View
1.579
Download
2
Category
Preview:
Citation preview
Rex Moulton-Barrett, MDRex Moulton-Barrett, MDPlastic & Reconstructive SurgeryPlastic & Reconstructive Surgery
San Leandro Surgery CenterSan Leandro Surgery Center
BoTox for Migraines BoTox for Migraines 2013 2013
Rex Moulton-Barrett, MD Plastic & Reconstructive Surgery Alameda and Brentwood Ca
‘Evidence Based Medicine: Often Disregarded by Insurance Carriers’
Rex Moulton-Barrett, MDRex Moulton-Barrett, MDPlastic & Reconstructive SurgeryPlastic & Reconstructive Surgery
San Leandro Surgery CenterSan Leandro Surgery Center
BoTox for Headaches BoTox for Headaches 2011 2011
• Does It Work : Evidence based medicine• Physiology• Techniques• Controversy• Nerve Blocks, Steroid and Surgery• Treatment Algorithms
Rex Moulton-Barrett, MDRex Moulton-Barrett, MDPlastic & Reconstructive SurgeryPlastic & Reconstructive Surgery
San Leandro Surgery CenterSan Leandro Surgery Center
BoTox for Headaches BoTox for Headaches 2011 2011
Botulinum Toxin Type A for Treatment of Migraine
‘incidental finding’
Dr. William Binder, in 1992, injected botulinum toxin type A into patient’s forehead to treat wrinkles
Several months later, patients reported a lessening of migraine symptoms
First correlation between use of botulinum toxin & reduction in headache severity
Single Dose 25/75U Randomized Single Dose 25/75U Randomized Double Double Blind Placebo Controlled Study, Blind Placebo Controlled Study, 20002000• N=123 N=123
• 25 or 75 Unit multiple pericranial muscles25 or 75 Unit multiple pericranial muscles
• Assessments: 1, 2, 3 months laterAssessments: 1, 2, 3 months later
• No statistical significance between either group No statistical significance between either group
Silberstein, SD. Neurology 2000; 55(60).754-762 Silberstein, SD. Neurology 2000; 55(60).754-762
Am Acad Neurology 2009: Am Acad Neurology 2009: Assessment on the Use of BoTox for Assessment on the Use of BoTox for Migriane andMigriane and Chronic Tension Type Headaches Chronic Tension Type Headaches
• No conclusive evidence in preventing No conclusive evidence in preventing chronic daily headacheschronic daily headaches
• Probably ineffective in episodic migraineProbably ineffective in episodic migraine
Rex Moulton-Barrett, MDRex Moulton-Barrett, MDPlastic & Reconstructive SurgeryPlastic & Reconstructive Surgery
San Leandro Surgery CenterSan Leandro Surgery Center
BoTox for Headaches BoTox for Headaches 2011 2011
271 pt study 2006 Blumenfeld Elkind A. H., O'Carroll P., Blumenfeld A., DeGryse R., Dimitrova R. ; BoNTA-024-026- 036 Study Group. A series of three sequential, randomized, controlled studies of repeated treatments with botulinum toxin type A for migraine prophylaxis. J Pain. 2006 Oct;7(10):688-96.
• 30 injections/ treatment• treated every three months• minimum of 2 treatments
• maximum of 5 treatments • 80% (217) head pain were less frequent,
less intense or both • 60.5% (164) excellent pain relief • 19.5% (53) some pain relief • 20% (54) reported no relief
Rex Moulton-Barrett, MDRex Moulton-Barrett, MDPlastic & Reconstructive SurgeryPlastic & Reconstructive Surgery
San Leandro Surgery CenterSan Leandro Surgery Center
BoTox for Headaches BoTox for Headaches 2011 2011
95% no side effectsside effects 4-5%:eyelid drooping (1%)neck muscle weakness (1%)flu-like symptoms (< 1%) head pain (2%)
PPhase III hase III ReReseacrh seacrh EEvaluating valuating MMigraine igraine PProphylaxis rophylaxis TTherapherapyy 11 ( (PREEMPT 1 & 2 TrialsPREEMPT 1 & 2 Trials) 2010: ) 2010: FDA FDA clearanceclearance • 24 wk, double blind • 24 wk, double blind • followed by 32 week open label use • followed by 32 week open label use
• injections every 12 weeks: • injections every 12 weeks: 155-195 U155-195 U • pooled 2 studies n= 1384 pts • pooled 2 studies n= 1384 pts• decrease:decrease:
•• frequency headaches: p< 0.001 frequency headaches: p< 0.001 •• disabilitydisability
• did not decrease did not decrease • • medication consumed during acute medication consumed during acute
episodeepisode Dodick DW, et al, 2010. Onabotulinumtoxin A for treatment of chronic migraine: Pooled results From a double-blind, randomized placebo-controlled phases of the PREEMPT clinical program. Headache 2010; 50(6): 793-803.
