In this episode of the Sarasota Neurology Podcast, Dr. Kassicieh, a recognized expert  in clinical Botox, provides an overview of  current techniques for treating dystonia, muscle spasm (which may be associated with pain), spasticity from stroke or brain injury with Botox.

Botox was first FDA approved for medical use in 1989. Since then, Botox has found many medical uses to treat clinical conditions that were previously difficult to treat. Conditions such as cervical dystonia, blepharospasm, hemifacial spasm and spasticity such as that seen in cerebral palsy, stroke or spinal cord injuries have all been successfully managed with Botox.

Other similar products such as Dysport and Xeomin all have uses for cervical dystonia. Most recently, Botox was approved for use for treatment of chronic migraine headaches. Listen for more information on the clinical use of Botox and other similar products.

If you would like to learn more about the benefits of Botox, please call (941) 955-5858 or click here to schedule your appointment today. If you’re outside the Sarasota area and unable to travel here, please locate a neurologist in your area.

In October 2010, the FDA gave approval to use Botox for the preventative treatment of chronic migraine headaches. Allergen, the manufacturer of Botox, has long sought approval of Botox for migraine treatment. After conducting numerous nationwide clinical studies using Botox for headache, the most recent study, PREEMPT, showed that patients suffering from chronic migraines who were treated with Botox for preventative therapy, had significantly fewer headaches days a month than those that did not get Botox.

Chronic migraine, as defined by having more than 15 headache days a month, is one of the most disabling conditions a person can suffer from. A severe migraine can be more disabling than blindness, rheumatoid arthritis or even chest pain (angina). It is estimated that there are 3.2 millions Americans who suffer from chronic migraine. This condition affects quite commonly working aged individuals. Seventy-five percent of affected migraine sufferers are female. Migraine and headaches are a complex medical disorder which can be affected by stress, poor sleep and dietary habits. These individuals tend to overuse over-the-counter medications resulting in rebound headaches. Preventative therapy and not constantly taking abortive medication is the correct approach to managing most headache and migraine disorders. The objective is to prevent the headaches from occurring in the first place. With optimized treatment, it is usually possible to get most patients down to a manageable number of headaches per month – in our clinic four headache days or less. Only then would abortive medications be used. Narcotic medications of any kind should almost never be used for the treatment and management of migraines or headaches.

Botox is not the answer to everyone’s headache and migraine problem. This is only one of the many treatment options that headache specialists have to manage chronic migraine and other headache disorders. Careful patient selection and meticulous Botox administration are necessary to have improved outcomes in headache reduction. Not all individuals will respond to Botox, just as any other preventative medication. Botox should not be considered the first or even second line treatment for patients suffering from chronic migraine. It should be reserved for those that meet the criteria for chronic migraine and have adequate trials of most other preventative medications. Botox administration also requires a patient to receive the drug administered via a number of injections in the scalp and upper neck regions. The smallest needles are used to minimize any discomfort. If successful, a patient who responds to Botox may get as much as two to three months of relief. Getting perceived relief for only 2-3 weeks is not considered a successful response to Botox.

If you think that you suffer from chronic migraine headaches, you should call us today for a complete evaluation and then have a treatment plan designed to address your specific type of headaches.

Recent studies have suggested that qualifying Parkinson patients benefit from earlier treatment with deep brain stimulation, as reported in Clinical Neurology News. The study indicates that younger Parkinson disease patients are more likely to benefit from early brain stimulator treatment. There is information that may suggest that this therapy may have a protective effect in delaying the progression of Parkinson’s disease. Deep brain stimulation (DBS) was FDA approved in 2002 for treatment of Parkinson’s disease. Symptoms that are best controlled include tremor and dyskinesias although brain stimulation can also help reduce freezing and off time. Younger Parkinson patients develop motor complications such as dyskinesias, off time and freezing much earlier than older patients with Parkinson’s disease. As reported by Dr. David Charles, a Vanderbilt University Medical Center Parkinson neurologist, “No therapy…has bee shown to slow the progression of Parkinson’s.” The previous thinking was to wait until a patient had severe motor complications that could not be controlled with medications prior to considering DBS therapy. The new thinking, and research, is exploring benefits of DBS in earlier stages of Parkinson’s disease. In various reported cases, patients not only benefited from better control of their Parkinson motor symptoms but also had improved quality of life. Added advantages is that Parkinson patients treated earlier with DBS used less medications over an 18 month period, as shown in one small study. There are two studies currently looking at the benefits of early DBS therapy in Parkinson patients: EARLYSTIM is a French study and a smaller study at Vanderbilt University are in progress. It should be noted that Parkinson’s disease is a progressive neurodegenerative disorder. Even patients with DBS therapy do have progression of their symptoms. Memory loss can be a part of the Parkinson syndrome and is not helped by DBS therapy. DBS is not a substitute for optimal neurological and medication management of Parkinson symptoms. Dr. Kassicieh, at Sarasota Neurology, provides medical and neurological management for patients with Parkinson’s disease and brain stimulators. For more information click here.

Namenda (memantine) is the newest medication used in the treatment of Alzheimer’s disease. New research has shown that Namenda may be effective in treating patients with both migraine and tension headaches. The study done by John Krusz, PhD, MD showed that some patients with chronic migraines that did not do well with other headache treatments, did well with Namenda therapy. Of the migraine sufferers, there was a 56% drop in the number of migraine attacks. In patients with tension headaches there was a 62% drop in the numbers of attacks. This study was well reviewed on the website, Help for Headaches and Migraines.

