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.

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