Welcome to Spotlight on Migraine, a podcast series hosted by the Association of Migraine
Disorders.
Through personal stories and interviews with experts, we expose the true scope of migraine
by exploring symptoms, treatments, research topics, and more.
This episode is brought to you in part by our generous sponsors, Amgen, Novartis, and
Alder BioPharmaceuticals.
In this episode, we hear a brief yet informative explanation on how best to determine which
migraine patients are candidates for Botox.
Additionally, you will hear what patients can expect when using Botox to manage migraine,
including side effects, injection placements, associated costs, and more.
Since 2015, Amgen and Novartis have been working together to develop pioneering therapies in
Alzheimer's disease and migraine.
Together, Amgen and Novartis share in a mission to fight migraine and the stereotypes and
misconceptions surrounding this debilitating disease.
Carolyn deBeauport: I'm so happy to be here.
This is a wonderful group, wonderful symposium that just shows me it takes a whole collaborative
effort in the treatment and diagnosing of migraine headache as well as cluster headache.
Chronic migraine -- what is it?
I think we've heard a lot about chronic migraine, so I'm not going to bore you with a lot of
details, but chronic migraine -- there's no cure for migraine, there's no cure for chronic
migraine, and there is a distinguishing factor between episodic and chronic migraine in terms
of cost for the healthcare system with patients being out on disabilities, missing work, missing
life, versus episodic.
Both are quite painful, but they are even doing recent studies now showing that there's
a change on some of the brain imaging from going from episodic to chronic migraine.
Fifteen headache days per month -- I think we've also heard threads in this symposium,
and I popped over to the other one as well.
Fifteen headache days per month -- that doesn't mean 15 migraine attacks.
Your migraine could last a couple of hours.
It can last all day.
It can go on for several days in a row.
So I think it's more important to actually look at how many migraine days you're affected
rather than just looking at the number of attacks.
When patients come into the provider's office, often this gets missed because they're asked,
"How many migraine attacks do you have per month?" and I think a better question is to
ask, "How many headache-free days do you have per month?" because then we can actually get
at, "Do you have chronic migraine versus episodic?"
I'm talking about Botox here, so according to the guidelines to get Botox approved, you
need to have at least eight headache days that are migraine -- associated with migraine.
All of the other days that make up that 15 can be multiple migraine days that run into
each other.
They can be tension headache days.
When someone turns from episodic into chronic migraine, it kind of blurs the picture on
what exactly is migraine and not.
I have a lot of patients that will come in and say, "Well, I think I only have three
migraines per month because the other ones I'm able to function."
When you have such a chronic disease state, your body starts to kind of re-morph itself,
and your pain level and threshold may have started -- an eight was really hard for you
to function, and now your eight is your new norm for your life.
Symptoms may include nausea, light sensitivity, moderate to severe pain, pulsating and throbbing
pain.
I know these are all the guidelines to diagnose, actually, migraine headache; however, when
your clients come in, your patients come in -- and I'd like to call migraine not just
"patients," but they're "people with migraine" versus classifying them as just patients.
They're actual people.
Sometimes, they will rate their pain a little bit lower on the moderate-to-severe scale,
so I like to ask them, "What are you missing during your day, your lifestyle.
What's affecting you?" because you can't always just go by these pain scales.
They're individual.
So onabotulinumtoxinA -- Botox is so much easier to say.
It was approved in 2010 for migraine headache.
It's been around, actually, since 1989, and it's currently being used -- I believe, if
I'm up to date -- I think 11 different treatment options for different types of medical reasons.
It relaxes the muscles; it does not paralyze the muscles.
It's given through an injection procedure, and the injection procedure is every 12 weeks.
That's one of the key factors that they found doing the studies for Botox to make it effective
for chronic migraine was the timing of things.
The Botox effectiveness -- it's been used, and it's been studied, and it is FDA-approved
for a chronic migraine prevention treatment.
On average, it prevents eight to nine migraines or probable migraine days, and this has been
shown at 24 weeks.
So the studies they did, PREEMPT 1 and PREEMPT 2 -- and I didn't put all the research studies
up here because I'd actually rather talk to you more about the treatment itself.
The two studies that they did showed after the second treatment, that's where they saw
the best results.
Botox takes about 10 to 14 days to start to actually work on the migraine, so within the
first week or so, you need to instruct patients that any headache that they get during that
time is more than likely their migraine headache.
It's not the Botox actually causing the migraine headache.
There's no drug-to-drug interaction with Botox and other pharmaceuticals that you may be
on.
It stays where we place it, for the most part, with chronic migraine headaches, so it does
not -- there is a general risk of going to other parts of your body and producing unwanted
effects.
