind but also strengthens some of the muscles and tendons that can contribute to stress.

Acupressure and Acupuncture For Headaches, Migraines, and Pain

Acupressure is a technique that involves applying pressure to certain parts of the body. Acupressure works particularly well for headaches if you apply pressure at the base of your skull/back of the neck area. Using your knuckle or fingertip, simply apply pressure gently for 15 to 30 seconds. This should provide some moderate relief for a headache. Acupuncture has also shown some benefit in headache disorders such as migraine and tension type headache.

 

IF YOU HAVE HEADACHE, MIGRAINE, OR FACIAL PAIN AND ARE LOOKING FOR ANSWERS ON ANYTHING RELATED TO IT, A HEADACHE SPECIALIST IS HERE TO HELP, FOR FREE!

FIRST, LET’S DECIDE WHERE TO START:

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR THE LATEST INFORMATION, HOT TOPICS, AND TREATMENT TIPS, VISIT OUR FREE BLOG OF HOT TOPICS AND HEADACHE TIPS HERE. THIS IS WHERE I WRITE AND CONDENSE A BROAD VARIETY OF COMMON AND COMPLEX  MIGRAINE AND HEADACHE RELATED TOPICS INTO THE IMPORTANT FACTS AND HIGHLIGHTS YOU NEED TO KNOW, ALONG WITH PROVIDING FIRST HAND CLINICAL EXPERIENCE FROM THE PERSPECTIVE OF A HEADACHE SPECIALIST.

 

IF YOU DON’T HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR POSSIBLE TYPES OF HEADACHES OR FACIAL PAINS BASED ON YOUR SYMPTOMS, USE THE FREE HEADACHE AND FACIAL PAIN SYMPTOM CHECKER TOOL DEVELOPED BY A HEADACHE SPECIALIST NEUROLOGIST HERE!

 

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR FURTHER EDUCATION AND SELF-RESEARCH ON YOUR DIAGNOSIS, VISIT OUR FREE EDUCATION CENTER HERE.




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Last updated on April 30th, 2021 at 11:13 pm

MIGRAINE HEADACHES EXPLAINED.

@Neuralgroover

Migraines are a very intense type of headache that are often accompanied by other symptoms, including nausea, vomiting, sensitivity to light and sound, as well as neurological symptoms such as visual disturbances, numbness or tingling, speech disturbances (slurred speech, difficulty getting words out), weakness, vertigo, cognitive dysfunction or “cognitive fog”, among other things. Migraines tend to be more prevalent in women than in men, with a 3:1 ratio. A common risk factor for migraines often involves family history, but not for everyone.  People who suffer from migraines report intense feelings of pain, including a pulsating/throbbing sensation. This often occurs on 1 side of the head, but can also involve both sides. Exercise and activity during a migraine will often make it worse. Migraine is usually associated with nausea, and/or sensitivity to light (photophobia) and sound (phonophobia)  Migraines often come in different phases, which are called prodrome, aura, the headache phase, and postodome, but not everyone gets all 4 phases:

  • The prodromal phase of a migraine often marks the beginning of a migraine attack and can happen over a period of a few hours ranging to a few days. Some of the symptoms include irritability and depression; food cravings; yawning and tiredness; and fatigue or muscle stiffness. Some patients report their prodrome as just a difficult to describe feeling that they recognize as an early warning sign of an impending migraine. Not every migraine attack includes the prodromal phase.
  • The aura phase of a migraine doesn’t necessarily always happen in every migraine attack, and only about 25% of patients with migraine get aura. Historically, those that get aura are called “classical migraine”, whereas “common migraine” refers to the more common variety of migraine which isn’t associated with aura. A large number of people who have migraines report that during the aura phase, they experience loss of sight, numbness, and other symptoms. Visual aura (loss of vision, jagged lines, flashing, colors, shapes, wavy lines, kaleidoscope, shimmering, expanding blind spot, etc.) are the most common aura. This is followed by numbness and tingling on 1 side (especially face and arm), and then dysphasia (trouble speaking; slurred speech, getting words out). There are also less common types of aura such as hemiplegic migraine aura (1-sided weakness), and brainstem aura (previously called “basilar migraine”; slurred speech, vertigo, tinnitus, double vision, hearing impairment, decreased level of consciousness, ataxia/imbalance). The aura phase should last between 5-60 minutes per ICHD3 criteria. Hemiplegic migraine can be associated with 1-sided weakness which can last up to 3 days. If the other types of aura last longer than 60 minutes, it is called prolonged or atypical aura, and usually warrants a brain CT or MRI, although it is not too uncommon to see. .
  • The headache phase of a migraine is often the longest and most intense period of a migraine. Symptoms include intensive throbbing, nausea, giddiness, irritability, stiffness, and soreness. According to ICHD3 criteria, an untreated or unsuccessfully treated migraine attack should last 4-72 hours. A headache lasting longer than 72 hours (3 days) is called status migrainosus. It is not uncommon for a refractory migraine to last days and sometimes weeks for some patients.
  • The postdrome phase is the drawing down of a migraine attack. It can last for up to 48 hours and some of the lingering symptoms remain from the other phases of a migraine attack. Patients often report feeling wiped out, fatigued, and sore as if they were “hit by a bus”.

 

According to the American Migraine Foundation, more than 36 million people suffer from migraines (although now estimated to be closer to 39 million), but only one out of three people actually talk to their doctors about their pain.

Statistics About Migraines and Their Prevalence

According to several different sources, migraines are one of the most common types of illness in the world. More specifically, it is ranked as the 3rd most prevalent illness in the world. It is estimated that migraine affects about 39 million Americans, and 1 billion worldwide. For example, 1 in 4 households in the United States have an individual that suffers from migraine attacks. Migraines impact 18-20% of women (1 in 5) and 6% of men (1 in 16) in the United States and they are also fairly common in children.

Migraines are also a common cause for an emergency room visit. In fact, there are more than 1.2 million emergency room visits each year in the United States for someone who is suffering from an acute migraine attack. Patients with migraine have a greater than 1.5 fold increase in office visits, and a greater than 2 fold increase in ER visits and hospital admissions. Migraines can also diminish the quality of life for the people who suffer from them. More than 4 million adults suffer from chronic migraine pain, which is an individual who is experiencing more than 15 days of migraine pain each month. Approximately 3% of patients will transform from episodic migraine to chronic migraine each year. Overall, it is estimated that 3-5% of patients in the United States have chronic migraine. Also, 20% of people who suffer from chronic migraines are disabled. Disability due to migraine peaks between the ages of 15-49 years old, which are peak employment years. Thus, migraine now accounts for the 2nd leading cause of years lived with disability following low back pain! Migraine also accounts for 50% of all neurologic disability. All of this puts a very high price tag on migraine, with an estimated 36 billion dollars spent in migraine costs in the United States each year.

 

Migraines in Children

Migraines are commonly undiagnosed in children. They are more commonplace in adolescent children, but 10% of school-age children suffer from migraines. Half of all migraine sufferers have their first migraine attack before they turn twelve and if a child has one parent who suffers from migraines, they have a 50% chance of developing migraines during their lifetime. Also, boys under the age of twelve tend to have migraines more often than girls, but that trend reverses in adolescence, typically with onset of menarche (which also highlights the hormonal influence on migraine).

 

What Causes Migraines?

There are a number of reasons that people suffer from migraines, but the true cause of them is not fully understood. Genetics and environmental factors play a role. In fact, around ⅔ of migraine cases run in families. Migraines also tend to happen in people who are prone to stress, bipolar disorder, and depression. There are also some common triggers for migraines, including:

  • Drinks, such as alcohol and caffeinated beverages.
  • Work stress or stress at home.
  • Bright lights or strong smells.
  • Drastic changes in one’s sleep cycle.
  • Bouts of overexertion.
  • Changes in the weather or other barometric pressure changes
  • Certain foods and food additives such as MSG, nitrates, aspartame, and other substances such as artificial sweeteners.

 

Migraine Theories:

1) Vascular theory; “vascular headache” (outdated):

a) Lack of blood flow (ischemia) caused by vasoconstriction (narrowing) of the intracranial arteries (arteries inside the brain) caused migraine aura.

b) The vasoconstriction was then followed by rebound vasodilation (dilation) of the arteries. This dilation activated pain receptors on the arteries, and this was the cause of the pulsating headache.

c) This theory has since been disproven and outdated. Studies have also shown that the physical pulsations of the arteries did not correlate to the pulsating sensations of the headache pain.