Rex Moulton-Barrett, MDRex Moulton-Barrett, MDPlastic & Reconstructive SurgeryPlastic & Reconstructive Surgery
San Leandro Surgery CenterSan Leandro Surgery Center
BoTox for Headaches BoTox for Headaches 2011 2011
History of Botox Clostridium botulinum (Purified Neurotoxin Complex)
• 1895 - C. botulinum first identified - 7 serotypes (A, B, C, D, E, F, G)• 1920 - Type “A ” first isolated• 1950s - Type “A ” shown to block release of Acetylcholine• 1973 - Therapeutic potential to relax extraocular muscles investigated by Dr. Alan Scott (San Francisco, CA)• 1978 - FDA approves type A (Oculinum) for human testing• 1989 - Allergan leads Oculinum through FDA testing & receives approval for Strabismus & Blepharospasm• 1991 - Allergan acquires rights to Oculinum - name changed to Botox®• 2000 - FDA approves Botox® for treatment of Cervical Dystonia• 2002 - FDA approves Botox Cosmetic® for Glabellar Lines• 2004 - FDA approves Botox for Axillary Hyperhidrosis• 2010 - FDA approves for Migraine Headaches
Rex Moulton-Barrett, MDRex Moulton-Barrett, MDPlastic & Reconstructive SurgeryPlastic & Reconstructive Surgery
San Leandro Surgery CenterSan Leandro Surgery Center
BoTox for Headaches BoTox for Headaches 2011 2011
Pharmacology of Botulinum Toxin
7 distinct antigenic types (serotypes): A, B, C, D, E, F, G A - OnabotulinumtoxinA:BoTox - Reloxin/Dysport ( FDA 4/2009 ) - IncobotulintoxinA: Xeomin ( FDA 10/2010 ) B - Rimabotulinumtioxin:Myoblock Serotypes differ:
• Biochemical structure• molecular weight• Potency (ED50)• Intracellular target
Rex Moulton-Barrett, MDRex Moulton-Barrett, MDPlastic & Reconstructive SurgeryPlastic & Reconstructive Surgery
San Leandro Surgery CenterSan Leandro Surgery Center
Mechanism of Nerve Action Potential & Muscle Mechanism of Nerve Action Potential & Muscle
ContractionContraction
Kiss-and-Run Exocytosis
Axon surface K+ positivity leads to muscle surface positivity:Ca2+
Neuromuscular Junction
Pre-Synaptic Bulb
Rex Moulton-Barrett, MDRex Moulton-Barrett, MDPlastic & Reconstructive SurgeryPlastic & Reconstructive Surgery
San Leandro Surgery CenterSan Leandro Surgery Center
BoTox Prevents SNARE Complex BoTox Prevents SNARE Complex
formationformation
Rex Moulton-Barrett, MDRex Moulton-Barrett, MDPlastic & Reconstructive SurgeryPlastic & Reconstructive Surgery
San Leandro Surgery CenterSan Leandro Surgery Center
• Paresis occurs after 4 - 5 days
• Lasts for 2-3 months before gradually it wear off • The paresis produces a reduction in the diameter of the targeted hyperactive muscle, or
• It will normalize the diameter of a hypertrophic muscle
Effects of BoTox- botulinum toxin A
• Cholinergic neuromuscular junctions are found between motor neurons & the extrafusal fibers+intrafusal fibers
( extrafusal fibers= motor contraction, intrafusal fibers= sensory to pressure )
• Botulinum toxin injection blocks extrafusal & intrafusal release of acetylcholine: a. reduces I & II aafferent signal from muscle spindle organs b. this reduces muscle tone by reflex inhibition
• This anti-dystonic effect, therefore, is caused not only by target
muscle paresis, but also by spinal reflex inhibition.
