Good Shepherd Rehabilitation Network offers migraine sufferers relief by using Botox®. Originally used to help women stave off wrinkles, researchers noticed that migraine sufferers who received Botox® injections for cosmetic purposes also had a reduction in migraine symptoms.
Asare Christian, MD, MPH, discusses the use of Botox® for Migraines, TMJ and Other Musculoskeletal Pain, and when to refer to the specialists at Good Shepherd Rehabilitation Network.
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Botox® for Migraines, TMJ and Other Musculoskeletal Pain
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Learn more about Asare Christian, MD
Asare Christian, MD, MPH
Asare B. Christian, MD, MPH, a physical medicine and rehabilitation physician, has joined the staff of Good Shepherd Rehabilitation Network. Dr. Christian is seeing outpatients at the Spine & Joint Center at the Good Shepherd Health & Technology Center in Allentown and at other Good Shepherd sites. He specializes in musculoskeletal issues (including joint pain, low back pain and arthritis), stroke, non-interventional pain management, spasticity and dystonia management.Learn more about Asare Christian, MD
Transcription:
Melanie Cole (Host): Diagnosis and treatment of painful muscle syndromes can be a difficult and frustrating task for any clinician. Our topic today is Botox for migraines, TMJ, and other musculoskeletal pain. My guest today, is Dr. Asare Christian. He's the Associate Outpatient Medical Director at Good Shepherd Rehabilitation Network. Welcome to the show, Dr. Christian. In the past several years, what’s been the mainstay therapy for pain sufferers for migraines and TMJ?
Dr. Asare Christian (Guest): For migraines, and other pain conditions in the past, the options we’ve had have been very limited to just oral pharmacotherapy. Basically, medications – specifically, medications that we use for migraines and these types of chronic pain syndromes are antiseizure medications, antidepressants – medications that we’re using off-label, and they have multiple side-effects that a lot of time patients cannot tolerate. Additionally, but fortunately now, we have botulin toxin, Botox specifically, which we can use to treat individuals with migraines and pain such as TMJ and other musculoskeletal pain complaints.
Melanie: Botox has been used for cosmetic surgery, obviously, for years. How is it breaking onto the scene for other issues such as pain control? Tell us a little bit about its intended purpose.
Dr. Christian: Right, so, I think most people are familiar with botulin toxin. Even before then, historically, we’ve known that Botox actually works for pain. Way back, when we were using Botox for treating dystonia, basically stiffness within the neck, we did recognize that when individuals get treatment for dystonia, they actually end up having improvement in pain. We have known that there are benefits of pain relief from Botox many, many years ago, and then subsequently, we started doing Botox for cosmetics. We also recognized these ladies – ladies or men who were using Botox for cosmetics, if they had migraines we also noticed this was also something that helped with migraines. Subsequently, we have had studies that have confirmed this, and this has become one of the ways to treat migraines.
Melanie: Speak about the clinical indications for its use. Are you looking to traditional forms of treatment first? Is this ever used as a first-line of defense?
Dr. Christian: Migraines alone – the indications for Botox is for chronic migraines, so these are individuals who have migraines more than 15 days out of the month. That’s the definition of a chronic migraine. We do have individuals who get migraines every once in a while, but if you get migraines 15 days out of the month and it’s debilitating, then those are the indications for Botox for chronic migraines.
Melanie: In the example of musculoskeletal pain and depending on where it is, where is the most likely area of concentration? What do you see?
Dr. Christian: When it comes to musculoskeletal pain complaints, we actually do not have a current indication for Botox from the FDA – I’m just talking about the FDA indication for Botox for musculoskeletal pain. We do have it for dystonia. Dystonia occurs within the muscles of the cervical spine, within the neck muscles, within the upper back, thoracic region, lumbar region. All of these areas can develop sustained muscle contractions that are very painful, and those can be considered as dystonic muscles, and those are the areas that we can treat with botulin toxin. For example, some people have had surgery on their back because of going through surgery, muscles and tendons heal, and things can become very tight and become very painful. Even though their surgical situation has corrected the problem that was initially there, scars and other immobility complications can lead to tight muscles, and this can be an indication to treat with Botox as well.
Melanie: Can you even use it for conditions such as Parkinson’s Disease when talking about maybe foot dystonia?
Dr. Christian: Yes. Dystonia is – Botox is an indicator for dystonia, so if individuals have Parkinson’s and they have tight muscles, that would be indicated. MS patients that have spasticity and have pain with that can also be used for treatment.
Melanie: Is there some variability as to how quickly patients begin to see benefits and are there certain patient selection criteria that you would like to discuss?
Dr. Christian: In general, botulin toxin, Botox, starts working in three days, it peaks around three weeks, and it lasts around three months. It’s kind of three, three, three – three days, three weeks, three months. We do know in clinical practice that there is variability in terms of how people respond to therapy, so everybody will respond to this differently. The majority of the people will see by four weeks if they’re going to notice any improvement in their symptoms. They do see that improvement within about four weeks or so.