2) Neurovascular theory (current):

a) Migraine is a neurogenic process with secondary changes in cerebral perfusion (related to neuronal dysfunction and hypometabolism during an attack). In other words, migraine is an electrical neurological event in the brain, not an event triggered by blood flow changes. This electrical event influences changes in brain metabolism such as hypometabolism and hypermetabolism. When the neurons are in a hypometabolism state, they have less oxygen and glucose requirement since they are not as active, and thus there is a lack of blood flow (not due to vasoconstriction of the brain arteries). This can be followed by hypermetabolism in which there is an increase in oxygen and glucose requirements and thus, increase in blood flow (so not necessarily simply rebound vasodilation).

 

b) Migraine aura is a good illustration of this phenomenon. Migraine aura is caused by an electrical wave spreading across the cortex of the brain moving at about 3 mm per minute (not by vasoconstriction as per the older vascular theory). At the front of this spreading electrical wave it causes hypermetabolism and an increase in blood flow. This hypermetabolism causes the “positive” migraine aura features (colors, flashing lights, kaleidoscope, shapes, zig-zags, tingling sensory changes, etc.). Following this electrical wave there is “neuronal depression” and hypometabolism, associated with a decrease in blood flow. This hypometabolism causes the “negative” migraine aura features (loss of vision, black spots, numbness, etc.). Depending on where this wave spreads, you may get different aura symptoms; visual aura as it spreads across the occipital (visual) cortex, sensory/numbness/tingling as it spreads across the parietal (sensory) cortex, dysphasia (trouble speaking, slurred speech) as it spreads across the frontotemporal (speech) cortex, one sided weakness in hemiplegic migraine as it spreads across the frontal (motor) cortex, brainstem symptoms such as vertigo, tinnitus, double vision, hearing loss, imbalance, decreased level of consciousness, slurred speech (previously called basilar migraine, now called migraine with brainstem aura) as it spreads across the brainstem.

 

c) The electrical event of migraine not only causes the changes in metabolism as described above, but the trigeminal nerves are also activated. Think of migraine as an electrical switch that gets turned on in the brainstem. It then turns on and activates the trigeminal nerves. The trigeminal nerves innervate all of the arteries in the brain and through the meninges surrounding the brain. When activated, the trigeminal nerves release a variety of inflammatory proteins (such as CGRP) and neuropeptides. The result of this is 3-fold:

1st, these inflammatory peptides cause neurogenic inflammation around the brain. Think of it like a sterile (non-infectious) meningitis. So, when you’re having a migraine, exercise and activity, moving around, bouncing in a car, etc. often worsen the pain.

2nd, it causes cerebral vasodilation in the brain and meninges. The dilation itself does not cause the pain, but rather it triggers the trigeminal nerves which innervate the arteries, and this sends signals back to the brain that something is going on, which in turn causes more release of inflammatory proteins and causes the migraine to worsen. This is the basis of why it is called the neurovascular theory of migraine.

3rd, it enhances and exaggerates the transmission of pain from the trigeminal nerves, into the brainstem, and into the cortex of the brain where the pain is recognized.

 

At baseline, a patient with migraine who is not having a headache always has a state of neuronal hyperexcitability in the cerebral cortex, especially in the occipital cortex (which is why the majority of aura symptoms tend to be visual aura). So, they have a much lower threshold to a migraine being activated and triggered as compared to someone without migraine. In other words, the neurological system in a patient with migraine can be thought of as always being in a hyperactive, hypersensitive, overdrive state with the “volume turned way up” compared to a person without migraine. Thus, I tell my patients the goal of preventive treatment is to “turn the volume down” and increase the threshold of migraine being triggered so easily.

 

What Are Some Common Treatments for Migraines?

There are two categories of treatment for any type of headache, including migraines. Migraines can be treated through abortive or preventive means. Abortive treatment for any type of headache includes medications such as aspirin, which treats the headache while it’s happening. Preventative treatments are intended to keep a headache or migraine from happening so frequently. Here are some of the different types of treatments for migraines.

 

Abortive Treatment for Migraines

The goal of migraine abortive treatments is to stop individual migraine attacks at onset so the migraine does not reach full severity, ends quickly, and your function is restored and maintained rather than having to go lay down and miss the whole day in bed.  Over-the-counter pain relievers for migraines, such as aspirin or ibuprofen, are fairly commonplace. Some more aggressive abortive treatments include prescription medications like triptans (such as Maxalt) that block pain pathways within the brain. Some people may also receive anti-nausea drugs and opioid prescriptions to deal with more intense migraine symptoms. The migraine specific abortive/acute (as needed) treatments include triptansgepants (Ubrelvy, Nurtec), ditans (Reyvow) or neuromodulatory devices.

Preventative Treatments for Migraines

Medications that lower blood pressure, antidepressants, anti-seizure drugs, CGRP monoclonal antibodies, and even botox are some of the common preventative treatments for migraines. The classification of the preventive medicine typically has nothing to do with its purpose when it is used for migraine. For example, there are specific anti-blood pressure medicines that are good for migraine prevention. However, they do not work for migraine because of blood pressure changes, but rather they affect the electrical pathways of migraine. The same scenario goes for the antidepressant/anti-anxiety and anti-seizure categories. The medicines selected within each of these preventive categories are very specific and based on clinical trials and evidence. In other words, not all medicines within a specific medication class (such as all antidepressants) have evidence for migraine prevention, but rather very specific ones within that class. Medications that are designed to lower blood pressure can sometimes prevent migraines with aura and without aura. Certain types of antidepressants can help prevent migraines, but have some undesirable side effects in some individuals. Anti-seizure drugs, such as Topamax, can reduce the frequency of migraines in some individuals. The preventive migraine treatments should be used until the migraine and headache frequency is significantly improved consistently for several months. As mentioned above, this can be done with a variety of medications which may also include the CGRP monoclonal antibody (mAb) treatments (Aimovig, Ajovy, Emgality, Vyepti), Botox, natural supplements, herbals and vitamins, or neuromodulatory devices.

Alternative Treatments for Migraines

Some other types of treatment for migraines include acupuncture, cognitive behavioral therapy, supplements, essential oils, yoga, meditation, and other techniques designed to enhance relaxation. For some individuals, exercise can decrease the frequency of migraines. In fact, some studies have shown that a routine exercise program can be just as effective as some of the prescription preventive medications used for migraine. Neuromodulatory devices that are FDA cleared for migraine prevention are also available and include sTMS (SAVI, SpringTMS, sTMS mini),  eTNS (CEFALY), and nVNS (GAMMACORE), all of which are discussed in much greater detail here. There are also nutraceuticals and supplements which have good evidence for migraine prevention.

 

Finding Help For Migraines

Migraines remain a poorly understood medical condition, but there are treatments available. Only 4% of people suffering from migraines work with a headache specialist or a pain specialist. It is estimated that preventative treatment could benefit around 25% of people who suffer from severe migraines.

If you suspect that your headaches are migraines, you should see your doctor. Furthermore, any type of headache warrants at least one visit with your doctor to make sure there are no concerns by medical history or examination for any other worrisome causes of your headaches. They may refer you to a neurologist or other type of headache specialist. Oftentimes, a wide variety of tests may be given, including CT scans and MRIs, to see what is contributing to the cause of the migraine. The good news is that migraines can be successfully managed for the majority of patients, and that many people live with them thanks to the treatments that they receive.

 

IF YOU HAVE HEADACHE, MIGRAINE, OR FACIAL PAIN AND ARE LOOKING FOR ANSWERS ON ANYTHING RELATED TO IT, A HEADACHE SPECIALIST IS HERE TO HELP, FOR FREE!

FIRST, LET’S DECIDE WHERE TO START:

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR THE LATEST INFORMATION, HOT TOPICS, AND TREATMENT TIPS, VISIT OUR FREE BLOG OF HOT TOPICS AND HEADACHE TIPS HERE. THIS IS WHERE I WRITE AND CONDENSE A BROAD VARIETY OF COMMON AND COMPLEX  MIGRAINE AND HEADACHE RELATED TOPICS INTO THE IMPORTANT FACTS AND HIGHLIGHTS YOU NEED TO KNOW, ALONG WITH PROVIDING FIRST HAND CLINICAL EXPERIENCE FROM THE PERSPECTIVE OF A HEADACHE SPECIALIST.

 

IF YOU DON’T HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR POSSIBLE TYPES OF HEADACHES OR FACIAL PAINS BASED ON YOUR SYMPTOMS, USE THE FREE HEADACHE AND FACIAL PAIN SYMPTOM CHECKER TOOL DEVELOPED BY A HEADACHE SPECIALIST NEUROLOGIST HERE!

