Blocks and Botox
(Adapted from Dr. Mauskop’s book, The End of Migraines: 150 Ways to Stop Your Pain)
Botox Injections
In the early 1990s, I was one of the first neurologists to start injecting onabotulinumtoxinA (Botox) for the treatment of migraine headaches. Many of my colleagues were incredulous. They could not believe that a treatment directed at the superficial nerves and muscles would help a brain disorder such as migraine. At first, we thought relaxing the tight muscles around the scalp was responsible for the relief many patients reported. Since then, scientists have discovered that Botox blocks the release of pain-signaling neuropeptides from nerve endings in the scalp and reduces transmission of pain messages to the brain, interrupting a vicious cycle that begins centrally but depends on input from peripheral nociceptors, or pain sensors.
The mechanism by which onabotulinumtoxinA works in chronic migraine is now well understood. Following injection into tissues, onabotulinumtoxinA inhibits SNARE-mediated vesicle trafficking by cleaving one of its essential proteins, SNAP-25, which occurs in both motor and sensory nerves. By inhibiting sensory nerve endings in the head and neck, onabotulinumtoxinA reduces the number of pain signals reaching the brain and prevents activation and sensitization of central neurons involved in migraine chronification.
My most dramatic result from Botox injections occurred in a 76-year-old woman. She had been suffering from migraines for 60 years, and, for the previous 20 years, they were occurring daily. She was referred by an experienced neurologist who had run out of options. My first thought was that after 60 years of relentless migraines, her brain circuits were burned in, and nothing could break the vicious cycle of pain. Three months after her first Botox treatment, she called to report that this was the first time in her life that she had three months without a single migraine.
More than 300 doctors from around the world have visited our clinic for training in Botox injections. We've participated in one of the pivotal trials that led to the approval of Botox for the treatment of chronic migraines. I have written extensively on my blog, in articles, and in book chapters. One of the chapters appeared in the volume on headaches in the authoritative 174-volume Handbook of Clinical Neurology. Despite these efforts and guidelines from our professional societies, Botox remains underutilized.
Nerve Blocks
Nerve blocks consist of injecting a drug such as lidocaine or bupivacaine to numb the nerves around the scalp. The most commonly blocked nerves are the occipital nerves, located at the back of the head. We also block the supraorbital (forehead) and temporal (temples) nerves. Your head will feel numb for a few hours after these shots. For many people, this stops migraines.
The evidence supporting occipital nerve blocks for migraine is substantial. A 2025 meta-analysis of randomized controlled trials involving 930 patients found that local anesthetic occipital nerve blocks significantly reduce headache severity in acute migraine attacks within 30 minutes. The 2025 American Headache Society guideline gives occipital nerve blocks a "must offer" recommendation for acute migraine in the emergency department, based on three positive randomized controlled trials. Adding supraorbital nerve blocks to occipital nerve blocks can provide additional benefit, and the same guideline gives the combination a "should offer" recommendation.
Nerve blocks are useful for people who do not respond to medications or have contraindications to taking drugs such as triptans, and for pregnant women who prefer to avoid taking medications. Weekly nerve blocks can also help patients who respond well to Botox (onabotulinumtoxinA) injections but whose effects last less than 12 weeks and who cannot receive more frequent injections because the insurer does not allow them.
Sphenopalatine Ganglion Blocks
The sphenopalatine ganglion (SPG) is a collection of nerve cells underneath the skull and behind the nasal cavity. These cells have a wide network of connections, and numbing them with a local anesthetic such as bupivacaine seems to help migraine headaches.
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This “book” appears to have largely been born out of his blog from the New York Headache Center. For years, he has regularly put up information, scientific and clinical, for his headache followers. He has created this “book,” actually an e-book, which takes relevant information from his experience and knowledge of migraine. There is no need for an index and chapter references. He uses hyperlinks, embedded in the e-book, to connect to material online, which he puts in context for the reader. This works very well as one hyperlink may go to an original paper or publication or a resource site.
He links to major medical journals including headache journals and his own publications, when helpful, as well as nonmedical literature and other sites. This format allows the e-book to be updated from time to time, which is easy to do with this approach.
The book has a very interesting introduction and deals with evidence-based medicine and its role in migraine therapy. When he begins the section on 150+ treatments, he starts with a very interesting comment. Many of the treatment ideas that I describe in this book are not just off-label (that is, not approved by the FDA) but may appear to be off-the-wall. It is refreshing to hear such intellectual honesty from a practicing neurologist.