In terms of duration, an individual’s course is from two months to four months, so there are people that will get treatment, it will last about a month, the majority of people will get three months, and then we do have some people who have pain relief for more than three months, up to four and six months.
Melanie: In an example, Dr. Christian, such as TMJ based on where it’s located, is there a learning curve for these injections? Have you seen that more experienced produces a better outcome? Tell us a little bit more about the physicians’’ experience with this.
Dr. Christian: Absolutely, and this is consistent with all types of interventions that we do in medicine. The more experienced clinicians are based on their training and exposure does make a difference in terms of outcome. For TMJ specifically, you have to understand the anatomy really. You have to have a good understanding of what’s going on with the patients’ history. Sometimes you might have to think about dentistry – I’m not a dentist but looking at all of these other components that can play into the patients’ symptoms. If we don’t have a good understanding of what’s going on in the patients’ life, other stresses. We know some of these things can be triggered by stress. TMJ, some people will have more grinding and other symptoms when they’re stressed, so getting a better picture of what’s going on with the patient, symptoms, and history, helps, and obviously, having had the experience with using the botulin toxin and having the right techniques makes a difference for patients.
Melanie: Dr. Christian, summarize this for us. Tell other providers what you’d like them to know about the use of Botox for migraines and other musculoskeletal pain, including TMJ, and when you think it’s important that they refer to the specialists at Good Shepherd Physician Group.
Dr. Christian: I think what I would like other doctors to understand is that throughout our medical training, we have some understanding of how botulin toxin works. It works by blocking acetylcholine. What we’ve learned in residency – if you do not have residency, neurology, or pain, or specifically, physical medicine, you don’t have this concept of the anti-nociceptive effect, meaning the pain effect we get from botulin toxin treatment. Historically, we have known this for a long time, so within our specialty, we’ve been using botulin toxin. Obviously, there are some side-effects, so it helps to have exposure and experience with how this works. If providers are out there who have individuals who have migraines and are not responding to current therapy, which are the medications that we have. They do have side-effects. If they can’t tolerate, and they’re having more than 15 days of migraines with functional impairment, this would be a good place to start. Also, if there are individuals who have had chronic muscle pain that has not responded to epidural injections, they have not responded to surgical interventions, which is actually something I see quite a bit in my practice. Post-laminectomy syndrome, individuals who have surgery, subsequently, the structure is fixed and now they have all of this muscle tightness, they have all of this pain, and that would also be a population that we can manage safely here in our clinic. The same goes for TMJ and other dystonia and other chronic pain conditions that relates to the musculoskeletal system.
Melanie: Thank you so much, Dr. Christian, for coming on with us today and sharing your expertise. This is such an interesting topic. Thank you so much, for joining us. This is Be Well, the podcast from the rehabilitation experts at Good Shepherd Rehabilitation Network. For more information on resources available at Good Shepherd Rehabilitation Network, please visit GoodShepherdRehab.org, that’s GoodShepherdRehab.org. I’m Melanie Cole. Thanks so much, for listening.
Melanie Cole (Host): Diagnosis and treatment of painful muscle syndromes can be a difficult and frustrating task for any clinician. Our topic today is Botox for migraines, TMJ, and other musculoskeletal pain. My guest today, is Dr. Asare Christian. He's the Associate Outpatient Medical Director at Good Shepherd Rehabilitation Network. Welcome to the show, Dr. Christian. In the past several years, what’s been the mainstay therapy for pain sufferers for migraines and TMJ?
Dr. Asare Christian (Guest): For migraines, and other pain conditions in the past, the options we’ve had have been very limited to just oral pharmacotherapy. Basically, medications – specifically, medications that we use for migraines and these types of chronic pain syndromes are antiseizure medications, antidepressants – medications that we’re using off-label, and they have multiple side-effects that a lot of time patients cannot tolerate. Additionally, but fortunately now, we have botulin toxin, Botox specifically, which we can use to treat individuals with migraines and pain such as TMJ and other musculoskeletal pain complaints.
Melanie: Botox has been used for cosmetic surgery, obviously, for years. How is it breaking onto the scene for other issues such as pain control? Tell us a little bit about its intended purpose.
Dr. Christian: Right, so, I think most people are familiar with botulin toxin. Even before then, historically, we’ve known that Botox actually works for pain. Way back, when we were using Botox for treating dystonia, basically stiffness within the neck, we did recognize that when individuals get treatment for dystonia, they actually end up having improvement in pain. We have known that there are benefits of pain relief from Botox many, many years ago, and then subsequently, we started doing Botox for cosmetics. We also recognized these ladies – ladies or men who were using Botox for cosmetics, if they had migraines we also noticed this was also something that helped with migraines. Subsequently, we have had studies that have confirmed this, and this has become one of the ways to treat migraines.
Melanie: Speak about the clinical indications for its use. Are you looking to traditional forms of treatment first? Is this ever used as a first-line of defense?