 

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR FURTHER EDUCATION AND SELF-RESEARCH ON YOUR DIAGNOSIS, VISIT OUR FREE EDUCATION CENTER HERE.

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Last updated on September 17th, 2021 at 06:44 am

FOODS THAT STOP NAUSEA IN ITS TRACKS.

@Neuralgroover

Nausea is an extremely common symptom across a wide spectrum of diseases. It is one of the main symptoms in the ICHD3 diagnostic criteria for migraine. Nausea is one of the 3 “most bothersome migraine symptoms” (along with photophobia (sensitivity to light) and phonophobia (sensitivity to sound)) which most acute/abortive (as-needed) migraine medication clinical research studies assess as a primary data endpoint in trying to resolve, because it is such a disruptive symptom.

 

As the electrical activity of migraine spreads through the brainstem, it activates the nausea centers of the brainstem, and you are well aware of the misery that follows that. So, are there tricks or things that you can do to lessen nausea other than using standard antiemetics (anti-nausea) medications such as Metoclopramide (Reglan), Prochlorperazine (Compazine), Promethazine (Phenergan), and Ondansetron (Zofran)? Are there certain foods or drinks that can help lessen the nausea? I’ll give you the quick answer which is detailed below. Yes there are!!

 

You may be searching terms such as, what helps with nausea, what helps nausea, how to get rid of a stomach ache, home remedy for nausea, home remedy for stomach ache, feeling nauseous, upset stomach remedies, nausea remedies, what to eat when stomach is upset, stomach upset remedy, stomach upset home remedies, how to help nausea, home remedies for stomach upset, how to get rid of stomach ache, home remedies for stomach ache, stomach ache remedies, best foods for nausea, etc., etc.

 

Let’s talk about how to treat nausea symptoms naturally…

 

Occasionally, Virtual Headache Specialist will allow guest bloggers to write an article on a migraine related topic. How to treat nausea including natural treatments for nausea is one of those very relevant migraine associated topics. It is certainly not a symptom associated only with migraine, and has a very wide range of causes. Whatever the cause may be, it is a miserable symptom to have to deal with. So, I hope the following article gives you some additional firepower to add to your migraine treatment war chest in treating the migraine associated symptom of nausea!

 

FOODS THAT STOP NAUSEA IN ITS TRACKS.

Guest author: Kristen Seymour

 

Nausea: It’s one of those universal human experiences we can all commiserate with. In fact, it’s estimated that each year half of the adult population experiences at least one bout of nausea, which may or may not lead to vomiting. That makes sense because there are many reasons people feel nauseous.

 

WHAT TO EAT AND DRINK WHEN YOU FEEL NAUSEOUS

If you feel sick to your stomach, eating or drinking may be the last thing on your mind. And if your symptoms only last for a short time, abstaining could be the right thing to do.

However, if your symptoms persist for more than a couple of hours, not only is it important to stay hydrated (especially if you vomit or experience diarrhea) but there are some foods and drinks that can help quell your nausea, too. That said, if your symptoms persist for more than a day or are especially severe, you should contact your doctor.

 

WATER AND LIGHT OR CLEAR BEVERAGES

Even when you’re healthy, being dehydrated can leave you feeling pretty crummy. When you already feel awful, dehydration exacerbates the effect. And, if you have a fever and/or ­­struggle to keep food or drinks down, you could become dangerously dehydrated without realizing it. Water alone is a great start, but if you lose fluids through vomiting or diarrhea, you may want to incorporate sips of coconut water, clear juices, or sports drinks. Flat ginger ale can also be a good option, but be cautious with carbonation as this could upset your stomach further.

Beverages and foods that are cold may be more appealing (or less likely to turn your stomach) than warm ones because they’re typically less fragrant. Sip small amounts rather than guzzling a whole glass, and consider sucking on small ice chips or a popsicle.

 

GINGER

This ancient herb has historically been used to relieve stomach upset, and the evidence that it works isn’t only anecdotal, it’s been proven in a variety of modern scientific studies, too. Keep in mind that effectiveness is tied to the amount consumed: Most studies use ½ to 1½ grams (or the equivalent) of dried ginger daily. But many common methods of consuming ginger (ginger tea, ginger ale, candied ginger slices, ginger cookies) make it hard to measure how much you’re getting. Taking ginger capsules or using your own fresh or dried ginger for tea is probably the best way to track your intake. If you’re pregnant or breastfeeding, talk to your doctor before using ginger for nausea.

 

BROTH OR SIMPLE SOUPS

When you’re ready to venture beyond clear fluids, broth is a great next step because it provides hydration, electrolytes, and a little more flavor, which may help you ease into real food. Broth is also a versatile base you can add more nutrition to in the form of chicken (diced small), vegetables, noodles, or rice as your body becomes capable of handling heartier fare. Just be sure to keep the spices and seasonings to a minimum at first.

 

BLAND, DRY STARCHY FOODS

Bread, crackers, rice, noodles, and other similarly simple foods are sick-day staples, although interestingly, this is one nausea-fighting food group that lacks scientific research to back up its effectiveness. It’s believed that starchy foods may help absorb some of the stomach acid that contributes to feeling nauseated, and it’s well-documented that we’re more likely to experience nausea on an empty stomach than when we’ve eaten a little something. So if you’re up for it, try nibbling on a soda cracker or a little steamed rice. You can add a small amount of seasoning, such as salt (or ginger) if it sounds appetizing.

 

APPLESAUCE

Not only is applesauce a gentle, healthy source of carbs (which can help you build back your energy), but it can also benefit you if you’re experiencing diarrhea. That’s because it has high dietary pectin, which helps by binding substances in the intestine, adding bulk to loose stools. Applesauce is part of the BRAT diet (bananas, rice, applesauce, and toast), which has long been a go-to grocery list for people with nausea.

 

BANANAS

Many of the foods on this list can soothe your stomach but lack in overall nutritional value. Not so with bananas. This nutrient-dense fruit is not only soft and easy to eat, it also provides you with approximately 105 calories, 27 grams of carbs, and 12 percent of potassium and 22 percent of vitamin B6 needs for the day (for a medium banana). One tip: The riper the banana, the more fragrant, so if smells turn you off, try a greener one.

 

HERBAL TEA

We mentioned that cold drinks are often more appealing than hot, but sometimes sipping on something warm provides much-needed comfort. In that case, try a caffeine-free herbal tea. See if perhaps peppermint, chamomile, or ginger sounds like something you’d like to sip. You may find that lukewarm or iced works better for you than hot.

 

Each person—and each instance of nausea—is different, so if you’re under the weather, don’t force yourself to eat a particular food if the smell turns your stomach. Listen to your body and take it slow; you’ll be back to your regular meals before long.

 

The original article can also be seen here, as originally published on Health Perch – A Digital Health Magazine.

 

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Last updated on December 3rd, 2021 at 07:22 am

NURTEC (RIMEGEPANT) VS. QULIPTA (ATOGEPANT) FOR MIGRAINE PREVENTION. THE GEPANTS AREN’T JUST FOR ABORTIVE TREATMENT ANYMORE! 

@Neuralgroover

BACKGROUND

The gepants were the first to emerge as new migraine abortive options, and the first new migraine specific abortive class since the triptans came to market in 1992. The first to become available was Ubrogepant (Ubrelvy) from Allergan in January 2020. Then Rimegepant (Nurtec ODT (orally dissolvable tablet)) became available by Biohaven shortly after in February 2020. The gepants have been game changers in the migraine abortive arena. However, they are now bringing their benefits to the migraine preventive realm, following a mind-blowing trifecta collision of the worlds of gepants, abortive and preventive therapy with Rimegepant (Nurtec ODT) and Atogepant (Qulipta)! These two medications are compared head to head in the table below.

 

On 5/27/21, Nurtec ODT made history as the first and only FDA approved medication for BOTH abortive and preventive migraine treatment simultaneously, and the only option with this flexibility! More recently, on 9/28/21, Qulipta (Atogepant) became the second oral CGRP preventive gepant medication to become FDA approved for migraine prevention. It is taken once daily. So these 2 options have become the first oral CGRP preventive medication options. They are both of the gepant medication family, which is different than the CGRP mAb family, but none the less now offer an oral alternative to once monthly CGRP monoclonal antibody injections.

