Botox for HA

[specepic]

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Can anyone here comment or even better provide a journal link for a protocol for botox for migraine?

Where I trained people were started at 50-100 units and several sites, front/back, B/L were used.

Now I'm in practice and my pt just saw his academic center headache guy who told him:

1) must use 155 units
2) must have 31 sites injected
3) must be off all preventatives for it to 'work'

Is this guy just being dogmatic or if there something I don't know--when I lok at the lit there are a variety of doses/methods

??

 

[BlackFrancis33]

None of that is proven. That is all his opinion. No injection technique has been proven over another. I probably have done around 50-75 individual patients, some of those multiple times. I don't think that 155 Units is based on any actual evidence. I start with around 80-100U. I do the frontalis with 4 to 8 injections, 5U per injection, then two into each temporalis muscle, 10U per injection. At this point I have injected anywhere from 60-80 Units. I may then do the occipital notch with 5-10U either unilaterally or bilaterally depending on location of pain, or do 1-2 spots in the upper cervical region with 5-10U. I usually use all 100U.

More studies needs to be done to prove any science behind different injection techniques. My technique is no better proven than the 155U, 31 injections above. I don't know if patients were 'washed out' in the most recent chronic migraine trials. I have had anecdotal success of using Botox in addition to and adding medications to patients getting botox injections. I would be suspicious of anyone who already has all the answers on how to best use Botox in migraine.

 

[specepic]

None of that is proven. That is all his opinion. No injection technique has been proven over another. I probably have done around 50-75 individual patients, some of those multiple times. I don't think that 155 Units is based on any actual evidence. I start with around 80-100U. I do the frontalis with 4 to 8 injections, 5U per injection, then two into each temporalis muscle, 10U per injection. At this point I have injected anywhere from 60-80 Units. I may then do the occipital notch with 5-10U either unilaterally or bilaterally depending on location of pain, or do 1-2 spots in the upper cervical region with 5-10U. I usually use all 100U.

More studies needs to be done to prove any science behind different injection techniques. My technique is no better proven than the 155U, 31 injections above. I don't know if patients were 'washed out' in the most recent chronic migraine trials. I have had anecdotal success of using Botox in addition to and adding medications to patients getting botox injections. I would be suspicious of anyone who already has all the answers on how to best use Botox in migraine.

You exactly confirm my thoughts. What you describe is exactly how I learned to do it. I think this guy is trying to discredit me with the pt so he can do the shots. 155 units, why not 156.3? GMAFB...

 

[Nirv]

I give Botox injections regularly (every 3 months or so) to over 100 patients. So I've given Botox for migraines over 500 times. I start at about 125-150 units. Then ave 150 to 200 units.
I dilute 100 units with 2 mL saline. For some back injections, more diluted and more superficial injections (trap vs rhomboids, etc.) produces less weakness and less pain.
The best easily accesable resource I've seen so far is Blumenfeld's article in Headache 43 (8):884+ (2003).
Problem with Botox is you can start everyone with the same protocol, but then have to evolve it as time goes on and how people's migraines evolve. I always inject bilaterally; if a person has 99% of migraines on one side, then the other side gets 50% dosage at the least.
I've inherited another 40 patients from another doctor who injected differently. Patient response is about the same so there is no "perfect" or optimal technique.

 

[bustbones26]

The new FDA approval recommends a dosage of 155 units, this is why this headache expert is making his claim.

Unfortunately, it comes in 100 units bottles. If you mix up 200 units, are you really going to waste 45 units (nearly $300)?

In my experience thus far, I start with 100 units. If a patient notes that he/she had good efficacy, but not a long duration, I will use 200 units the subsequent time.

So far, I have had many satisfied patients. Some will claim "placebo" effect. My argument to that is this, if the patients come back every 3 months for reinjection, they don't whine in between, stop taking loads of xanax and narcotics, and stay out of the ER, then is "placebo" effect so bad?