• Prolonged botulinum toxin leads to true muscle atrophy
• Muscle atrophy occurs in: extrafusal & intrafusal muscle fibers
Rex Moulton-Barrett, MDRex Moulton-Barrett, MDPlastic & Reconstructive SurgeryPlastic & Reconstructive Surgery
San Leandro Surgery CenterSan Leandro Surgery Center
Mechanism of Action of Mechanism of Action of BoToxBoTox
Muscle• Alpha motorneuron inhibition• Gamma motorneuron inhibition• Ia afferent reduction
Decrease Nociceptors/pain pathways:• C and A delta fibers (group III and IV)• Mechano- and chemo-nociceptors• Substance P • Calcitonin Gene Related Peptid (CGRP) • glutamate release
Mechanism of ActionMechanism of Action
• Reduction of nerve entrapment alone Reduction of nerve entrapment alone ??
• Reduction of spinal Ia afferents Reduction of spinal Ia afferents ??
• Reduction of Nociceptive afferents Reduction of Nociceptive afferents ??
• Reduction of Substance P Reduction of Substance P ??
YES TO BOTOXYES TO BOTOX
• • Tension Type Headache Tension Type Headache SymptomSymptom
• • Temple HeadachesTemple Headaches
• • Daily HeadachesDaily Headaches
• • Headache OccipitalHeadache Occipital
• • Headache in the Back of HeadHeadache in the Back of Head
• • Headache on the Top of HeadHeadache on the Top of Head
• • HeadachesHeadaches with with Neck PainNeck Pain
• • Sex HeadachesSex Headaches
NO TO BOTOXNO TO BOTOX
High Blood Pressure High Blood Pressure
Menstrual HeadachesMenstrual Headaches
Vestibular HeadachesVestibular Headaches
Headache Rebound Headache Rebound
Middle Turbinate Middle Turbinate ‘‘SinusSinus’’ HeadacheHeadache
Headache Behind the EyesHeadache Behind the Eyes
Dehydration HeadacheDehydration Headache
Barometric Pressure &Barometric Pressure & HeadacheHeadache
Principles BoTox for MigrainePrinciples BoTox for Migraine
IndividualizedIndividualizedPalpate muscle spasm ( trigger point )Palpate muscle spasm ( trigger point )Consider nerve block if unsure of siteConsider nerve block if unsure of siteOnset of benefit 2-4 weeksOnset of benefit 2-4 weeksIncreased duration with repeat Increased duration with repeat
injections (80%)injections (80%)
Rex Moulton-Barrett, MDRex Moulton-Barrett, MDPlastic & Reconstructive SurgeryPlastic & Reconstructive Surgery
San Leandro Surgery CenterSan Leandro Surgery Center
BoTox for Migraine: BoTox for Migraine: TechniquesTechniques
3 different types of injection protocols:
• fixed site approach
• follow-the-pain approach
• combination of both
Rex Moulton-Barrett, MDRex Moulton-Barrett, MDPlastic & Reconstructive SurgeryPlastic & Reconstructive Surgery
San Leandro Surgery CenterSan Leandro Surgery Center
BoTox Fixed Site BoTox Fixed Site Technique Technique
SupraTrochlear/ Orbital Nerve: Corrugators
ZTN:Temporalis
Greater Occipital Nerve: Semi-Spinalis Capitis
5.0 units/side 12.5U units/side
12.5 units/site• •• •• •
•
Lesser Occipital Nerve: Sternocleidomastoid
Fixed Site Fixed Site ApproachApproach
• migraine-type headaches• fixed symmetrical injection sites: pre-determined 12.5U/site except Corrugators 5
U/side • patients injected unilaterally for a unilateral headache • may develop headaches on the contra-lateral side
Rex Moulton-Barrett, MDRex Moulton-Barrett, MDPlastic & Reconstructive SurgeryPlastic & Reconstructive Surgery
San Leandro Surgery CenterSan Leandro Surgery Center
BoTox for Temporal BoTox for Temporal
MigraineMigraine
• •• •
ZygomaticoTemporal (ZT) Branch of Maxillary Trigeminal nerve
ZT•• 12.5 Units / 4 pointsUsing 4 ml=100units1/2ml / 4 points= 0.125ml/point