 

I can hear you now. Rimegepant (Nurtec ODT) for migraine prevention? Atogepant for migraine prevention? Yes, you heard correctly. Are these available yet? We’ll discuss this and these new options a bit further down.

 

HOW DO THE GEPANTS WORK?

To review, during a migraine attack, the trigeminal nerves release a variety of inflammatory proteins. One of the main proteins is called CGRP (calcitonin gene related peptide). CGRP causes inflammation around the brain and cerebral arteries (“sterile inflammation”) in the dural membrane surrounding the brain, intensified pain signals, enhanced transmission of pain signals through the trigeminal nerves into the brainstem and into the brain, and dilation of the cerebral arteries through the dural membrane, which in turn leads to further increasing pain signals via the trigeminal nerve endings covering the cerebral arteries. The result is intense migraine pain (as you are unfortunately very familiar with). So, if we can block these steps of migraine pain, the attack should be aborted quickly, and not as severe. That’s the thinking here, and that’s where the CGRP medications (gepants and CGRP monoclonal antibodies) come into play.

 

The gepants work as CGRP receptor antagonists, which means they directly target and block (antagonist) the CGRP receptor. This results in the medication “blocking” the CGRP inflammatory protein from sticking to the CGRP receptor to activate it, and thus prevents it from “turning on” these pathways of migraine pain. So, you get reversal of cerebral vasodilation, which decreases the firing off of the trigeminal nerves, and cessation of electrical pain signals. Notably, the gepants do this in a way that does not cause vasconstriction, in contrast to the triptans. Thus, they are felt to be safe in those with cardiovascular or cerebrovascular disease (as opposed to the triptans which can not be used in these patients). By blocking the CGRP receptor, you also get reversal of the neurogenic inflammation going on through the brain and around the arteries, and you block the electrical transmission of migraine pain from traveling from the trigeminal nerves into the brainstem, and ultimately into the brain.

 

GEPANTS FOR MIGRAINE PREVENTION

Rimegepant (Nurtec ODT) and Ubrogepant (Ubrelvy) were created and FDA approved for the abortive (as needed) treatment of migraine in 2020. The goal of migraine abortive treatment is to stop individual migraine attacks at onset so the migraine does not reach full severity, ends quickly, and your function is restored and maintained. We want you to avoid having to go lay down and miss that family/social event, work meeting, or whatever else you had planned, and instead end up spending the whole day in a dark quiet bedroom. As opposed to conventional migraine abortives such as triptans, NSAIDs, and other analgesics, the gepants have the unique characteristic that they do not cause rebound headache (medication overuse headache), which is why they have also been evaluated as daily preventive medications as we’ll discuss below.

 

Abortive treatments are different than migraine preventive treatments, which are a continuous treatment (not just taken as needed) meant to lessen the frequency and/or severity of migraine attacks (hopefully both). Conventional preventive treatment options include a daily pill, a monthly/quarterly CGRP monoclonal antibody (mAb) (Aimovig, Ajovy, Emgality, Vyepti) injectionneuromodulation devices, Botox injections, or alternative treatments such as vitamins and supplements, acupuncture, acupressure and pressure points, or yoga and meditation. The goal of migraine preventive treatment is to lessen the frequency and/or severity of migraine attacks and are discussed in more detail here. If you have migraine, you want to have both a good abortive and preventive treatment plan to lessen migraine’s nasty habit of interfering and disrupting life and function.

 

Notably, for many decades, we have never had migraine specific preventive treatment. What I mean is that the treatments we have always used have been adopted from and limited to medications including antiseizure, antidepressant/anxiety, and blood pressure medications. Although many patients certainly do well with these preventive options, none of these medicines have been scientifically engineered and created specifically to target migraine pathophysiology for migraine prevention. In addition, many patients do not tolerate the side effects or cannot use many of these medications due to other medical conditions. So a lot of patients have been stuck without adequate preventive migraine therapy. That was until 2018 with the first once monthly self-injection CGRP monoclonal antibody (mAb) Erenumab (Aimovig) came to market, and was followed by 3 more CGRP mAbs; Fremanazumab (Ajovy), Galcanezumab (Emgality), and Eptinezumab (Vyepti).

 

The CGRP mAbs have been a major step forward for migraine prevention. However, up to this point, we still have not had an oral pill that has been engineered and created purely and only for migraine prevention (not “adopted” from a different medicine class such as the anti-seizure, antidepressant, and anti-blood pressure pills). That was until now. These new oral gepant medications will be the first in history to assume this new role, finally giving migraine patients a new unique treatment option to add to their war chest.

 

The two gepants being targeted for preventive migraine therapy are Rimegepant (Nurtec ODT) from Biohaven and Atogepant (Qulipta) from Allergan/Abbvie. On 5/27/21, Nurtec ODT made history as the first and only FDA approved medication for BOTH abortive and preventive migraine treatment simultaneously, and the only option with this flexibility! The perspective and reasoning behind this is that migraine is truly a fluid and variable disease, commonly fluctuating between periods of episodic migraine (1-14 headache days per month), and other periods of chronic migraine (15 or more headache days per month). So having a medicine that can function as both types of treatment, depending on what type of phase the migraine is in (episodic or chronic) opens up an entirely new flexible treatment paradigm and approach which we have never had up to this point.

 

More recently, on 9/28/21, Qulipta (Atogepant) became the second oral CGRP preventive gepant medication to become FDA approved for migraine prevention (not dually approved for both abortive and preventive). It is the first gepant that was designed and studied purely for only migraine prevention. It is taken once daily. So, Nurtec ODT and Qulipta have become the first oral CGRP preventive medication options. They are both of the gepant medication family, which is different than the CGRP mAb family, but none the less now offer an oral alternative to once monthly injections.

 

Compared to standard historical oral preventive options, the gepant preventives Nurtec and Qulipta work extremely quick (within even a day!) as detailed below. So you are not having to wait the usual 4-6 weeks to start working and 2-3 months to see full effect as oral preventives have typically required.

 

Yes, I know your mind has just been blown. Let’s discuss them both and the currently available data, which can be found on each company’s website.

RIMEGEPANT ODT (Nurtec ODT)

Rimegepant ODT 75 mg every other day was studied and published in the preventive treatment of both episodic (4-14 days per month) and chronic migraine (15-30 days per month) during a 12-week double-blind randomized placebo-controlled treatment which included 747 patients. Migraine frequency was first observed and tracked for 4 weeks. Then, the 12 week treatment phase began. Patients were allowed to take 1 preventive migraine medication, (excluding CGRP receptor antagonists and CGRP monoclonal antibodies), as long as they were on a stable dose for at least 3 months and did not change it during the study. Patients were instructed to take 1 tablet every other day (which was either rimegepant or placebo) for migraine prevention. They were allowed to use rescue medications including triptans, nonsteroidal anti-inflammatory drugs (NSAIDs), and other typical analgesics. Rimegepant was not permitted as a rescue medication during the 12-week double-blind treatment phase. Migraine preventive benefits were seen in patients with episodic migraine, as well as those with and without a history of chronic migraine. Detailed results can be seen in the table below comparing Nurtec vs. Qulipta for migraine prevention.

 

The primary endpoint of this study:

-Change in monthly migraine days from the observation baseline compared to weeks 9-12. The study met its primary endpoint, demonstrating a statistically significant reduction from baseline in monthly migraine days in patients treated with Rimegepant compared with placebo. Patients receiving rimegepant 75 mg every other day (N=348) experienced a statistically significant reduction of 4.3 monthly migraine days for Rimegepant compared to a 3.5 day reduction in the placebo group (N=347).

 

Secondary endpoints included:

-50% or more reduction in monthly moderate to severe migraine days in weeks 9-12. Rimegepant was superior to placebo. 49% of patients taking Rimegepant had a 50% or more reduction in moderate to severe migraine days compared to 41% in placebo.

-Change in the mean monthly migraine days across the full treatment phase (weeks 1-12). Rimegepant was superior to placebo. Patients taking Rimegepant had 3.6 less monthly migraine days compared to 2.7 less days in placebo.

-Rescue medication days per month in weeks 9-12. There were slightly less rescue medication days per month in the Rimegepant group (3.7 days) compared to placebo (4 days), but this was not statistically superior.

-Change in monthly migraine days in the first 4 treatment weeks (weeks 1-4). Rimegepant was superior to placebo. Patients taking Rimegepant had 2.9 less monthly migraine days compared to 1.7 less days in placebo..

 

Preventive benefits began fast. Within the 1st week, there was a 30% drop in migraines (compared to 9.4% drop in the placebo group).

