1. Treating Migraines with Botox
A presentation with a short video on injection technique
Dr Chris Blatchley

2. Botox for Migraines
More than 1 in 10 women suffer from migraines
You will primarily see aesthetics patients who also have migraines
Botox can be enormously effective
It is not difficult to optimise your injection technique for migraine treatment
See the article in this month’s Aesthetic Medicine Magazine for the science

3. What is Migraine?
Migraine is a Primary Headache diagnosed from the history.

4. How does Botox Work? Transcytosed through gut epithelium
Endocytosed by neurons - as the vesicles are reabsorbed after releasing their neurotransmitter load
BoTN-A is cleaved as it crosses the vesicle wall. The light chain becomes active
Seven serotypes of BoNT – act in different ways. BoTN-A blocks the SNAP25 complex, which prevents vesicle binding and any further neurotransmitter release
Some evidence that the active light chain is transported centrally, but little that it can then jump across synapses to other neurons

5. How does Botox work?
Peripheral Free Nerve Endings Botox blocks the release of Neuropeptides from the vesicles in the free nerve endings by the same process as at the Neuro-Muscular Junction

6. The pain is largely linked to the distribution of the Greater Occipital Nerve (C2) in the neck and ophthalmic branch of the Trigeminal Nerve (V1) around the eye
Their pain centres overlap in the Trigemino-Cervial Tract in the brainstem and send info to trigger the migraine in higher centres

7. Injecting the glabella with 60 units (100U Botox/Xeomin in 2
Injecting the glabella with 60 units (100U Botox/Xeomin in 2.5ml Preserved Saline = 1.5ml) green dots 10 units (0.20ml) yellow dots 4 units (0.10ml) - blue dots 2 units (0.05ml)

8. How do we inject the botulinum?
60U Botox/Xeomin (150U Dysport) directly into the Corrugators and 20-30U into the Forehead
100U diluted with 2.5ml preserved saline
Most patients don’t need injections into the neck

9. Danger of Lid Ptosis??
Botulinum Toxin is a large 1000Kdalton molecule specially adapted to piggy-back onto natural neuro-synaptic endocytosis processes
It is too big to:
cross cell membranes by passive diffusion
enter neurons along their axon length
cross the Blood Brain Barrier or fascial septa

10. Injecting the Corrugators to avoid Ptosis Anatomy – X-section of upper eyelid

11. Fascial compartment of the Corrugators Anatomy – Forehead layers showing glide layer during surgical brow lift – free nerve endings are in fascial aponeurosis
Forehead
peeled forward
exposing glide layer
Brow
incl corrugators
Hair line
Periosteum
on forehead

12. Injecting the glabella with 60 units (100U Botox/Xeomin in 2
Injecting the glabella with 60 units (100U Botox/Xeomin in 2.5ml Preserved Saline = 1.5ml) green dots 10 units (0.20ml) yellow dots 4 units (0.10ml) - blue dots 2 units (0.05ml)

13. Injecting the brow without lateral brow lift blue dots 2 units (0
Injecting the brow without lateral brow lift blue dots 2 units (0.05ml) - red dots 1-2 unit ( ml)

14. Injecting the high-acting Frontalis and reducing brow lift blue dots 2 units (0.05ml) - red dots 1-2 unit ( ml)

15. Where did the PREEMPT Protocol come from?
In 2000’s Allergan were being investigated in the USA for making claims they couldn’t substantiate so they needed a controlled trial.
Allergan tell me they were worried about lid ptosis so a decision was made to keep away from the corrugators in the trial designed by a team of neurologists working with them
After several attempts they got approval from the FDA in Oct In Sept 2010, presumably knowing they were to get FDA approval, they settled the previous Department of Justice investigation for $600million because “it was in the interests of the shareholders to do so” as they were selling $billions of Botox a year
Allergan tell me there are no plans for further studies to improve on the PREEMPT Protocol. Apparently they have also managed to patent Botox for migraine use making it difficult for other manufacturers to do migraine research.

16. Almost no Botox goes into the Glabella

17. Injecting the brow with lateral brow lift blue dots 2 units (0.05ml)

18. Injection Plan Combine Surgeon’s and PREEMPT Protocols
Inject Glabella and Forehead only
Will be adequate for the majority of patients and will keep the costs down to something the patient can afford
If the neck needs to be done then this can be done later

19. Why the difference? Turf war between the Surgeons and Neurologists
Neurologists refused at first to believe that Botox could work and certainly not that surgery could help, let alone ‘cure’ migraines
This trenchant disagreement has kept both sides from exploring the positive sides of each others’ theories/methods and has slowed down improvement in treatment protocols

20. Avoiding Lid Ptosis – Anatomy of the Glabella
Botox is too big to pass through Fascia
The glabella and eye socket have a series of fascial compartments designed to reduce spread of infection.
The Botox has to be injected within each compartment to have any action
Free Nerve Endings are present in skin, muscles, tendons and facia, particularly in the aponeuroses of muscle attachments:-
bony attachments of the small muscles to the vertebrae and the base of the skull
Non-bony attachments of glabellar muscles to the fascial aponeuroses

21. How do we inject the Botox?
Surgeon’s approach – 50U Botox into the corrugators
Neurologist’s approach - 150U Botox everywhere except the corrugators - the PREEMPT Protocol designed by Allergan
Combined approach – U to corrugators and U to the forehead. If necessary the neck can be injected later, but generally not necessary.

