So, what is a Migraine Headache?

Migraine Definition At least 2 of the following: Moderate to severe pain One sided Throbbing or pulsating in character Worsening with movement or bending over & At least one of the following: Nausea and/or vomiting Sensitivity to lights, sounds or smells

Other Common Migraine Symptoms Precipitated by certain foods, alcohol, stress, sleep patterns Peri-menstrual 60% of the time involves the neck region Strong family history (“sick headaches”) 3:1 female Worsened with bending over (it’s not your sinuses!) Next day “hang-over headache” Responds to caffeine

F AMOUS M IGRAINEURS

Botox Binds to the Nerve Terminal

Botox is Internalized into the Nerve Ending

Botox Cleaves SNAP-25 ( Now the nerve can’t release acetylcholine and tell the muscle to contract, so your wrinkles are gone!)

After 3 months, new nerve sprouts develop (and your wrinkles return)

Eventually the sprouts retract and the original nerve ending regains its normal function (That’s why Botox is re-injected every 3 months)

Beverly Hills, CA October 15, 2010 William J. Binder M.D., F.A.C.S. Inc., Beverly Hills plastic surgeon and pioneer in the cosmetic (anti-wrinkle) and therapeutic use of the BOTOX® neurotoxin, made headlines in the early 1990’s by discovering that BOTOX was effective in relieving the pain and preventing the onset of migraine headaches. Friday the U.S. Federal Drug Administration (FDA) approved BOTOX injections as a preventative treatment for chronic migraine sufferers.Beverly Hills plastic surgeon and pioneer in the cosmetic (anti-wrinkle) and therapeutic use of the BOTOX® neurotoxin, made headlines in the early 1990’s by discovering that BOTOX was effective in relieving the pain and preventing the onset of migraine headaches. Friday the U.S. Federal Drug Administration (FDA) approved BOTOX injections as a preventative treatment for chronic migraine sufferers.

Botox is only approved for “Chronic Migraine” So, what constitutes a “Chronic Migraine”?

Diagnostic Criteria for Chronic Migraine Chronic Migraine is a defined condition or more headache days per month Headaches lasting 4 hours per day or more At least 8 headache days classified as migraine days With or without medication overuse What are migraine characteristics 1 ? 14 Patients should experience at least 2 of these pain characteristics: UnilateralMigrainous, pulsating qualityModerate to severe intensity Aggravated by routine physical activity And at least 1 of: Nausea and/or vomiting Photophobia and phonophobia 1.Headache Classification Committee; Olesen J et al. Cephalalgia. 2004;24: Headache Classification Committee; Olesen J et al. Cephalalgia. 2006;26: Lipton RB. Headache. 2011;51(S2):77·83..

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So, how do we inject Botox for Chronic Migraine?

BOTOX ® for Chronic Migraine Patients: Recommended Order of Injection* per Phase 3 Injection Paradigm 1 1. BOTOX ® (onabotulinumtoxinA) Prescribing Information. Allergan, Inc., Blumenfeld AM et al. Headache. 2010;50: Order * MuscleTotal Dosage (Number of Sites**) ACorrugator † 10 Units divided in 2 sites BProcerus5 Units in 1 site CFrontalis † 20 Units divided in 4 sites DTemporalis † 40 Units divided in 8 sites EOccipitalis † 30 Units divided in 6 sites FCervical paraspinals † 20 Units divided in 4 sites GTrapezius † 30 Units divided in 6 sites Total number of Units 155 Units divided in 31 sites * Recommended order of injection based on phase 3 injection paradigm; table in prescribing information differs. ** Each IM injection site = 0.1 mL = 5 Units BOTOX ®. † Dose distributed bilaterally. Dosing and results in these studies are specific to the formulation of BOTOX ® manufactured by Allergan, Inc. (Irvine, CA). The Allergan, Inc., formulation is not interchangeable with other botulinum toxin products and cannot be converted using a dose ratio. 17 Patient is in supine position 2 Patient is in sitting position 2 Please see Important Safety Information, including Boxed Warning, throughout this deck.

Facial Muscles

Order of Injection and Patient Position Supine Sitting D. Temporalis: 20 Units each side F. Cervical paraspinals: 10 Units each side E. Occipitalis: 15 Units each side A.Corrugator: 5 Units each side C. Frontalis: 10 Units each side B. Procerus: 5 Units (one site) G. Trapezius: 15 Units each side 0.1 mL = (5 Units/site). BOTOX ® (onabotulinumtoxinA) Prescribing Information. Allergan, Inc., Please see Important Safety Information, including Boxed Warning, throughout this deck.

Injection Sites: Corrugator and Procerus Corrugator: 10 Units divided in 2 sites Procerus: 5 Units in 1 site 5 Units BOTOX ® (0.1 mL injected) BOTOX ® (onabotulinumtoxinA) Prescribing Information. Allergan, Inc., Please see Important Safety Information, including Boxed Warning, throughout this deck.

Injection Sites: Frontalis Region BOTOX ® (onabotulinumtoxinA) Prescribing Information. Allergan, Inc., Units BOTOX ® (0.1 mL injected) Frontalis: 20 Units divided in 4 sites 21 Please see Important Safety Information, including Boxed Warning, throughout this deck.

Injection Sites: Temporalis Having the patient clench teeth will produce a palpable anterior bulge to the temporalis muscle, directing the anterior injection site 5 Units BOTOX ® (0.1 mL injected) BOTOX ® (onabotulinumtoxinA) Prescribing Information. Allergan, Inc., Temporalis: 40 Units divided in 8 sites 22 Please see Important Safety Information, including Boxed Warning, throughout this deck.

Injection Sites: Occipitalis Occipitalis: 30 Units divided in 6 sites Nuchal ridge 5 Units BOTOX ® (0.1 mL injected) BOTOX ® (onabotulinumtoxinA) Prescribing Information. Allergan, Inc., Please see Important Safety Information, including Boxed Warning, throughout this deck.

Cervical paraspinal muscle group: 20 Units divided in 4 sites Trapezius: 30 Units divided in 6 sites Injection Sites: Cervical Paraspinal Muscle Group and Trapezius 5 Units BOTOX ® (0.1 mL injected) BOTOX ® (onabotulinumtoxinA) Prescribing Information. Allergan, Inc., Please see Important Safety Information, including Boxed Warning, throughout this deck.

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