Landmark for Nerve: 1.5 cm ( 1.5-1.7 cm ) lateral to lateral canthus & 0.6 cm ( 0.4-1.1 cm ) superior to this point
nose
temple 12. 5 U
Rex Moulton-Barrett, MDRex Moulton-Barrett, MDPlastic & Reconstructive SurgeryPlastic & Reconstructive Surgery
San Leandro Surgery CenterSan Leandro Surgery Center
BoTox for Greater Occipital NerveBoTox for Greater Occipital Nerve Entrapment Tension Type Entrapment Tension Type Headache Headache
Landmarks: 3.0 cm ( +/- 7mm ) inferior to Occipital Prominence, 1.5cm ( +/- 4 mm ) lateral to midline 2.5cm deep ( 8-9 mm deep to Semispinalis Capitus )
Rex Moulton-Barrett, MDRex Moulton-Barrett, MDPlastic & Reconstructive SurgeryPlastic & Reconstructive Surgery
San Leandro Surgery CenterSan Leandro Surgery Center
BoTox for Greater Occipital BoTox for Greater Occipital NerveNerve Entrapment Tension Type Entrapment Tension Type Headache Headache
12.5U = 1/2 ml ( 100U = 4 ml )
Landmarks: 3.0 cm ( +/- 7mm ) inferior to Occipital Prominence, 1.5cm ( +/- 4 mm ) lateral to midline 2.5cm deep ( 8-9 mm deep to Semispinalis Capitus )
*Occipital Prominence
Rex Moulton-Barrett, MDRex Moulton-Barrett, MDPlastic & Reconstructive SurgeryPlastic & Reconstructive Surgery
San Leandro Surgery CenterSan Leandro Surgery Center
BoTox for Suprorbital BoTox for Suprorbital Migraine Migraine
100U=4ml, 5U/side ie place 2 injections of 0.1ml each
Innervation of Corrugator Muscle: 40% deep to muscle 34% deep and superficial 22% from above 4% superficial
Janis, et al, 2008 PRS 121(1), 233-40
Corrugator arises laterally from undersurface of frontalisCorrugator passes between orbital and palpabral orbicularisInserts in a medial & downward direction into the skin
Patient Care Patient Care ConsiderationsConsiderations
Avoid the orbit: Avoid the orbit: ptosisptosisAvoid periosteumAvoid periosteum: painful: painfulAvoid Superficial Temporal Avoid Superficial Temporal
VesselsVesselsAvoid Avoid Sentinel VeinSentinel Vein
•
Combination of fixed point & follow the pain techniques:
1. refractory to fixed point or2. exact site of the pain may be non - specific3. Site of pain not over 3 usual sites, ie:a. SCM: lesser occipital nerveb. Trapezius: lateral neck no name nervec. Medial Para-scapular: rhomboids no name nerved. Superior Medial Para-scapular: Levator Scapulae
Follow The Pain Technique
Individualized; large persons take Individualized; large persons take MOREMORE
Frontal HA Only: 30-60 UnitsFrontal HA Only: 30-60 Units
Posterior HA Only: 70-100 UnitsPosterior HA Only: 70-100 Units
Front and Back: 100-160 UnitsFront and Back: 100-160 Units
Upper back injections 40-60 UnitsUpper back injections 40-60 Units
Follow The Pain Approach
Indications ( Trott, 2002 ) :Indications ( Trott, 2002 ) :
Intractable headacheIntractable headache807 Patient Injections 807 Patient Injections 295 Patients295 PatientsFrontal Headache : 70% betterFrontal Headache : 70% betterChronic Daily Headache: Posterior-Neck HA:Chronic Daily Headache: Posterior-Neck HA: 87% better 87% betterSide Effects: minor bleeding, Side Effects: minor bleeding, rare burning sensationrare burning sensation
Rex Moulton-Barrett, MDRex Moulton-Barrett, MDPlastic & Reconstructive SurgeryPlastic & Reconstructive Surgery
San Leandro Surgery CenterSan Leandro Surgery Center
Follow the Pain Follow the Pain Approach Approach
Trapezius SternocleidomastoidSemispinalis Capitis
Erb’s point
• SCM is an anterior neck flexor
• Botox causes temporary neck flexion weakness