 

The safety and tolerability of rimegepant across the 12-week double-blind treatment phase was similar to that of placebo. Adverse events (AEs) occurring in greater than 2% of participants in the rimegepant treated group were nasopharyngitis (4%), nausea (3%), urinary tract infection (2%), and upper respiratory tract infection (2%). Nearly all AEs were mild or moderate in intensity. No treatment-related serious AEs were reported in the rimegepant group. Discontinuations due to an AE were low in both groups (rimegepant 2% and placebo 1%). Four (1%) participants who were treated with rimegepant and 2 (1%) participants who were treated with placebo experienced transaminase (ALT or AST) elevations greater than 3x upper limit of normal (ULN). One participant in the rimegepant group had asymptomatic elevation of transaminases with ALT greater than 10x ULN; alkaline phosphatase and bilirubin levels remained within normal limits. One participant in the rimegepant group had bilirubin levels greater than 2x ULN and was diagnosed with Gilbert’s syndrome after genomic testing.

 

A 52-week open-label extension phase followed the above double-blind study. Patients dosed rimegepant 75 mg every other day and were allowed to take up to one dose of rimegepant 75 mg as needed on non-scheduled dosing days to treat migraine attacks as well. The data from this will be forthcoming.

 

Personally, I think this opens many treatment possibilities that we haven’t had available up to this point. For one thing, taking it every other day could be used as an ongoing daily preventive strategy (the long half life allows for this spread out dosing) when the migraine is in a high frequency to chronic migraine phase. If it evolves back into a lower frequency episodic migraine pattern, it can then just be used abortively only when needed for a migraine attack. This new flexible dosing option could also be used as a “mini-prophylaxis” within the month. For example, if patients know they are approaching a predictable migraine trigger, such as menstrual migraine, barometric trigger from an airplane trip, upcoming stressful event such as an exam, etc., the medication could possibly be taken daily or every other day starting a few days before the anticipated trigger, and stopping it a day or so after the trigger is no longer present. Unlike other migraine preventive treatments which take 4-6 weeks to start working and 2-3 months to see full effect, the gepants work fast and this would allow this potential treatment option to work. Headache specialists often do this “mini-prophylaxis” for the above mentioned scenarios with long acting triptans such as Frovatriptan and Naratriptan. However, for some people, this could lead to having to use it more than 10 days per month on average, which could then start to fuel rebound headache (medication overuse headache). The nice thing about the gepants is that there is no rebound headache associated with them, so this would also not be a risk when used for mini-prophylaxis.

 

ATOGEPANT (Qulipta)

Atogepant 10 mg, 30 mg and 60 mg doses once daily were studied in the preventive treatment of episodic migraine (4-14 days per month) during a 12-week double-blind randomized placebo-controlled treatment which included 910 patients. Detailed results can be seen in the table below.

 

Atogepant met the primary endpoint of statistically significant reduction from baseline in mean monthly migraine days, compared to placebo, for all doses evaluated across the 12-week treatment period. Patients treated in the 10 mg/30 mg/60 mg atogepant arms experienced a decrease of 3.69/3.86/4.2 days per month averaged over the 12 weeks, respectively, compared to placebo at 2.48 days less. By weeks 9-12, there was a 4-4 day reduction in migraine days with 60 mg. On average across the 12 week trial, patients on the 60 mg dose had a 54% reduction in monthly migraine days!

 

It worked very fast as well. The day following the first 60 mg dose, patients were 51% less likely to have a migraine. Within the 1st week there was a 53% reduction in migraines (compared to 15% in placebo)!

 

Atogepant also showed statistically significant improvements in six secondary endpoints in the 30 mg and 60 mg once-daily treatment arms. Additional secondary endpoints measured across the 12-week treatment period included change from baseline in monthly headache days, mean monthly acute-medication use days, and mean monthly performance of daily activities and physical impairment domain scores. The 30 mg and 60 mg doses resulted in statistically significant improvements in all secondary endpoints, while treatment with the 10 mg dose resulted in statistically significant improvements in four out of the six secondary endpoints.

 

A key secondary endpoint measured the proportion of patients that achieved at least a 50% reduction in monthly migraine days across the 12-week treatment period. Results showed that across the 12 week trial, 56%/59%/61% of patients in the 10 mg/30 mg/60 mg atogepant arms, respectively, achieved a 50% or more reduction in migraine days compared to 29.0% of patients in the placebo arm. By weeks 9-12, 71% of patients on 60 mg had reduced their monthly migraine days by 50% or more!!

 

The trial also assessed the proportion of patients that achieved a 75% or more reduction in monthly migraine days across the 12-week treatment period. Results showed that 30%/30%/38% of patients in the 10 mg/30 mg/60 mg atogepant arms, respectively, achieved a 75% or more reduction in monthly migraine days, compared to 11% of patients in the placebo arm. By weeks 9-12, 50% of patients on 60 mg had reduced their monthly migraine days by 75% or more!!

 

And they didn’t stop there. The trial then assessed the proportion of patients that achieved a 100% reduction in monthly migraine days across the 12-week treatment period. Yes, you read that correctly, they went to 0 migraines per month. Results showed that 8%/5%/8% of patients in the 10 mg/30 mg/60 mg atogepant arms, respectively, achieved a 100% reduction in monthly migraine days, compared to 1% of patients in the placebo arm. By weeks 9-12, 28% of patients on 60 mg had 100% reduction in monthly migraine days… complete resolution!! Amazing. We just aren’t used to seeing these kinds of results.

 

After the main trials were completed, they began a 52 week (1 year) open label trial (patients knew they were taking the medicine) where patients took 60 mg daily. The goal was to assess for further side effects or safety concerns, of which there were none. By the end of the trial, and after a continued decline in migraines, patients were averaging 71% less migraine days per month, which equated to 5.2 less migraine days per month on average.

 

No significant safety risks were observed. Serious adverse events occurred in 0.9% of patients treated in the atogepant 10 mg arm compared to 0.9% of patients in the placebo arm (so basically, no difference). No patients in the atogepant 30 mg or 60 mg treatment arms experienced a serious adverse event. The most common adverse events reported with a frequency ≥ 5% in at least one atogepant treatment arm, and greater than placebo, were constipation (6.9-7.7% across all doses vs. 0.5% for placebo), nausea (4.4-6.1% across all doses vs. 1.8% for placebo), and upper respiratory tract infection (3.9-5.7% across all doses vs. 4.5% for placebo). The majority of cases of constipation, nausea and upper respiratory tract infection were mild or moderate in severity and did not lead to discontinuation. There were no hepatic safety issues identified in the trial.

 

The gepants (Nurtec, Qulipta) and the CGRP mAbs (Aimovig, Ajovy, Emgality, Vyepti) are all compared to each other in more detail here.

 

Nurtec ODT vs. Qulipta are compared in the following table. As I obtain additional data, this table will continue to be updated.

  Nurtec ODT (Rimegepant) Qulipta (Atogepant)
Medication Class Gepant Gepant
Mechanism of Action CGRP receptor antagonist CGRP receptor antagonist
Available dosing 75 mg orally dissolvable tablet 10 mg, 30 mg, 60 mg pill
Pills per prescription (standard, may be more depending on insurance) 16 30
Dosing frequency 1 dose every other day 1 dose daily
Reduction of monthly migraine days across weeks 1-12 Averaged weeks 9-12:

75 mg: -4.3

Placebo: -3.5

 

Averaged weeks 1-12:

75 mg: -3.6

Placebo: -2.7

 

 

Averaged weeks 9-12:

10 mg: -4.24

30 mg: -4.25

60 mg: -4.44

Placebo: -2.5

 

Averaged weeks 1-12:

10 mg: -3.7

30 mg: -3.9

60 mg: -4.2

Placebo: -2.5

% reduction of migraine days in week 1 75 mg: 30%

Placebo: 9.4%

10 mg: N/A

30 mg: N/A

60 mg: 53%

Placebo: 15%

% reduction of migraine days in weeks 1-12 75 mg: N/A

Placebo: N/A

10 mg: N/A

30 mg: N/A

60 mg: 54%

Placebo: 33%

% of patients with a 50% or more decrease in monthly migraine days across weeks 1-12 75 mg: 49%*

Placebo: 41%*

*Assessed during weeks 9-12 only, not weeks 1-12

10 mg: 56%

30 mg: 59%

60 mg: 61%

-Weeks 1-4: 61%

-Weeks 5-8: 66%

-Weeks 9-12: 71%

Placebo: 29%

% of patients with a 75% or more decrease in monthly migraine days across weeks 1-12 75 mg: N/A