22. The headache in migraine comes from the meninges which are innervated primarily by V1 and C2/3, which may account for why there is pain in the temples even though the external anatomy is innervated by V3. The Vagus nerve is also involved

23. Botox?
I’m using “Botox” as a generic name for Botulinum Toxin A (BoTN-A)
All 3 commercial varieties can be used
I use Xeomin by Merz because you don’t need to store it in a fridge

24. What is Migraine?
Migraine is a Primary Headache diagnosable from the history
We don’t generally have to worry about secondary headaches caused by tumours etc because the migraine sufferers we see will have had it for years

25. What is Migraine?
Migraine is a Primary Headache diagnosable from the history
We don’t generally have to worry about secondary headaches caused by tumours etc. because the migraine sufferers we see will have had them for years
If the headache is new or the pattern has changed markedly then they need to be seen by their GP

26. What is Migraine?
Migraine is a Primary Headache diagnosable from the history
We don’t generally have to worry about secondary headaches caused by tumours etc. because the migraine sufferers we see will have had them for years
If the headache is new or the pattern has changed markedly then they need to be seen by their GP
You don’t need to know too much about migraines - just enough that you sound as though you know what you’re talking about!

27. What is Migraine?
Migraine and other Primary Headaches result from an imbalance of the normal excitatory and inhibitory control processes within the brain
Usually associated with N&V, photophobia etc – closely linked to autonomic control systems
Set off by
the fall in Estrogens just before the period
visual patterns and flashing lights
strong smells, loud sounds and visual patterns
Food is surprisingly unimportant
Some people have a visual or other sensory aura an hour or so before the headache starts

28. What we’ll talk about What are Migraines? How does Botox work?
How and where do you inject it for Migraines?
Do you want to join a research project?
A download will be available with a guide to the migraine consultation and an injection plan

29. What is Migraine?
Often genetic – Women > Men - can start in childhood
Associated with N&V, photophobia etc
Migraines FEEL different to other headaches but some neurologists feel that ALL primary headaches have the same migrainous process
So common that everyone thinks they have THE treatment
Osteopaths – a neck problem
Dentists – a TMJ problem
Neurologists – a brain problem
They’re all right … to a degree

31. What is Migraine?
The trigeminal nerve carries a mixture of somatic and autonomic sensory information.

32. What is Migraine?
The trigeminal nerve carries a mixture of somatic and autonomic sensory information.
Diffuse pain can perhaps be considered part of the autonomic process and travels
from Free Nerve Endings in muscles and fascia
via unmyelinated fibres
to a complex array of nuclei in the Trigemino-cervical tract in the brain stem

33. What is Migraine?
The trigeminal nerve carries a mixture of somatic and autonomic sensory information.
Diffuse pain can perhaps be considered part of the autonomic process and travels
from Free Nerve Endings in muscles and fascia
via unmyelinated fibres
to a complex array of nuclei in the brain stem
There’s a suggestion that migraines are an aberration of the avoidance reflex
close eye and turn head

34. How does Botox work?
Neurologists dismissed migraine surgery, favouring the explanation that it acts on the pain pathways, either peripherally from Free Nerve Endings or centrally.
Peripheral Free Nerve Endings Botox blocks the release of Neuropeptides from the vesicles in the free nerve endings by the same process as at the Neuro-Muscular Junction

35. None of the theories are mutually exclusive
How does Botox work?
None of the theories are mutually exclusive
Paralysing the muscles will reduce the mechanical stimulation of the free nerve endings
Direct action on the free nerve endings reduces afferent pain signal
There is some evidence of central axonal flow which may affect the central synapse of that neuron, there is no definite evidence of inter-neuronal spread

36. Injection Instructions for Botox/Xeomin
100u in 2.5ml preserved saline
Inject using 8mm 30g insulin syringe, held at 30 degrees to the skin, in line with the corrugator to avoid injecting outside the fascial compartment.
Now for the video…

37. How effective is Botox for Migraines?
10% total cessation of migraines
10% no effect
80% patient is happy with improvement
Less pain for shorter time
Fewer migraines
Less feeling that the next migraine is about to happen (people are often happiest with this)

38. Would you like to be part of a research project?

39. Thank you….