• Compensary recruitment from other muscle groups, may lead to altered posture: subsequent pain
Sternocleidomastoid Muscle Botox
Arch Otolatryngol Hand N Surg 2002128: 956-959 • post XRT painful neck spasm• 20-25 U BoTox/muscle• EMG guided for maximum signal• 4/6 benefited from the treatment
•
•
• • •••
•• • • •
35 Units each Trapezius
•
Rhomboids BoTox Rhomboids BoTox injectionsinjections
Palpate the Muscle Spasm a.k.a. trigger point
5-15 units per site
5-15 Units per injection site: up to 3 sites per side
Levator ScapulaeLevator Scapulae
• 9% neck pain• 5% headaches• 4% eyelid ptosis• 4% muscular weakness• 4% muscular stiffness• 3% bronchitis• 3% injection site pain• 3% musculoskeletal pain• 3% myalgia• 2% facial paresis• 2% hypertension• 2% muscle spasms
Overall Complications with BOTOX for Chronic Migraines
Rex Moulton-Barrett, MDRex Moulton-Barrett, MDPlastic & Reconstructive SurgeryPlastic & Reconstructive Surgery
San Leandro Surgery CenterSan Leandro Surgery Center
Criteria of Success
Decrease frequency & intensity of headache
Improve function & decrease disability
Reduce medication usage for headaches
Increase efficacy of acute headache medications
Happiness = Reality / Expectation
INDICATIONS: BoTox for chronic INDICATIONS: BoTox for chronic
migraine for prophylaxis in migraine for prophylaxis in
adultadult • Allergan:Allergan: •• Frequency: => 15 days / month, Frequency: => 15 days / month, •• Duration: => 4 hrs / dayDuration: => 4 hrs / day•• AetnaAetna + tried => 3/5 classes of migraine + tried => 3/5 classes of migraine
prophylaxis drugs for at least 60 daysprophylaxis drugs for at least 60 days • • ACE inhibitors, ie lisiniprilACE inhibitors, ie lisinipril
• • Antidepressants, ie nortryptilineAntidepressants, ie nortryptiline • • Antiepileptic drug, ie gabapentinAntiepileptic drug, ie gabapentin • • Beta blockers, ie atenololBeta blockers, ie atenolol • • Ca channel blocker, ie dlitiazemCa channel blocker, ie dlitiazem
Insurance Criteria: BoTox for Insurance Criteria: BoTox for chronicchronic migraine for prophylaxis in migraine for prophylaxis in
adultsadults • Blue CrossBlue Cross: : ““Recent clinical data Recent clinical data does notdoes not support support the use of BoTox in the treatment of migrainethe use of BoTox in the treatment of migraine””
• Blue ShieldBlue Shield: + 2/6 migraine : + 2/6 migraine IHC-2IHC-2 criteria criteria >= 15 days /month, >= 4hrs >= 15 days /month, >= 4hrs
> 3 consecutive months> 3 consecutive months
failed failed ‘‘adequateadequate’’ trials >= 2 agents trials >= 2 agents
• • 6 6 ( 4C1+( 4C1+2C22C2 ) ) International Headache Classification-2International Headache Classification-2 criteria:criteria:
4: unilateral, pusatile, mod/severe, aggravated routine activity4: unilateral, pusatile, mod/severe, aggravated routine activity
2: nausea/vomiting, photophobia2: nausea/vomiting, photophobia
Insurance Criteria: BoTox for Insurance Criteria: BoTox for chronicchronic migraine for prophylaxis in migraine for prophylaxis in
adultsadults • United Health CareUnited Health Care: : Must fulfill IHC-2 for chronic migraine as defined:Must fulfill IHC-2 for chronic migraine as defined:• >=15 days/month, >=15 days/month, • >=3 consecutive months,>=3 consecutive months,• >= 5 attacks without aura/month, >= 5 attacks without aura/month, • >=8 days per month 2/4 criteria: >=8 days per month 2/4 criteria: unilateral, pusatile, unilateral, pusatile,
mod/severe, aggravated by routine activitymod/severe, aggravated by routine activity