Placebo: N/A

10 mg: 30%

30 mg: 30%

60 mg: 38%

-Weeks 1-4: 39%

-Weeks 5-8: 41%

-Weeks 9-12: 50%

Placebo: 11%

% of patients with a 100% decrease in monthly migraine days across weeks 1-12 75 mg: N/A

Placebo: N/A

10 mg: 8%

30 mg: 5%

60 mg: 8%

-Weeks 1-4: 19%

-Weeks 5-8: 24%

-Weeks 9-12: 28%

Placebo: 1%

Time to peak plasma concentration TMAX 90 minutes 60-120 minutes
½ life 11 hours 11 hours
Notable side effects Nausea

75 mg: 2.7%

Placebo: 0.8%

 

Abdominal Discomfort

75 mg: 2.4%

Placebo: 0.8%

 

Nausea

10 mg: 5%

30 mg: 6%

60 mg: 9%

Placebo: 3%

 

Constipation

10 mg: 6%

30 mg: 6%

60 mg: 9%

Placebo: 1%

 

 

Somnolence/Fatigue

10 mg: 4%

30 mg: 4%

60 mg: 6%

Placebo: 3%

 

Decreased Appetite

10 mg: 2%

30 mg: 1%

60 mg: 2%

Placebo: <1%

 

% of Patients with Weight Loss of 7% or More

10 mg: 3.8%

30 mg: 3.2%

60 mg: 4.9%

Placebo: 2.8%

 

Can I use a CGRP monoclonal antibody (mAb) (Aimovig, Ajovy, Emgality, Vyepti) with the gepants (Nurtec, Ubrelvy)?

An insurance battle often ensues when trying to use the large molecule preventive CGRP mAbs with the small molecule abortive gepant medications (Nurtec, Ubrelvy), which also work by a CGRP mechanism. Insurance companies will often not allow these to be used together, but again, no good scientific basis. Actually, there is some limited evidence showing that these medications can work synergistically together, which would make sense when taking their mechanisms of action into account. Specifically, there was a publication of data from only a 2-patient cohort showing that the use of these acute and preventive CGRP migraine therapies together can be successful and safe. These two patients had been using rimegepant (Nurtec) in a long-term safety study and they had added erenumab (Aimovig) once monthly injection as a preventive treatment. After Aimovig was added, patient 1 had 100% relief for 7 of 7 acute migraine attacks treated with Nurtec. Patient 2 had 100% relief for 9 of 9 acute migraine attacks treated with Nurtec. So, the combination of using Nurtec abortively in addition to using Aimovig preventively appeared to provide an even more effective acute migraine response. Theoretically, it would make sense that benefit would be greater with both classes of medicines combined because they are entirely different types of medications targeting aspects of the same migraine pathway simultaneously (either targeting the CGRP receptor or the CGRP ligand protein). Larger studies to confirm the suspicion that they likely work together synergistically will be helpful.

 

There was a larger safety study publication which evaluated the acute treatment of migraine with Rimegepant while using a CGRP monoclonal antibody for the prevention of migraine. The CGRP mAbs used were Erenumab (Aimovig) (7 patients), Fremanezumab (Ajovy) (4 patients), and Galcanezumab (Emgality) (2 patients). The study determined that Rimegepant used as an acute migraine treatment in combination with CGRP mAbs for migraine prevention was well tolerated with no safety issues identified. The researchers concluded that the probability between these 2 classes (gepants and CGRP mAbs) was low, especially because they have entirely different pathways of drug metabolism. They also concluded that existing evidence supports the safety of combined use, although further larger research was warranted.

 

 

 

IF YOU HAVE HEADACHE, MIGRAINE, OR FACIAL PAIN AND ARE LOOKING FOR ANSWERS ON ANYTHING RELATED TO IT, A HEADACHE SPECIALIST IS HERE TO HELP, FOR FREE!

FIRST, LET’S DECIDE WHERE TO START:

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR THE LATEST INFORMATION, HOT TOPICS, AND TREATMENT TIPS, VISIT OUR FREE BLOG OF HOT TOPICS AND HEADACHE TIPS HERE. THIS IS WHERE I WRITE AND CONDENSE A BROAD VARIETY OF COMMON AND COMPLEX  MIGRAINE AND HEADACHE RELATED TOPICS INTO THE IMPORTANT FACTS AND HIGHLIGHTS YOU NEED TO KNOW, ALONG WITH PROVIDING FIRST HAND CLINICAL EXPERIENCE FROM THE PERSPECTIVE OF A HEADACHE SPECIALIST.

 

IF YOU DON’T HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR POSSIBLE TYPES OF HEADACHES OR FACIAL PAINS BASED ON YOUR SYMPTOMS, USE THE FREE HEADACHE AND FACIAL PAIN SYMPTOM CHECKER TOOL DEVELOPED BY A HEADACHE SPECIALIST NEUROLOGIST HERE!

 

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR FURTHER EDUCATION AND SELF-RESEARCH ON YOUR DIAGNOSIS, VISIT OUR FREE EDUCATION CENTER HERE.

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Last updated on September 17th, 2021 at 06:41 am

BOTOX (OnabotulinumtoxinA) FOR CHRONIC MIGRAINE; EFFECTIVE PATTERN, TECHNIQUE, AND WHAT YOU NEED TO KNOW. NOT ALL BOTOX TREATMENTS ARE CREATED EQUAL.

@Neuralgroover

Background

Let’s talk about Botox for migraines. Botox (Onabotulinum Toxin A) has been a game changer for the treatment of chronic migraine. I’ve frequently seen it give people their life back (as they often tell me), restored their ability to function normally in all aspects of life, and pulled them from the dark rut of chronic migraine that people get stuck in as described here. It can assist in stopping medication overuse headache (rebound headache), which often accompanies and drives chronic migraine. Once Botox is working, patients can often wean off daily pills being used for migraine prevention. Botox is a neurotoxin made by the Clostridium botulinum bacteria. When ingested, it is the same toxin that causes botulism, a severe form of food poisoning. Yes, this concept freaks many patients out. However, the amount used for chronic migraine is a much lower potency and dose, and when used correctly, can be an amazingly helpful medication.

 

Botox is produced by Allergan (now an AbbVie company), and was FDA approved for the treatment of chronic migraine in October 2010 following this study. Since that time, it has technically remained the only FDA-approved treatment specifically indicated for the treatment of chronic migraine prevention. With that said, the array of standard preventive migraine treatments as well as the CGRP monoclonal antibodies are also commonly used for all spectrum of migraine from episodic migraine (14 or less headache days per month) to chronic migraine (15 or more headache days per month). Most insurances will generally require a failure of at least 2 categories of standard preventive medications before they will approve Botox coverage. With that said, 98% of commercial insurance plans cover Botox, and it’s actually fairly easy to get it approved through Medicare and Medicaid. In addition, Allergan provides a Botox Savings Program which will cover $1500 of any out of pocket costs per treatment and $4000 per year. So for most patients, Botox treatments can be covered 100% between this savings program and insurance coverage.

 

It is my hope that this blog can provide the education and guidance in optimizing Botox procedure precision and technique for medical providers to give the best results, as well as a great educational overview on Botox for patients so they have a better idea of how Botox works, the best pattern to get (which can be shared with their doctors), and what to expect in terms of how long it takes to work, suggested duration of use, side effects, and safety in pregnancy and breastfeeding.

 

How does Botox work for chronic migraine?

The primary and most important mechanism of how Botox works for chronic migraine is by disrupting the electrical communication signals of pain between nerves and ultimately stopping these signals from reaching the pain circuitry of the brain. Thus, it prevents the activation of pain and migraine networks in the brain. Botox does this by entering the nerve endings and cleaving a specific protein called SNAP25. The inactivation of this protein leads to the inhibition (stopping) of neurotransmitter and neuropeptide release from the nerve endings and the prevention of the electrical pain signals from firing off. It also causes temporary (3 months) paralysis of the muscle being innervated by those nerve endings. Thus, it also causes the muscles to chemically relax (by chemically paralyzing them). For example, this muscle relaxation is why Botox works for facial wrinkles. It causes the thin muscular layers to relax to where they can’t contract (and wrinkle the skin), and wrinkles go away. Interestingly, one of the early clues that led to Botox being studied for migraine treatment was that women who were getting Botox were also noticing that they would have much less migraine headaches. This eventually led to further trials looking at Botox treatment to prevent migraine.

