Botox for chronic cluster headaches

I just saw a man with chronic cluster headaches whom I’ve been treating for the past 5 years. He had tried various treatments and still remains on verapamil which provides partial relief, but he finds excellent relief from monthly intravenous infusions of magnesium and Botox injections given every 2 to 4 months. He sometimes needs a magnesium infusion every three weeks. He occasionally takes sumatriptan (Imitrex) injections as needed for breakthrough headaches, but many of his remaining attacks are mild and are relieved by rizatriptan (Maxalt) tablets or zolmitriptan (Zomig) nasal spray. Botox is not approved by the FDA for the treatment of cluster headaches, only for chronic migraines. However, there are several case reports of successful use of Botox in patients similar to mine. I’ve treated several other cluster headache patients with Botox with good results, but this is the only one who has been receiving Botox for three years (he has had 15 treatments to date). As far as the use of intravenous magnesium, we’ve published an article showing that 40% of patients with cluster headaches are deficient in magnesium and respond to intravenous infusions.
Cluster headache
Photo credit: IHS-Classification.org

15 comments
  1. Rachel Katz says: 04/18/20128:55 pm

    Dear Dr. Mauskop:
    Remember me? I have a patient with chronic cluster headache (female 49 years old ) I have tried everything and she is really suffering. I want to try Botox and I read your article. Could you tell me how many units you use, and where do you inyect? Do you follow the pain? Also, how much IV Magnesium do you put and how diluted?
    Thanks I will appreciate your answer.
    Rachel

  2. Dr. Mauskop says: 04/18/201210:26 pm

    Dear Dr. Katz,
    Yes, of course I remember you – we’ve met at several conferences. IV magnesium seems to help 40% of cluster headache sufferers. I give 1 gram of magnesium sulfate in 10 cc’s of normal saline by slow push over 5 minutes. As you probably know in the US Botox is only approved for chronic migraine headaches, but we do use it off label for other types of headaches. You probably know what the status of Botox for headaches is in Mexico, but I am sure that it is not approved for cluster headaches since no large studies have ever been done. I have tried in few desperate patients similar to the ones you describe and have had some success. I usually use 100 units, bilaterally in the forehead and the rest on the side of the headache – temporalis, occipitalis and suboccipital muscles. All the best.

  3. Annie Guillemette says: 07/05/20125:25 pm

    Dear Dr Mauskop,

    I am a neurologist in Quebec city. I was wondering what do you think about Botox in episodic cluster headache?

    Annie

  4. Dr. Mauskop says: 07/05/20128:25 pm

    I have given Botox injections to several chronic cluster patients with success. Some of them converted to episodic clusters and would come to repeat Botox injections when headaches returned. So, it seems that Botox might also help episodic cluster headaches.

  5. Sarah says: 10/16/201211:16 am

    Dr. Mauskop, this information is very interesting to me. My husband suffers from chronic cluster headaches that recur every two years and then episodes last for a year. Are you familiar in your patients with any pattern such as this? Would a magnesium deficiency cause such a steady pattern. (and if so, why would there be two years of quiet if the patient is still deficient in magnesium?)
    I would appreciate your professional opinion.
    Thank you so much.

  6. Dr. Mauskop says: 10/17/20128:29 pm

    We do not know why cluster headaches exhibit very peculiar patterns, but regardless of the pattern our research indicates that magnesium deficiency is present in 40% of patients. It is worth considering a trial of magnesium supplementation, at least by mouth. Intravenous infusion of magnesium is much more likely to help those who are deficient because oral magnesium is often poorly absorbed and can take weeks to work. Some of my patients take magnesium all the time in the hopes of preventing future cluster episodes, but for some this strategy does not work – they still have to come in for an infusion whenever they develop a cluster. At times magnesium provides only partial relief, and we still have to use preventive drugs such as verapamil.

  7. Sarah says: 10/18/20121:01 pm

    Dear Dr, Mauskop,
    Thank you for your prompt response. In lieu of your suggestion, my husband took a blood test to check magnesium levels. His numbers came out to 2.13 MG/DL which seems to be in the normal range. Could it be that his headaches may still be magnesium deficient promoted and that for some reason he needs a higher level of magnesium than normal?
    Again, i thank you for your help. i know it is not easy to diagnose via online details but we are currently out of the country and we are finding it difficult to treat him effectively.
    Thank you again.

  8. Dr. Mauskop says: 10/18/20121:20 pm

    Unfortunately, serum magnesium level that your husband had is completely unreliable. RBC magnesium levels are somewhat more accurate, but also not entirely reliable. So, the best test is to try taking a magnesium supplement.

  9. Sarah says: 10/19/20126:44 am

    how much would you recommend? thanks so much for your help!

  10. Dr. Mauskop says: 10/19/201211:25 am

    The usual recommended dose of magnesium is 400 mg a day; you can read about different types of magnesium at http://www.nyheadache.com/blog/?p=516

  11. Sarah says: 10/23/20128:05 am

    thanks for your help! we really appreciate your bedside (“siteside”) manner!

  12. Ruthann barrs says: 12/17/20129:19 pm

    My son is 32 he has had clusters for 14 years where is the closest place to us that a doctor could treat him with Botox and the magnesium? Thank you for a prompt answer.

  13. Dr. Mauskop says: 12/18/20129:38 am

    You can find a doctor who injects Botox for chronic migraines at the manufacturer’s (Allergan) site – http://www.botoxchronicmigraine.com/find-botox-specialist/
    Before making an appointment ask if the doctor would inject Botox for cluster headaches.
    As far as getting IV magnesium, you may want to call a local urgent care facility (this is not an emergency room at a hospital, but usually a private clinic) and see if they would do it.

  14. dr leila sadien says: 01/01/20134:31 am

    Doc, my GP/homeopath has administered magnesium iv before. I found that it brought on an attack within 24hrs and then they would subside for a few days. I suffer episodic CH and am currently 8weeks pregnant and in the longest cycle yet… 8 weeks so far. Would u recommend magnesium for me now? If so, what dose and how would u decide how often?
    I am a south african MD and have booked myself into hospital for fe days because I’m afraid I’ll take my life if I continue like this at home.
    Thank u
    Leila

  15. Dr. Mauskop says: 01/01/201311:30 pm

    Actually, it is very good for pregnant women to get magnesium infusions – babies born to women who had intravenous magnesium (usually given for eclampsia and premature labor) are less likely to have spina bifida, cerebral palsy, and other neurological problems. Magnesium infusions with 1 gram of magnesium sulfate can be given as often as every few days or daily while in the hospital. For premature labor and eclampsia the dose of magnesium is 5-6 grams. Kidneys are very good and sometimes are too good at excreting magnesium, so the only people at risk of having too much magnesium, which can be dangerous, are those with serious kidney problems. Another treatment that I’ve given to pregnant women with very frequent migraines is Botox since it is injected into the skin and muscles so it is a local treatment with very little of Botox absorbed into the circulation.

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