Jessa Engelstein's 15-year search for migraine relief has made her a reluctant expert in pain medicines through her encounters with at least 50 different drugs–from anti-inflammatories like ibuprofen to anti-depressants, homeopathics, beta-blockers, triptans, and narcotics. She has also tried combining them with non-pharmacological therapies including biofeedback, hypnosis, and massage therapy.
“I've had migraines for three-quarters of my life,” says Engelstein, a 23-year-old office machine sales rep from Delmar, NY, who has suffered from chronic daily migraines since she was 6.
A few years ago, her physician, Alan Rapoport, M.D., director of the New England Center for Headache in Stamford, Conn., asked if she'd like to try botulinum toxin type A, commonly known as Botox. While advising that the drug was still considered an experimental treatment for migraine by the Food & Drug Administration (FDA), he said some of his other patients had found relief with it.
“This solution is far better than anything I've ever imagined,” says Engelstein. “My migraines were so bad that I had to go to the hospital emergency room three to four times a year. This treatment reduces the frequency of the migraine. Instead of sidelining me twice a month, I may get one migraine every month and a half. It has reduced my migraines at least 75 percent.”
Botulinum toxin type A has been in use for about 15 years by dermatologists, podiatrists, and pain specialists, according to Dr. Rapoport, but it has only come into use as a headache treatment during the last five years. It works well for chronic daily headache and post-traumatic headache, but is not as effective for common or tension-type headaches, says Dr. Rapoport.
Stephen Silberstein, M.D., director of the Jefferson Headache Center in Philadelphia, Pa., says many neurologists specializing in headache are prescribing botulinum toxin type A along with traditional migraine therapies, “but we don't use it as a first-line drug.”
He says there are three occassions when he considers using botulinum toxin type A as a migraine treatment:
- When a patient has very frequent migraines (more than 50 percent of the time)
- When a patient has additional pain such as dystonia or cervical spasm
- When other treatments fail
How Does it Work?
When botulinum toxin type A is injected into the muscles, it prevents nerve endings—or synapses—from triggering the release of calcitonin gene-related peptide, which can lead to muscle contractions.
“We always inject it on the forehead,” says Dr. Rapoport. Other insertion points could be in the two little muscles on top of the nose—the procirus muscles—the temples, in back of the head or neck, or in the shoulders, if pain extends to those areas.
What Does it Cost?
A botulinum toxin type A treatment can range from $750 to $1,500, depending on where you live. While expensive, the treatment can last from three to four months, and therefore may compare favorably to the costs of other medications. Some patients are on two or three preventative medicines, which can vary from $20 to $200 per month.
But Engelstein feels the costs are definitely worthwhile for preventative treatment. “I've saved money in the long run, especially factoring in the frequent trips I used to make to the emergency room.”
Dr. Rapoport says neurologists are looking forward to seeing the results of two major multi-center studies that will be released soon. If the results are positive, the FDA may approve the medication for headache treatment.
Drawbacks to the Therapy
Engelstein says an adverse side effect of the treatment is feeling flushed, hot and slightly nauseous for a few minutes, but it quickly disappears. The site of the injection can turn a little red and swollen.
Dr. Silberstein tells patients that there is some risk. “It can temporarily paralyze muscles where you don't want to have them paralyzed,” resulting in a droopy eyelid. And Engelstein notes that botulinum toxin type A does not eliminate the triggers that can lead to a migraine. She rarely goes to concerts and tries to avoid other loud noises and flashing lights; still, the therapy has reduced her migraines significantly, she says. Since starting the therapy, she's only been to the hospital once.