 

How long does it take for Botox to work, how long should Botox be used for chronic migraine, and how effective is Botox?

Botox typically starts to kick in within 1-2 weeks, but many times patients say they feel it working within a day or so after they have been getting it for a while. Botox lasts about 3 months. Patients commonly notice some gradually increasing migraines 1-2 weeks or so before getting to the 3-month wear-off window. I have quite a few patients that can actually get a good 4 months out of a treatment, but that is not common. If patients consistently start to come in for their 3-month Botox appointment and migraines are not starting to increase significantly as it is wearing off, I will often try to extend the next treatment to 4 months. If they are still doing well at that time, I suggest that we try stopping it to see if the migraines have entered and sustained into a more infrequent episodic pattern. It can always be restarted if needed in the future. It should be avoided from repeating much earlier than 3 months because early dosing before the prior dose has worn off can lead to cumulative medication and subsequent side effects. This can also increase the risk of antibody formation against Botox which can make it less effective over time.

 

It is recommended to give the Botox a minimum of 2 rounds 3 months apart to get a good sense of how much benefit one can likely expect. The reason for this is that in the trials after the 2nd round, there was continued upwards improvement. With that said, I typically expect (and usually see) good improvement with the 1st round. Some doctors advocate for giving a full year (4 rounds separated by 3-month intervals) to see the full effect. However, I typically tell patients if they have gotten absolutely no benefit after the 2nd round that we should move on to another treatment option. On average, Botox decreased chronic migraine days by 8-9 days per month, as opposed to placebo which was 6-7 days per month.

 

What are the Botox side effects?

A great thing about Botox is that it is so well tolerated with much lower side effect risks compared to many of the medications used for migraine prevention. I’ve done thousands of Botox treatments and have never seen someone have a bad reaction or an allergic response. In general, I tell patients there may be some tenderness in the injection sites temporarily. It is a very tiny needle injected just under the skin in a specific standardized dosing pattern and takes only a few minutes. Infrequently, patients can have a temporary flu-like muscle achiness for a day or so after the Botox. If the Botox spreads into some of the muscles in the forehead, I always mention that there is a risk of eye lid droopiness (ptosis), although I have not seen this occur. A more extensive list of potential side effect risks (which are extremely rare and I’ve not seen), can be read on the Botox for chronic migraine Allergan website. Caution is also advised if Botox is mixed with bupivacaine or other “caine” medications as this can be a fairly common allergy of some patients to these medications.

 

Can I get Botox with the Covid-19 vaccine?

The short answer is that we need to gather more data on this, so check back periodically for updates. However, this hasn’t been a reported issue thus far. There is no current evidence for an interaction between the Covid-19 vaccine and Botox injections, the same as any other vaccine. This has also been stated by the American Migraine Foundation. Patients receiving Botox were not excluded from the Covid-19 vaccine trials. There is no evidence at this time that Botox can not be used along with receiving Covid-19 vaccination, nor does it need to be delayed or timed any differently in relation to receiving Covid-19 vaccination. Most physicians feel that there should theoretically be no interaction or contraindication to receiving both because they are entirely different proteins with different mechanisms of action. The Covid-19 vaccine stimulates the immune system to form antibodies against the virus, should you encounter it.  However, Botox does not have any significant influence on the immune system (it does not cause immunosuppression, etc). Rarely, the immune system of some patients can form neutralizing antibodies against Botox, and this can weaken Botox’s effectiveness in decreasing migraine frequency and severity. However, this issue really has nothing to do with the mechanism and how the Covid-19 vaccine works. So, it is not felt that the Covid-19 vaccine will lessen the effectiveness of Botox, nor will Botox lessen the effectiveness of the Covid-19 vaccine. The topic of Covid-19 headache, Covid-19 vaccination, and the use of Botox or CGRP monoclonal antibodies (Aimovig, Ajovy, Emgality, Vyepti) is discussed further here.

Notably, there have been just a few isolated reports of dermal fillers used in dermatology causing some facial swelling in association with Covid-19 vaccination. These reports were with the Moderna Covid vaccine and resolved with steroids and/or antihistamines.

 

Is Botox safe in breastfeeding and pregnancy?

Historically, Botox has generally been avoided and saved as a last resort option in these scenarios, and often still is. The longstanding concern for using Botox during breastfeeding is based in theoretical concern that the Botox could seep into the breastmilk and effect the baby, although this really hasn’t been reported. It has been shown that Botox is not detectable in the blood after intramuscular use, so excretion into breast milk is considered unlikely. In fact, there was a reported case of a lactating woman who had foodborne botulism. However, when the breastmilk and infant were analyzed, neither showed any botulinum toxin at all, and the infant was safely breastfed. With this in mind, the doses of Botox used medically are much lower than those that cause botulism. Therefore, the amounts ingested by an infant, if any, are suspected to be small and not cause any adverse effects in breastfed infants. Regardless, for extra precaution, it is suggested to breastfeed before the Botox treatment, store some milk, and then wait a few hours after the treatment before breastfeeding again.

 

Similar to breastfeeding, there are no published studies on Botox use during pregnancy. So, it is still often avoided if possible and saved as a last resort option. However, since Botox is not detectable in the blood after intramuscular use it is not expected to affect fertility or pregnancy outcomes, and an Allergan safety database report has remained consistent with this conclusion. Botox is designated as a US Food and Drug Administration (FDA) pregnancy category C medicine, meaning that there are no well controlled studies in pregnant women, so it should only be used during pregnancy if the benefits outweigh the potential risks. The good thing is that the majority of women naturally get significant migraine improvement during pregnancy (especially 2nd and 3rd trimester) and it is not uncommon to hear migraines go away during pregnancy. So many times preventive therapy may not even be necessary.

 

What is the best way to do Botox for chronic migraine?

If you are going to get Botox, you need to make sure you are getting the optimal dose, pattern, and technique. A headache specialist will have the most refined technique and experience doing Botox injections, and should be sought out to ensure you are getting the best technique if one is available near you. If you cannot find a headache specialist near you, make sure whomever you get the Botox injections from does them very frequently with good reviews. Other doctors that may do Botox injections as alternatives if a headache specialist is not available include some neurologists, pain management doctors, and primary care doctors, as well as some physician assistants (PA) and nurse practitioners (NP). With knowledge of the precise pattern and technique as outlined below, and enough practice, anyone should be able to do Botox procedures proficiently in the office. It is an easy procedure and can provide dramatic improvement in chronic migraine pain and disability.

 

The pattern that should be used and modeled after is the PREEMPT protocol (Phase III REsearch Evaluating Migraine Prophylaxis Therapy), based off the trial that led to FDA approval for Botox in the prevention of chronic migraine. The pattern of injections described and illustrated below are of the PREEMPT protocol. However, sometimes I will tweak some of the injection sites depending on the patient’s pain pattern. For example, if their chronic migraine is 100% one sided, I may give additional on that side in the temporalis muscle and occipital regions, taken from the opposite side where they have no or minimal pain. If they have prominent occipital neuralgia, then I will give additional dosing over the occipital nerves. The PREEMPT protocol used 155-195 units of Botox. Botox vials come in 200 units (either two 100 unit vials or one 200 unit vial). For almost all patients, I use the full 200 units and spread the additional 5 between the trapezius muscles, or use it somewhere else where the pain is most common such as over an occipital nerve in the back of the head. I may use slightly less in patients that have no pain at all in many areas of the head or shoulders and have a very localized pain (such as just in one side of the forehead), are elderly, or young in late teens or early twenties and have not had it before. Regardless, many of the spots the patient may receive it in, they may not have much pain. However, there should still be some degree of symmetry for muscle weakness balance and to still hit potential areas of chronic migraine input that aren’t recognized as overly painful areas by the patient. I also prefer to gently and briefly rub in the Botox spots right after injection. This helps to distract the brain from the immediate injection pain, flattens the area so it doesn’t leave the Botox as a small lump, and helps to slightly spread the area of coverage for the Botox to work (hitting as many of those nerve fibers and neuromuscular junctions as possible with each injection.