There is a great section on supplements and finding someone to help with your migraine, such as coach, a partner, or a sympathetic friend. A diagnostic discussion follows and is most helpful, as proper diagnosis directs treatment, as are the detailed sections on triggers including environment, food, exercise, physical therapies, and sleep. Herbal therapies are covered as is neuromodulation and injections/blocks among others.
In the sections on drugs, he deals with acute therapies and the modern use of triptans and gepants, and a ditan. Preventive therapies start with monoclonal calcitonin gene-related peptide antibodies, tricyclic medications, and many other preventive therapies including beta blockers, anti-seizure drugs, nonsteroidal anti-inflammatory drugs, and botulinum injections. From acupuncture to Feldenkrais methods, he covers the contemporary plethora of migraine “treatments” as he sees it in practice.
He ranks all medications on a 1 to 10 scale regarding his own subjective opinions of the utility of each treatment. He indicates that no treatment gets 10 as a score and any receiving a score of 1 were not rated. He also lists his favorite migraine therapies separately. He includes a lot of data links here, from single case reports to full-scale randomized clinical trials, and detailed reviews. His clinical acumen shines through the volume and one gets the impression that this is a very personal view at times, not always backed by evidence, as there may not be any, but by experience, practice and pragmatism. He carefully notes the general things to be careful of in taking some treatments and warns if there are serious concerns. Nonetheless, he indicates clearly that the advice of a medical professional should be sought before trying the therapies mentioned.
Diagnosing secondary headache that can mimic migraine or vice versa is a useful section but does not go into depth about the disorders/diseases mentioned, as this is not the intention of the book. Special circumstances are given sections including menstrual migraine, pregnancy, resistant/refractory headache, aura and headache, and many others.
The author is a senior, highly experienced neurologist and has a high degree of interest in migraine and other headache disorders. He has a sense of curiosity about the brain and migraine and that comes through to the reader of this small volume. I count 23 endorsements, including the excellent foreward of the book from a wide range of well-known people, which includes two prior editors of this journal. He is well liked and highly respected by his colleagues.
In many ways, this book does what online databases on diseases cannot do most times. He tells the reader what he knows and how to use that knowledge. He directs the novice and experts to the right literature and takes the reader on a personal journey through the field of migraine treatments. He tells people, “…keep seeking relief, not to give up on or blame yourself for the pain you experience from migraine.”
There is a printed version of the book; however, the e-book is ideal for the intended purpose. I would recommend it the first instance. It is available via a commercial site and inexpensive.
I would recommend this book to anyone who has migraine or cares for people with migraine and wants a broad and sometimes detailed overview of the treatments. Available in the e-book format, it represents a lot of work for one person, but his passion, occasional humor, and historical perspectives are evident in this work. You don’t have to agree or accept everything the author says to enjoy and benefit from this “book,” and I know he would want people to be critical and skeptical where warranted. However, you will find more than you would usually need to know from this banquet of 150 ways to help your migraines! Enjoy, I did very much. Read it through once and save as reference.
Alexander Mauskop, Director of the New York Headache Center, and Marietta Abrams Brill, a freelance medical writer, have written principally for headache sufferers in North America. They answer questions like “is Rolfing covered by medical insurance?”, and include an excellent resource section in the back. of the book which lists American organizations for the various therapies. But they provide enough background information on both headache and alternative treatments to make their book interesting to readers from other countries, too. In covering most of the more common alternative therapies~like herbs, acupuncture, massage, Ayuverda and Eastern medicine, and qigong-they aim to inform rather than judge, cite research evidence where it exists, and point to potential dangers as well as benefits.
Each of the 10 chapters is introduced with a pithy quote: “Divine is the work to subdue pain” (Hippocrates) heads the first chapter. After general background on pain theories and headache diagnosis, common alternative approaches are covered in turn and there is, of course, oodles of advice on diet and nutrition. A helpful glossary guides readers through words that conventional doctors are familiar with, like Scotoma, and those with which we aren’t, like Qi, Vatta, and Pitta. To round off, a comprehensive resource section and selected bibliography give useful directions to readers wanting more information about specific therapies.
Like all good guides, this one follows a logical structure and so it is relatively simple to go quickly to the information you want to find. It is easy to read. All in all, it is a guide which headache sufferers looking for good information on alternative therapies can be thankful for.
