Why Botox Is Not a 'One-Size-Fits-All' Treatment for Migraine


A few months ago, I had a conversation with a nurse. We needed to discuss my medical history and current diagnoses. Of course, this would mean we would be discussing my diagnosis of migraine which was the last thing I wanted to do. The nurse seemed very interested in my life with migraine. She asked me all kinds of questions about my symptoms and treatments. As we spoke, I kept referring to my diagnosis as migraine, however I noted she consistently said headaches. I decided not to let it bother me at first. I decided she was lacking education about my neurological disease, so although it is not the best thing I could assume her knowledge of migraine was set. Who was I to correct her? As much as I would love to educate her there was only so much I could do.

Then, my nurse asked about my treatment plan. My neurologist has worked very hard on my treatment. It has taken several years to figure out just what will work. I was ready and willing to tell her about the breakthroughs and progress we have made. I was proud of the combinations of prophylactic and abortive treatments that were keeping my attacks at a manageable level. I was not cured and still am not cured from migraine, but migraine has no cure. We were working on treatments that were individualized to how migraine presented in me, and we have not given up looking at the complexity of my particular case of migraine. The nurse did not match my enthusiasm. The nurse followed up by saying, “If you really want to get better, why aren’t you doing Botox for your headaches?”

In that moment, I could not figure out what emotion I was feeling. I came to realize very quickly what was considered better for one was not considered better to another. I made progress. It was progress I celebrated. I discussed Botox as an option for treatment with my care team before, but it was not right for me and is still not right for me. Aside from my opinions about the treatment, we are still trying to pinpoint all of the complexities of migraine in my case. Botox is not right for everyone diagnosed with migraine. I have come to understand a migraine attack can include more symptoms than a bad headache. What about hypersensitivity? What about nausea? What about aura symptoms? What about the postdrome one experiences as the brain calms down from the attack? I understand Botox is said to eliminate all of the symptoms because it is preventive. However, this is only in those individuals with chronic migraine.

When I learn about new treatments for migraine, I do all I can to educate myself about them. I understand Botox is provided to individuals diagnosed with chronic migraine meaning the individual has 15 headache days per month. Botox is only an option for those with chronic migraine. The treatment is said to eliminate eight headache days a month, giving an individual seven headache days, on average. It is very important for an individual with migraine to have the correct diagnosis of migraine before committing to this type of treatment.

Botox is administered every 12 weeks. When one receives Botox, they receive a total of 31 injections in the head and neck. It is said, Botox should have a lasting impact of a total of 12 weeks for the average individual with chronic migraine. Often, Botox is not effective on the first or even second time. Many individuals must undergo three treatments before they see any improvement. This is a 24-week process. The goal is to eliminate headache pain for three months. I am concerned, with the focus being on pain, migraine is portrayed as a pain disorder and not a neurological disease.

Pain is certainly a part of a migraine attack for the majority. No one is denying this fact. Migraine is far more complex than headache. We have been saying it, and it holds true. Migraine is not just a bad headache. We look for treatments that treat the whole migraine experience and not just a headache. For some Botox is a step in the right direction, but for others with migraine it has left much to be desired.

We want a cure. However, I do not believe it can be a singular approach. According to the American Migraine Foundation, there are six different types of migraine. In order to treat all of the manifestations of migraine, I believe considerations for pain, hypersensitivity, variability of aura manifestations and other neurological symptoms will need to be considered. I believe Dr. Goadsby got it right when he said, “Migraine is not a headache disorder, but a brain disorder.”

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