They've not seen any of that with chronic migraine.
They do use it in different doses for other medical conditions.
Side effects from Botox treatment -- there's a whole host of them, and if, actually, you
pull out the insert or you look online or you see any of the commercials that scare
everyone where you have the multiple side effect profile, including death, these are
the most common ones I actually see in practice.
You see headache, migraine after the procedure.
Like I said, usually with the first 10 to 14 days, it's allowing the Botox to start
to work.
Four percent risk of what's called an eyelid ptosis, which is an eyelid droop.
Nine percent risk of neck pain.
A lot of migraine folks actually have neck pain as part of their migraine symptomatology.
Three percent risk of injection site pain, and I said, "Please refer to the website."
I didn't want to bore you with all the other side effect profile that they had on it.
These are the most common ones that I actually see in practice.
Again, the neck pain, I wanted to talk a little bit about because there's a 9% risk of neck
pain with Botox treatment, and as I said, a lot of migraineurs or people with migraine
experience neck pain as part of their migraine symptomatology.
The neck pain can come as the migraine is coming on.
A lot of folks, when they come into providers' offices, say they have a lot of neck pain,
and they're actually saying the neck pain is what's causing their migraine headache.
Sometimes, I actually think it's the reverse.
What is Botox treatment like?
It's a very fine needle, not as fine as the acupuncture needles that you just got to look
at and feel, but it is a very small gauge needle.
It's a shallow injection that actually goes into the seven key muscle groups of the head
and the neck area.
So the places that we put Botox would be here on the corrugator muscles, the middle with
the procerus, two on either side of your frontalis.
I feel like Vanna White up here.
You get four in your temporalis, and then you have three back here to your occipital
region to your cervical paraspinals, which we do up higher than what they used to do.
They used to do injections -- and this was not part of the study -- into the neck area,
so providers, before they were properly trained and had the studies out, would do injections
here because patients were complaining of neck pain.
If you actually inject into these muscles and someone doesn't have what's called spasticity,
you can actually relax part of that muscle, so you will get neck pain from the treatment
itself because the rest of your neck needs to hold your head up.
And then three into the trapezius muscles.
A common question that we get from patients when they come in for Botox treatment -- they'll
say, "I have the biggest muscles spasm here in my neck and shoulders.
Can you treat those?"
You actually don't want to put Botox into just a regular what's called a muscle spasm
or trigger point unless a person is diagnosed with spasticity.
The cost in insurance coverage for Botox is always a question that I get asked because
patients have such high co-payments for treatments and treatment options.
They don't need the added stress of knowing that they're going to have a high co-payment
for this.
Most insurance plans will cover the majority of the cost of this.
Allergan, as a company for Botox, does have other options for patients that don't have
commercial insurance, and we, as providers, are also able to sometimes get samples of
Botox to treat patients who are having a difficult time with their insurance companies actually
getting coverage.
The migraine stigma, I also wanted to talk about while talking about Botox treatment.
Migraine headaches, officially, they're classified as a disease.
I know there's still some talk back and forth between who you talk to about that, but it
is classified officially as a disease state.
There is no cure for it, so just as if you had diabetes or hypertension, you would work
with your providers to actually treat that disease state.
Oftentimes, migraineurs, if they're not actually in a migraine or a chronic migraine cycle,
don't show up to their providers on a regular basis.
They may or may not continue with their lifestyle changes that they were implementing in order
to not have their migraine headache.
When it's not there, they don't think about it as much as some other folks, and I think
it's important to continue all of those things.
Chronic migraine is a separate entity from episodic migraine.
Often, coworkers, family, and others may not understand the severity of your experience,
which is why we like to call migraine "migraine attack" versus "episode."
It gives it a little more juice behind it that they know the severity of what's going
on.
We're now trying to change the language -- for example, "people with migraine" versus a "migraineur"
or "migraine patient" -- because we're treating you as a person, not necessarily as your disease
state.
Another common thread that I've seen through this whole symposium, which is really important,
is I'm not touting Botox as the end-all and be-all as a treatment.
It's just another tool to put in your toolbox.
I think migraine -- because there's no cure for it and, scientifically, no one's been
able to find one thing that works for all patients, I think it's really important to
keep an open mind about different treatments and having a more comprehensive approach to
treating things.
Unfortunately, in this day and age with insurances, we can't always get a combination of different
things for patients, and that's part of the frustration that we're all working on as providers.
Thank you.
[applause]
Thank you for tuning in to Spotlight on Migraine.
For more information on migraine disease, please visit MigraineDisorders.org.