• and or 1/2 criteria:and or 1/2 criteria:nausea/vomiting, photophobianausea/vomiting, photophobia
• Responds to tripans and or ergotsResponds to tripans and or ergots• no medication overuseno medication overuse• Failed trials of all preventive anti-migraine medication Failed trials of all preventive anti-migraine medication
after titration to maximum tolerated doses after titration to maximum tolerated doses
Insurance Criteria: BoTox for Insurance Criteria: BoTox for chronicchronic migraine for prophylaxis in migraine for prophylaxis in
adultsadults • Medicare:Medicare:• ““Unresponsive to conventional methods of treatment Unresponsive to conventional methods of treatment • • medicationmedication • • physical therapyphysical therapy”” • • Primary treatment tension &/or migraine: Primary treatment tension &/or migraine: not not
coveredcovered• Requires Requires physician letter supporting medical
necessity: number of units, concentrations, map of sites, supporting literature
• 1 injection per site, maximum of 31 sites / patient1 injection per site, maximum of 31 sites / patient• 3 vials maximum per patient3 vials maximum per patient• If vial not split bill for full vial regardless if not usedIf vial not split bill for full vial regardless if not used• If split between > 1 pt must bill for exact unitsIf split between > 1 pt must bill for exact units
BoTox Billing CodesBoTox Billing Codes
Code346.70 chronic migraine without aura, without mention of
intractable migraine, without mention of status migrainous
346.71 no aura, + intractable migraine, no status migrainous
346.72 no aura, not intractable with + status migrarainous
346.73 no aura, +intractable, + status migainous
350.1 Trigeminal neuralgia
NEVER USE with the word “HEADACHE” when coding
Medicare Guidelines for BoTox UseageMedicare Guidelines for BoTox Useage
• • Code J0585, Trade Name Code J0585, Trade Name ‘‘BoToxBoTox’’, , • • use code use code ‘‘Botulinum toxin type A, per [Allergan] unit’
• • Recommend change from ‘BoTox’ to ‘Onabotulinatoxin’
• If change USAN then for code J0585, should read: ‘Onabotulinatoxin’, per unit’.
BoTox Billing CodesBoTox Billing Codes
Code Description
C9278 Injection, incobotulinumtoxinA, 1 unit
J0585 ( 100 units= $530 ) Injection, onabotulinumtoxinA, 1 unit
J0586 Injection, abobotulinumtoxinA, 5 units
64612 = $150 ( Medicare, 10%more PPO) either / or: 64613 = $200 ( Medicare, 10% more PPO)
Chemodenervation facial nerve muscles
Chemodenervation of muscle(s); neck muscle(s) (eg, for spasmodic torticollis, spasmodic dysphonia)
64614 Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) (eg, for dystonia, cerebral palsy, multiple sclerosis)
67345 Chemodenervation of extraocular muscle
64650 Chemodenervation of eccrine glands; both axillae
64653 Chemodenervation of eccrine glands; other area(s) (eg, scalp, face, neck), per day
Xeomin = incobotulinumAMyoblock = rimabotulinumABoTox = onabotulinumA
BoTox Assistance BoTox Assistance ProgramProgram
Allergan, Inc. donates BOTOX® vials for qualifying patients at no charge Cash payments are not involved
Provider and patient must complete the following steps: • Sponsor/MD signs the certification and consent statement • patient signs the certification and consent statement • patient must submit an acceptable form of the patient’s (or guardian’s) • • income documentation:• 1040, 1040A or • 1099 from the most recent tax year • W-2 • Social Security Statement
call 1-800-44-BOTOX (Option 6) between 9:00AM and 8:00PM EST or email at PatientAssistance@BOTOX.com.