Dr. Christian: Migraines alone – the indications for Botox is for chronic migraines, so these are individuals who have migraines more than 15 days out of the month. That’s the definition of a chronic migraine. We do have individuals who get migraines every once in a while, but if you get migraines 15 days out of the month and it’s debilitating, then those are the indications for Botox for chronic migraines.
Melanie: In the example of musculoskeletal pain and depending on where it is, where is the most likely area of concentration? What do you see?
Dr. Christian: When it comes to musculoskeletal pain complaints, we actually do not have a current indication for Botox from the FDA – I’m just talking about the FDA indication for Botox for musculoskeletal pain. We do have it for dystonia. Dystonia occurs within the muscles of the cervical spine, within the neck muscles, within the upper back, thoracic region, lumbar region. All of these areas can develop sustained muscle contractions that are very painful, and those can be considered as dystonic muscles, and those are the areas that we can treat with botulin toxin. For example, some people have had surgery on their back because of going through surgery, muscles and tendons heal, and things can become very tight and become very painful. Even though their surgical situation has corrected the problem that was initially there, scars and other immobility complications can lead to tight muscles, and this can be an indication to treat with Botox as well.
Melanie: Can you even use it for conditions such as Parkinson’s Disease when talking about maybe foot dystonia?
Dr. Christian: Yes. Dystonia is – Botox is an indicator for dystonia, so if individuals have Parkinson’s and they have tight muscles, that would be indicated. MS patients that have spasticity and have pain with that can also be used for treatment.
Melanie: Is there some variability as to how quickly patients begin to see benefits and are there certain patient selection criteria that you would like to discuss?
Dr. Christian: In general, botulin toxin, Botox, starts working in three days, it peaks around three weeks, and it lasts around three months. It’s kind of three, three, three – three days, three weeks, three months. We do know in clinical practice that there is variability in terms of how people respond to therapy, so everybody will respond to this differently. The majority of the people will see by four weeks if they’re going to notice any improvement in their symptoms. They do see that improvement within about four weeks or so.
In terms of duration, an individual’s course is from two months to four months, so there are people that will get treatment, it will last about a month, the majority of people will get three months, and then we do have some people who have pain relief for more than three months, up to four and six months.
Melanie: In an example, Dr. Christian, such as TMJ based on where it’s located, is there a learning curve for these injections? Have you seen that more experienced produces a better outcome? Tell us a little bit more about the physicians’’ experience with this.
Dr. Christian: Absolutely, and this is consistent with all types of interventions that we do in medicine. The more experienced clinicians are based on their training and exposure does make a difference in terms of outcome. For TMJ specifically, you have to understand the anatomy really. You have to have a good understanding of what’s going on with the patients’ history. Sometimes you might have to think about dentistry – I’m not a dentist but looking at all of these other components that can play into the patients’ symptoms. If we don’t have a good understanding of what’s going on in the patients’ life, other stresses. We know some of these things can be triggered by stress. TMJ, some people will have more grinding and other symptoms when they’re stressed, so getting a better picture of what’s going on with the patient, symptoms, and history, helps, and obviously, having had the experience with using the botulin toxin and having the right techniques makes a difference for patients.
Melanie: Dr. Christian, summarize this for us. Tell other providers what you’d like them to know about the use of Botox for migraines and other musculoskeletal pain, including TMJ, and when you think it’s important that they refer to the specialists at Good Shepherd Physician Group.
Dr. Christian: I think what I would like other doctors to understand is that throughout our medical training, we have some understanding of how botulin toxin works. It works by blocking acetylcholine. What we’ve learned in residency – if you do not have residency, neurology, or pain, or specifically, physical medicine, you don’t have this concept of the anti-nociceptive effect, meaning the pain effect we get from botulin toxin treatment. Historically, we have known this for a long time, so within our specialty, we’ve been using botulin toxin. Obviously, there are some side-effects, so it helps to have exposure and experience with how this works. If providers are out there who have individuals who have migraines and are not responding to current therapy, which are the medications that we have. They do have side-effects. If they can’t tolerate, and they’re having more than 15 days of migraines with functional impairment, this would be a good place to start. Also, if there are individuals who have had chronic muscle pain that has not responded to epidural injections, they have not responded to surgical interventions, which is actually something I see quite a bit in my practice. Post-laminectomy syndrome, individuals who have surgery, subsequently, the structure is fixed and now they have all of this muscle tightness, they have all of this pain, and that would also be a population that we can manage safely here in our clinic. The same goes for TMJ and other dystonia and other chronic pain conditions that relates to the musculoskeletal system.
Melanie: Thank you so much, Dr. Christian, for coming on with us today and sharing your expertise. This is such an interesting topic. Thank you so much, for joining us. This is Be Well, the podcast from the rehabilitation experts at Good Shepherd Rehabilitation Network. For more information on resources available at Good Shepherd Rehabilitation Network, please visit GoodShepherdRehab.org, that’s GoodShepherdRehab.org. I’m Melanie Cole. Thanks so much, for listening.