Migraine and other headaches are chronic medical conditions that require aggressive preventative treatment. Many therapies have been tried but no cure has been found. Botox treatment has been promoted by the press but no clinical studies have showed that it is superior in migraine treatment than placebo. Having said that, there are certainly patients that have had migraine and headache reduction after Botox therapy.

It is important to note that the use of Namenda, Botox and most other migraine treatments are off-label uses of these and other medications. The majority of medications routinely used in the prevention of migraines are off-label. This is the standard of care in most headache clinics. If you suffer from migraines that prevent you from routine activities or interfere with work, you need to seek out help from a qualified neurologist who specializes in migraine headache treatment.

Botox (botulinum toxin Type A) has been available in the United States for clinical use since 1989. At that time it was approved by the FDA for treatment of eye and facial muscle spasm disorders, blepharospasm and hemifacial spasm respectively. Then in 2000 the FDA approved Myobloc (botulinum toxin Type B) for treatment of cervical dystonia, a condition of involuntary neck muscle spasm. The dystonias, as a class of muscle spasm disorders, are characterized by involuntary muscle spasms involving the muscles in the neck, face and extremities. The cause of the majority of these conditions is unknown. In some individuals, spasticity (tight muscles which cannot be relaxed, a form of dystonia) can result from stroke, traumatic brain or spinal cord injury or cerebral palsy.

Prior to the use of Botox, it was very difficult to treat muscle spasm disorders. Medications had side effects and surgery had limited benefit associated with the risk of complications. Botox opened an entirely new avenue to treat spasticity. The drug works by causing a chemical relaxation of muscles that are injected. Botox is highly selective in that it remains in the muscles that it is injected into. Patients with cervical dystonia have difficulty with their head pulling to one side of the other. They may also have their head pulling backward or forward. Not only is this condition painful, it also causes patients to have functional difficulty with activities such as driving, playing sports or even eating. In patients with limb dystonia, there is involuntary spasm of an arm, leg or both. This can cause difficulty with dressing, walking or even personal hygiene (if their hand is fisted up.) Botox (or Myobloc) can provide excellent relief of these symptoms thereby improving patients’ quality of life. For patients with severe muscle spasticity from stroke, Botox provides relief of the tight muscles allowing for greater ease in certain activities. It is important to note that Botox (or Myobloc) will not restore function of any limb affected by the stroke. What the treatment will do is provide increased comfort due to reducing pain from spasm and allow for improved ease in doing some daily activities.

Blepharospasm is characterized by involuntary blinking which can result in forced eye closure and functional blindness. Affected individuals may have difficulty driving or watching a movie because of this. Botox has been shown to be the single most effective treatment for this condition. Of all the muscle conditions treated with Botox, none respond as well as those patients affected with hemifacial spasm. This condition affects one side of the face and is characterized by spasm the facial muscles on that side. This can also result in a degree of functional blindness. While most conditions treated with Botox (or Myobloc) have a therapeutic effect for 2-3 months before requiring retreatment, patients with hemifacial spasm may not need retreatment for anywhere from 3-6 months.

For any patient considering receiving Botox or Myobloc, it is important to see a physician familiar with diagnosing and treating these uncommon movement disorders. These individuals are familiar with administration of Botox or Myobloc which will help to obtain optimum results from each treatment

Botox is a potent neurotoxin that causes muscle paralysis by blocking the release of the neurotransmitter, acetylcholine, from the nerves that control muscles. When given under controlled clinical applications, this medication can have a dramatically beneficial effect in relieving muscle spasm due to certain conditions such as cervical dystonia, blepharospasm, hemifacial spasm and limb dystonia. Over the past several years the media has reported that Botox can relieve migraines. These claims are based on random reports of individuals who may have gotten some benefit. The manufacturer of Botox, Allergan, has conducted several nationwide studies on the use of Botox for headaches, none of which have shown a statistically significant difference over placebo. Sandra Leong writes in Natural Headache Remedies a summary about the use of Botox in the treatment of various headache disorders. She notes that one theory on how Botox works for migraine is by relieving the muscle tension. It should be noted however that physiologic studies have not shown an overall increase in muscle spasm around the head in patients suffering from acute headache attacks. It is also important to note that the placebo effect in headache studies is as high has 35%.

In a summary of the studies done by Allergan for headaches, Medical News Today lists the previous and ongoing studies that the company is conducting to analyze the potential benefits of Botox in the treatment of migraine and other headache disorders. Personally, having participated in several of these Botox trials, I would agree with the study results that there was no distinct clinical benefit from Botox over placebo. It is important to note however that these were randomized, double blind placebo studies where neither I or the patient knew if they were getting Botox or placebo saline injections. I base my conclusions on reading the final study reports. At the Florida Headache & Movement Disorder Center, we carefully screen patients with head and neck pain for the possibility of benefiting from Botox therapy. Only very few patients actually meet my criteria for using Botox for migraine treatment. Even with this careful selection of patients, our results are about 50% success rate, slightly higher that the placebo effect rate. The patients that benefit the most from Botox treatment most commonly have a high degree of muscle spasm in their neck and head, associated with but separate from their actual headaches. There have been reports by other respected headache specialists, in non-controlled trials, that Botox may effective for some patients with migraine.

In conclusion, Botox has not been shown to have a major therapeutic advantage in the treatment of otherwise intractable migraine and headache disorders. The “media hype” is without scientific basis to back up the claims cited in many reports. If you have recurrent headaches, your best bet it to be evaluated and treated by a board certified headache specialist.