 

The depth of injection isn’t supposed to be deep. So if the needle is hitting the bone, it is too deep and will be less effective. The target of the injections is just below the skin and into the top of the muscle. This is where the neuromuscular junction occurs (where the nerves that innervate and control the muscles enter the muscle). This is the main target of the Botox. I like to be strategic where the Botox goes. If your doctor or health care provider is just rapid firing it in (which is always more painful), hitting the bone, you have Botox running down your face, it is more painful than when you get it done with other providers, or you get eye-lid droopiness (ptosis), you should think about moving on to someone with a more refined technique. I see patients all the time that have been getting Botox with me and then they have to get a round sometimes with a different provider for some reason. They invariably say it doesn’t work as well, is significantly more painful, and afterwards they refuse to get Botox with anyone else besides me following that experience. There is validity in that. I’ve spoken to one of the main doctors/scientists involved with developing the original Botox pattern, technique, and dosing for chronic migraine and he agreed that technique and spreading the Botox around strategically and precisely will certainly lead to a better result as opposed to just quickly and less carefully “throwing the injections in”. In fact, they were originally thinking of adding more spots to further spread the Botox around to hit more nerve endings, but they settled on the current pattern to make it easier and less complex to do.

 

The Botox trials were done by mixing Botox in 0.9% normal saline (basically, sterile water). However, I will sometimes mix the Botox instead with a numbing medicine such as bupivacaine or ropivacaine. The Botox typically takes about 1-2 weeks to start kicking in. So the addition of a numbing medicine can provide some temporary relief as the Botox is slowly kicking in. Many times chronic migraine patients are significantly tender throughout their head to the point the hair can “hurt” and feel sore. This is called allodynia, or central sensitization, and is a common finding in chronic migraine. The additional numbing medicine can also provide some temporary relief throughout some of these sore areas. In most patients, they have tenderness over their occipital nerves in the back of the head (occipital neuralgia), and this can also provide some additional temporary relief over these nerves. Many chronic migraine patients also have tenderness throughout their shoulders, and many have associated fibromyalgia. This can also be helpful with some temporary relief through these muscles, and in a way is like getting trigger point injections at the same time.

 

So, let’s go over the treatment pattern that I have seen to be most useful. First, you will need to get the supplies together, of course. For doctors and health care providers who are here to learn how to do Botox or fine-tune their skills, a detailed video of what you need and how to draw up the Botox can be seen here. I won’t go through the detailed steps here in mixing and drawing the Botox up, but in short, you will need:

-Botox 200 units (100 unit vials x 2 are typically used, but single 200 unit vials available too)

-1 cc syringes x 4

-3 cc syringe x 1 (to draw up diluent and mix in Botox vial)

-30 gauge ½ inch needles x 4 (to place on end of 1 cc syringes prior to injections)

-18-22 gauge needle x 1 (to place on end of 3 cc syringe to draw up diluent and mix in Botox vial)

-0.9% normal saline vial x 1 (alternatively can consider 0.25% bupivacaine or similar)

-Alcohol pads

-Gauze pads

The Botox procedure: Face and frontal regions of head (frontalis and corrugator muscles)

For these injections, I prefer to have the patient lying supine on their back and I stand at the head of the exam table behind them. That way they don’t see the needle coming towards their face and all spots are easily accessed from the top and sides of the patient. These spots are pretty standard in all patients. The things to keep in mind are not doing the Botox too low in the forehead. This can cause ptosis, eyelid droop, and asymmetric eyebrow pointing (think Joker in Batman). I typically inject somewhere just below the hair line and in the very top edge portion of the frontalis muscles or just above it. The 1stfrontalis muscle injection is identified as drawing an imaginary line from mid-pupil up to the top of the frontalis muscle and injecting there. The 2nd is in a horizontal line about a half inch medial to the first injection on each side. The procerus is injected at approximately the middle of the brow right between the eyebrows. The corrugators are injected just lateral to each side of this central injection, about a half inch to each side. All injection sites are 5 units.

 

The Botox procedure: Side of head (temporalis muscles)

For these injections, I prefer to have the patient lying supine on their back and I stand at the head of the exam table behind them. That way they don’t see the needle coming towards their face and all spots are easily accessed from the sides of the patient. The way that I teach our headache fellows and other staff to do the temporalis muscles are to have the patient clench their jaw and feel for the temporalis muscle to contract. This is felt at the anterior point of the muscle just behind the hair line in the temple region. This is the 1st injection. From here, imagine a triangle with this 1st injection as the 1stpoint in the triangle. Then draw an imaginary triangle from here extending further back on the side of the head with the next 2 injection points above and below (see illustration) this 1st point. Then from here, imagine a square connected to the triangle. The next 2 injection points are horizontal and further back from the prior 2 injections points. All injection sites are 5 units.

 

The Botox procedure: Back of head (cervical paraspinal and occipitalis muscles)

For these injections, I prefer to have the patient sitting up on the exam table with their legs hanging over 1 side. I stand on the opposite side of the exam table behind them. The cervical paraspinal muscles are injected 1st on each side. The 1st cervical injection site is located by feeling the occipital protuberance (bump in the middle along the skull base), and going 2 fingerbreadths down and 1 over. This happens to be where the greater occipital nerve pierces through the musculature, and is also the first site of where occipital nerve blocks are done. The 2nd cervical injection site is located just superior and lateral to the 1st injection site.

 

Next come the 4 occipitalis muscle injections. These are done along the skull base and are evenly spaced out. The 1st site is just lateral to the occipital protuberance. The 2nd site is lateral to the 1st over the occipital groove (this is a palpable groove). This is where the occipital nerve travels, and is also the 2nd site where I normally do an occipital nerve block. The 3rd site is lateral to the 2nd site. The 4th site is lateral to the 3rd site and is located just posterior to the mastoid bone in another palpable groove. This also happens to be where the lesser occipital nerve travels, and is typically the 3rdspot I usually do for an occipital nerve block.

 

If the patient has prominent occipital neuralgia on one or both sides, instead of the standard 5 units over the occipital groove region (where the occipital nerves travel), I will inject 10 units at once and take that extra dose away from the shoulder or temporalis muscle regions (depending on where they typically have the least amount of pain and may not need it as much). Otherwise, all injection sites are normally 5 units. Notice that the PREEMPT protocol does not include Botox injections further down through the neck. The reason is because this can often increase headaches and can cause head drop to the point where some patients may need to wear a soft collar for 3 months. Therefore, this area should be avoided.

 

The Botox procedure: Shoulders (trapezius muscles)

For these injections, I prefer to have the patient sitting up on the exam table with their legs hanging over 1 side. I stand on the opposite side of the exam table behind them. Patients with chronic migraine most often have a lot of neck and shoulder pain. 70% of patients that get a migraine will get pain and tightness in these regions. So, if they are stuck in a smoldering cycle of chronic migraine and high frequency headaches, it would make sense that they would have a lot pain and tightness in these areas. Many patients also have concurrent fibromyalgia, so these injections can also be helpful, similar to trigger point injections. The 1st 3 injections are along the top ridge of the trapezius muscle. If you feel the superior medial corner of the scapula, there is invariably a tender point and knot here. This is the 4th injection site. The 5th site is in the middle of the trapezius muscle bulk. This is the end of the PREEMPT protocol dosing. However, the last 5 units that is left over I typically split between sides by giving 2.5 units somewhere in the trapezius region on each side where there may be a tender or trigger point, or I’ll just give it all on one side if they have more spasm or pain on one side compared to the other.

 

IF YOU HAVE HEADACHE, MIGRAINE, OR FACIAL PAIN AND ARE LOOKING FOR ANSWERS ON ANYTHING RELATED TO IT, A HEADACHE SPECIALIST IS HERE TO HELP, FOR FREE!

FIRST, LET’S DECIDE WHERE TO START:

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR THE LATEST INFORMATION, HOT TOPICS, AND TREATMENT TIPS, VISIT OUR FREE BLOG OF HOT TOPICS AND HEADACHE TIPS HERE. THIS IS WHERE I WRITE AND CONDENSE A BROAD VARIETY OF COMMON AND COMPLEX  MIGRAINE AND HEADACHE RELATED TOPICS INTO THE IMPORTANT FACTS AND HIGHLIGHTS YOU NEED TO KNOW, ALONG WITH PROVIDING FIRST HAND CLINICAL EXPERIENCE FROM THE PERSPECTIVE OF A HEADACHE SPECIALIST.

 

IF YOU DON’T HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR POSSIBLE TYPES OF HEADACHES OR FACIAL PAINS BASED ON YOUR SYMPTOMS, USE THE FREE HEADACHE AND FACIAL PAIN SYMPTOM CHECKER TOOL DEVELOPED BY A HEADACHE SPECIALIST NEUROLOGIST HERE!

 

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR FURTHER EDUCATION AND SELF-RESEARCH ON YOUR DIAGNOSIS, VISIT OUR FREE EDUCATION CENTER HERE.

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