A new way to adminster Botox for cluster and migraine headaches

Botox injections are currently approved for the treatment of chronic migraines but not cluster headaches. However, my experience at the New York Headache Center suggests that Botox injections may also help relieve cluster headaches, which some call suicide headaches. We inject Botox for cluster headaches in a similar way we do for chronic migraines, that is the injections are given in the forehead, temple and back of the head and neck. One difference is that since cluster headaches are strictly one-sided we inject only one side with the exception of the forehead because injecting only one side of the forehead will result in a lopsided appearance.

Researchers at the Norwegian University of Science and Technology in Oslo came up with an idea of injecting Botox into the sphenopalatine ganglion. This ganglion is a bundle of nerve cells that sits behind the back of the throat and has been a target for all kinds of procedures to relieve various pain problems. Doctors have attempted numbing those cells with cocaine and lidocaine, destroying it with heat, and stimulating it with electric current in an attempt to relieve not only cluster and migraine headaches but a range of painful conditions, including low back pain. Unfortunately, we do not have any good scientific studies proving that any of these procedures on the sphenopalatine ganglion work for any condition it’s been tried for. We have many so called anecdotal reports describing successful cases, but no large controlled trials have ever been performed.

It is not clear why the Norwegian doctors think that injecting Botox into the ganglion will be effective, beyond the fact that Botox “can stops the flow of impulses along the nerves”. A report in StudyNordic.com says that “The researchers strongly believe in their treatment method, in part because a new study unrelated to their work has shown an effect by using an electric current to paralyse the nerve bundle.” So far it does not seem that they’ve treated any patients, but did start recruiting patients for a study.

They hope to enroll 30-40 cluster headache patients and then another 80 with migraine headaches. ScienceNordic.com also reports that the treatment uses an MRI of the patient’s head to make certain that the surgeon knows exactly where the nerve bundle is. A navigation tool, composed of three small spheres on the pistol, and a plate with three spheres mounted on the patient’s head, enables the surgeon to find the nerve bundle using the MRI image. “A computer sends light signals to all the spheres to form precise points. We don’t miss, but anyone who wants to participate in the study must accept the risk that it could happen, because this has never been done before. If the Botox hits an area near the nerve bundle, it could cause temporary double vision, or weaken the ability of the patient to chew,” says the lead researcher, Dr. Tronvik.

Until we have some evidence that this treatment works we have to work with the standard approaches to cluster headaches, which include, occipital nerve blocks, oxygen, a course of steroid medications, sumatriptan (imitrex) injections, verapamil, lithium, and other drugs. Two of my patients for whom none of these approaches and Botox injections worked did respond to vagus nerve stimulation, or VNS. This procedure involves wrapping a wire around the vagus nerve in the neck and connecting it to a pacemaker-like device which is implanted under the skin in the upper chest. This is also a totally unproven method with only anecdotal evidence. However, VNS has been approved by the FDA for difficult to treat epilepsy and depression. Considering that antidepressants and epilepsy drugs help migraine and cluster headaches, it is logical to conduct studies of VNS before going for a more invasive procedures.

Art credit: JulieMauskop.com

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