Consent for BoTox for Headache Procedure
RISKS AND COMPLICATIONS OF PROCEDUREThe following is a list of possible complications in your proposed procedure. Though some complications are more rare than others, they could occur. In any human endeavor, there are many unknowns. Hence, it is impossible to have a complete list of possible complications. If you are not satisfied with any explanation, please feel free to postpone the procedure until you believe that the potential benefit of the procedure outweighs the risks. If you would like, we encourage you to obtain a second opinion. If you have concerns or desire further explanation, please do not hesitate to ask. Understand that BOTOX injection has certain expected, but temporary side effects. Understand that BOTOX treatment is only temporary. It is not considered permanent treatment for any type of condition. BOTOX used will either be fresh or frozen. It is also understood that no injection is guaranteed to be perfect each time and that there may be variation in outcome with each injection. Several injections may need to be performed over time before the appropriate amount for a good effect can be determined for a given patient.
BOTOX Injection for Headache1. Pain at injection site2. Infection3. Bleeding (Hematoma)4. No noticeable effect5. Droopy eyelids6. Allergic reaction to medicine or material7. Headache8. Rash9. Itching10. Flu-like symptoms11. Dry mouth12. Hoarseness13. Bruising14. Temporal hollowing15. Weakness to the back of the head
I have read the above and am willing to accept the risks of surgery and I believe that the potential benefits outweigh the potential risks.________________________________Name of Patient Signature of Patient or Guardian___________________________Date
Nerve Blocks: safe test for Nerve Blocks: safe test for determiningdetermining fixed site injection efficacy fixed site injection efficacy• Nerve Block: Nerve Block: • • 1/4 ml 1% Lidocaine with 1:200,000 1/4 ml 1% Lidocaine with 1:200,000
epinephrine & 1/4 ml marcaine with 1:200,000 epinephrine & 1/4 ml marcaine with 1:200,000 epinephrineepinephrine
• Total = 1/2 ml ie. = volume injected with BoToxTotal = 1/2 ml ie. = volume injected with BoTox
Steroid Blocks: alternative to Steroid Blocks: alternative to BoTox or to determine efficacy for BoTox or to determine efficacy for first BoTox treatment: first BoTox treatment: neck onlyneck only
• When in doubt 1/4 ml kenalog 40 with When in doubt 1/4 ml kenalog 40 with 1/4 ml of 1/2 % Marcaine and 1/4 ml of 1/2 % Marcaine and 1:200,000 epinephrine can be injected1:200,000 epinephrine can be injected
• Avoid near eye and near Avoid near eye and near communicating vessels to orbit, ie communicating vessels to orbit, ie neck onlyneck only
Surgery for Chronic Surgery for Chronic MigraineMigraine
3 sites: • Endoscopic Corrugator resection, 3 sites: • Endoscopic Corrugator resection, • • Endoscopic ZT Nerve divisionEndoscopic ZT Nerve division • • Open division Third Occipital NerveOpen division Third Occipital Nerve release Greater Occipital Nerverelease Greater Occipital Nerve
80-90 % success rate at > 1 yr if BoTox responder80-90 % success rate at > 1 yr if BoTox responder
Migraine Treatment AlgorithmsMigraine Treatment Algorithms
• Nerve BlockNerve Block when in doubt when in doubt
• Steroid injectionsSteroid injections by MD to the neck only: alternative or to by MD to the neck only: alternative or to preceed BoToxpreceed BoTox
• BotoxBotox fixed site protocol based on history of site of pain and fixed site protocol based on history of site of pain and palpable trigger point, MD for follow the painpalpable trigger point, MD for follow the pain
• SurgerySurgery for BoTox responder who wants permanent for BoTox responder who wants permanent correctioncorrection
Thanks for your time
Recommended