Melanie Cole (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole. And joining me today to highlight botox for headaches and migraines is Dr. Tiffany Lin. She's an Assistant Attending Anesthesiologist at New York-Presbyterian Hospital Weill Cornell Medical Center, and an Assistant Professor of Clinical Anesthesiology at Weill Cornell Medical College, Cornell University.

Dr. Lin, it's a pleasure to have you join us again. So, this is a great topic and people have a lot of questions about this. Can you tell us how Botox works to alleviate headaches and migraines? What's the science behind it? Maybe tell us what Botox even is.

Dr. Tiffany Lin: Yes. And thanks for having me back. So before talking about Botox, I'd like to kind of just touch on headache and migraine a little bit first and talk about its pathophysiology. So, migraine is a primary headache disorder characterized by enhanced sensitivity of the nervous system. It can have a combination of neurologic, gastrointestinal, or autonomic disturbances. It is a complex disease process. Its pathophysiology is not completely understood, but it is thought that there is a stimulation of the trigeminal sensory neurons that results in the release of neurotransmitters and vasoactive peptides that can cause neurogenic inflammation, vasodilation, sensitization of the nerve fibers, which can ultimately lead to pain and their associated symptoms.

So, botulinum toxin, which we usually called Botox. It is a powerful biological toxin that is produced by a bacterium called Clostridium botulinum. It is commonly found in soil and water. And the way that a toxin works is that it binds to the peripheral cholinergic nerve terminals of the neuromuscular junction. And so, it can inhibit the release of acetylcholine into the synaptic cleft, which causes a denervation in the local neuromuscular junction, which causes muscle weakness. So, as most people know about Botox in the cosmetic realm, that's kind of how it works because it prevents muscle contraction, which reduces wrinkle production.

However, Botox doesn't just work in the neuromuscular junction, it also works in sensory fibers. So in the case of migraine and headache, the Botox actually inhibits the release of neuropeptides that are associated with pain signaling from the primary sensory neurons. And so, that reduces the flow of input into the trigeminal cervical complex that is involved in the migraine pathophysiology process. It is very interesting to note that we are injecting Botox into the muscles that are outside of the brain, on the scalp, but it can actually influence the pain signaling inside the brain. And that's because these sensory neurons are involved in migraine, they have branches that terminate in the scalp. So, it's essentially reducing the nociceptive input into these nerves and studies have shown that with Botox injection, you actually have a lower level of the circulating neuropeptides such as CGRP, which is involved in the pathophysiology of migraine.

Melanie Cole, MS: Wow. That was quite an explanation, Dr. Lin. Thank you so much. Now, how does it compare? Because people are sometimes afraid of needles and certainly needles that are going into their head, but how does it compare to other migraine treatments like oral meds, lifestyle changes, other injectables? Is it better, equal? Tell us a little bit how you would decide that Botox is the way to go.

Dr. Tiffany Lin: Sure. So, typical treatment for migraine, number one would be like lifestyle changes to avoid any migraine triggers. You can also be prescribed abortive medications that can help relieve pain and prevent progression of migraine, and those can include your aspirin, Tylenol, NSAIDs, or even tryptans or ergot derivatives.

But when someone has very frequent headaches, or if the acute treatments are not effective, you can be prescribed preventive medications to reduce the frequency, severity, and duration of migraine attacks. And these are usually anti-convulsants, antidepressants, or some blood pressure medications, including beta-blockers and calcium channel blockers.

The problem with these medications is that sometimes patients can have adverse effects to the medications. They might not be able to tolerate it. With preventive medications, it's also a daily dosing regimen, which can create some compliance issues. So, the benefit of Botox is that it is effective. It has very low side effect profile, so it's very well-tolerated. And it has very little risk of having drug interaction with other medications. And it is also just a quarterly injection in the doctor's office, so you don't have to worry about compliance with a daily dosing regimen.

Melanie Cole, MS: So it's not used as a rescue medication if they're in the midst of an intense migraine.

Dr. Tiffany Lin: No, it is used as a prophylaxis for chronic migraine. So, a criteria for someone to be a good candidate for Botox would be history of chronic migraine with at least 15 days per month of headache for at least three months. And out of those 15 days, eight of those days have to have migraine features. And the patient also has to have failed at least two classes of migraine prophylaxis medications.

Melanie Cole, MS: So, what's the actual procedure like, Dr. Lin? As I said before, I mean, that's one of the limiting factors for some patients is just the fear of what the actual injection procedure is like. Tell us what that's like.

Dr. Tiffany Lin: So, a typical migraine paradigm involves 31 sites of injection, across seven specific head and neck muscles. So, it's across the forehead, the temporal area, occipital area, the upper neck, and your shoulder trapezius regions. They are done with very small needles, 25 to 30 gauge needles, and it's actually really fast. It takes about 5 to 10 minutes to do.

Melanie Cole, MS: So, it's like acupuncture in that way, right? It's little tiny needles and it doesn't hurt that much.

Dr. Tiffany Lin: Actually, some patients can have pain with the injection sites, and that's just due to the irritating effect of the needle. It can worsen headache for a few days for some patients, but it is so effective that it is really the reason for someone to terminate treatment. We can also apply some skin cooling or apply some local anesthetic cream to help reduce the injection pain.

Melanie Cole, MS: So, how soon does someone experience that relief? You said that it can be given quarterly. So, four times a year they can get these Botox injections for migraines and chronic headache conditions. How long does it take to work if they've been suffering them in between treatments and does it work for that whole amount of time?

Dr. Tiffany Lin: Yeah. So, there is a delayed response to Botox. It takes about two weeks for it to take effect. And the Botox effect lasts for about three months. So, I would advise patients to keep on their strict schedule every three months so they don't have a relapse in their migraine. They have to wait two more weeks for the Botox to take effect before they start feeling better.

Melanie Cole, MS: Wow. Isn't that so interesting? So how long, if you want people to adhere, if there's someone who suffers from these headaches? How long can they be on Botox four times a year?

Dr. Tiffany Lin: So, they can be safely on Botox every three months indefinitely. So, there have been long term systematic reviews that show that the benefit of Botox tends to persist and only a small minority of patients lose their response to treatment over the years. So, most of my patients have been on Botox for years and years.

Melanie Cole, MS: Wow, you've answered every single question so clearly, Dr. Lin. Final thoughts. Tell patients what you would like them to know, especially if they're patients with misconceptions about using Botox for headaches, why this is so important and exciting and an exciting time for people that are suffering from chronic headaches and migraines. Give us your final thoughts and best takeaways here.

Dr. Tiffany Lin: I will say the most common misconception about Botox is that it's used for cosmetic purpose only. However, it's actually used in many different clinical settings to help treat many different pain syndromes, including headache and migraine. It is safe, it is effective, it is well tolerated than oral pain medications. And it only requires a visit to the doctor's office every three months, and you don't have to take your daily medications. So, I definitely think this is a very good alternative, for your headache treatment.

Melanie Cole, MS: Thank you so much, Dr. Lin. What great information you've given us today. And Weill Cornell Medicine continues to see our patients in person, as well as through video visits, and you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Back to Health. We'd like to invite our audience to download, subscribe, rate, and review Back to Health on Apple Podcasts, Spotify, iHeart, and Pandora. And for more health tips, you can always go to weillcornell.org and search podcasts. And parents, don't forget to check out our Kids Health Cast. We have so many great podcasts there. I'm Melanie Cole. Thanks so much for joining us today.

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