Many of you have heard that Botox (botulinum toxin) has been approved by the FDA for chronic daily headaches or migraines.
Chronic daily headache is defined as more than 15 days with headache in one month, so you don't have to have headache every single day to have this diagnosis. It does require injection into mutiple places in the head (25-30 places, very small amounts in each place)
I have not heard anything from the major insurance companies here in North Carolina about authorizing the use for Botox. Most of them were not paying for it in the past. We are still waiting for them to figure out how what the criteria are for using it (or for getting insurance coverage for it). One suggestion I've seen is that they may require a patient to have no response (or fail to improve) with at least 2 headache prevention medications.
How Botox works for headache prevention is not clear, but there is research looking into this (FYI, exactly how the other medications work for headache prevention is not understood either, so we don't really know why Topamax or Depakote work)
Botox has some potential side effects--It causes weakness in the muscles it is injected into. The weakness wears off, but it takes 3 months to wear off. So if you are injected with Botox and get a droop of the eyelid, it will be there for 3 months.
There are other side effects listed for Botox, but these are very very rare when it is used for chronic daily headaches, and I haven't personally seen them in my patients.View Thread
Which medications work for migraine prevention? This question comes up all the time, so I've made a list of some of the medications we use for headache prevention, along with a little information about the medication.
The dose is important, so your doctor has to be familiar with both the "normal" dose and the maximum dose. (A dose that is too small may not work, even if you take it for a long time)
Propranolol--this is a "betablocker" type of blood pressure medication. Atenolol and nadolol are similar medications
Verapamil--this is a "calcium channel blocker" type of blood pressure medication. We usually prescribe the 24 hour long lasting capsules, but it comes in a less expensive immediate release version.
Divalproex Sodium--This is the generic name for one of the common medications used for migraine prevention (you can look up the brand name). It is pretty important to be on the 24 hour extended release tablets of this one, because the side effects are much less common with the extended release version.
Topiramate--This is the generic name for a common medication used for migraine prevention. Many people like this because it can cause modest weight loss in 1/5 people who take it. It also causes tingling in the hands in more than 50% of people who take it. It is important to start at a small dose and go up slowly to avoid side effects
Nortriptyline (and Amitriptyline)--These older medications can work at relatively low doses for migraine prevention. They were originally used to treat depression, but at much higher doses than we use for headache prevention
Trazodone--This is another older medication originally used for depression. It is pretty sedating, and can really help patients who have trouble sleeping and frequent headaches.
Gabapentin--This is helpful for some headache patients, but usually a 2nd or 3rd choice medication for headaches. Because it is also used for fibromyalgia, back pain and neuropathy pain, some patients may take it for more than one problem. Doses up to 3600 mg/day are "normal". It has no medication interactions, so is safe with other medications.
Pregabalin--this is the generic name of a medication that has been advertised heavily for diabetic peripheral neuropathy. It can help with headaches. It is often used with other medications haven't worked.
Zonisamide--This is a generic medication that is used to treat epilepsy (like Topiramate, Divalproex, Gabapentin, and Pregabalin). It can cause weight loss and tingling like Topiramate, but is less likely to cause memory problems. If you are allergic to Sulfa mediations, you cannot take it.
Levetiracetam--This is the generic version of a medication used to treat epilepsy. Its sometimes used for people with chronic daily headaches.
Tizanidine--This muscle relaxer is sometime used for headache prevention, usually in patients with chronic daily headaches, or tension headaches.View Thread
I get asked this question pretty often in my clinic.
Aside from the legality issue (and its a major risk for jail time in some states) there are a couple of problems: You never know how much you are getting of the active ingredient (dose) and taking marijuana orally causes some of the active ingredient to be metabolized (so less effective).
Smoking it is as bad (or worse) for your lungs than tobacco (because most people hold their breath when smoking marijuana, gives the smoke more time to damage your lung).
there are no scientific studies looking at this.
I've seen 3 daily marijuana smokers in my clinic with daily headaches, and was concerned they were having drug induced headache. None of them returned for their scheduled follow up visit after I talked with them about this---and included the possibility of inpatient treatment of their headache at the start of a 30 day trial off marijuana.View Thread
The glaucoma from topamax is acute (sudden onset) severe glaucoma, and causes sudden onset of severe eye pain and redness. I've only seen 2 patients in the last 10 years who have had this from topamax.
Your are correct, more patients need to know about this. Blurred vision can be caused by Topamax (and many other medications) but is not a serious problem like the painful eye condition caused by topamax.View Thread
A lot of my patients ask about herbal supplements for headaches.
There are very few studies of supplements for headaches, but there are 2 or 3 things that do have pretty good evidence for migraine prevention:
Vitamen B2 (riboflavin)---this works OK for headache prevention, but you have to take 200 mg twice a day for it to work. There was a clinical trial in 1996 that showed this was better than placebo at migraine prevention.
Butterbur Root Extract (also called Petadolux, plant name is petasites hybridus)--There was a nice stude in 2004 that showed this was effective for migraine prevention. The dose is 50 mg 3 times a day (or 150 mg/day). This occasionally causes an upset stomach, but I have not had other complaints of side effects from patients.
Co Enzyme Q10: This had a nice study done in 2004 showing it was effective for headache prevention. Unfortunately they used a form not on the marked. I've suggested using 100 mg 2 or 3 tiems a day to patients. This medication is kind of expensive, so not very many of my patients have tried it.View Thread