Botulinum Toxin A has been approved by the Federal Drug Administration for treatment of chronic migraine in individuals 18 years of age and older. Botulinum toxin does not cure chronic migraine and it may not be effective in some patients. There have, however, been no serious injuries or deaths resulting from its use in chronic migraine.
Administration of botulinum toxin is performed by injecting a small amount of botulinum toxin into the muscles of the head and neck. Any benefits resulting from botulinum toxin tend to wear off after about 3 months, with a repeat injection required if benefit is to be maintained. Injections are usually done every 12 weeks with maximal effect peak achieved by about 2-3 weeks. Botulinum toxin is expensive and you should be sure of what costs you will incur from the injections.
The side effects of botulinum toxin used for chronic migraine may include:
Temporary transient, and usually mild, facial weakness with facial injections
Transient, and usually mild, head or neck weakness with head/neck injections
Reduction or loss of forehead facial animation due to forehead muscle weakness
Eyelid drooping (ptosis) – although this is rare
Pain at the site of the injection or ecchymosis (bruising) at the site of injection
Dry eye
Double vision
Potential unknown long-term risks
It is also possible that as with any injection, there may be an allergic reaction or no effect from the medication. Reduced effectiveness after repeated injections is sometimes seen. All care will be taken to prevent these side effects. If therapy is given over a long period of time, atrophy and wasting in the injected muscle may occur. Occasionally patients become refractory to treatment because they developed antibodies to the toxin. I n this event, therapy needs to the modified.
What is Dihydroergotamine (DHE)?
Dyhydroergotamine (DHE) is a medication from the ergotamine family that acts on some of the same receptors that triptan medications act on (i.e. Imitrex (sumatriptan)), but it is a distinct medication. DHE is generally well tolerated and very helpful to many patients with frequent headache. The goal of inpatient DHE treatment is that it will help to start to improve a chronic headache disorder. It is viewed as part of a comprehensive treatment plan for chronic headache, and do not anticipate that it will necessarily “break” the headache by itself.
DHE has been used for headache for over 50 years. Inpatient treatment with IV DHE is an established practice used in many medical centers for both episodic and chronic headache disorders.
Due to potential adverse medication interactions, triptan medications should not be given within 24 to 48 hours (before and after) of DHE administration.
What to expect during your stay
The most common side effect is nausea, and we take steps to try to prevent or reduce the symptom by giving an anti-nausea medication prior to each dose of DHE. There are also other measures we can take to help with nausea so it is important to tell the staff how well your nausea is being controlled.
Other potential side effects include leg cramping, stomach cramping, and diarrhea. Occasionally, it becomes difficult to keep IV sites working, so they may need to be replaced.
In a small number of patients, their headaches may become briefly and slightly worsened, typically after the first few doses of DHE. When this occurs, it is not an indication of effectiveness. If this occurs, and is intolerable, often slowing the administration of the dose will usually resolve this side effect.
What happens when my stay is over?
While IV DHE is not a cure for migraine, most patients will achieve the goal of a reduction in their headaches for weeks to months after discharge.
Many patients still have headache at the time of discharge. It may take two weeks to a month following hospital stay before the maximum improvement occurs. Headache freedom at discharge is not predictive of the overall benefit from IV DHE.
Prior to discharge, you will discuss a headache care plan. It is important to remain committed to the plan which is individualized to your specific situation. If after your discharge, you have questions or concerns with the treatment plan, please call our West Campus Neurology clinic nurses or send a MyChart message to your physician or nurse to discuss these issues.
What an Occipital Nerve Block Is?
During a nerve block, pain-relieving medicine is injected in the region around a nerve in the posterior head region. This procedure is straightforward and typically performed in clinic, without sedation. During the procedure, a needle is placed near the nerve and an anesthetic (or a combination of anesthetic and steroid) are injected. Pain relief may be immediate and sometimes longer lasting.
An occipital nerve block is done to manage:
Pain that affects the back of the head or one side of the head.
sensations of shooting, zapping, stinging or burning pain
migraine or cluster headaches
A tender or painful scalp, which may be a sign of an inflamed nerve
What should I expect after the Occipital Nerve Block?
Immediately after the injection, you may feel that your scalp is numb and pain lessoned due to the local anesthetic injection. This is due to the local anesthetic injected. This sensation may last for a few hours. Your pain can return and the area of injection may feel sore for a day or two. This is due to the mechanical process of needle insertion and injection of medication into the tissue. Benefits may also be noticed beginning after a couple of weeks, sometimes in conjunction with continuing a migraine preventative medication.
What are the risks and side effects of Occipital Nerve Blocks?
This procedure is generally safe. However, with any procedure there are risks, side effects and possibility of complications. The most common side effect is temporary pain at the injection site. Some people may also experience temporary light-headedness. Other uncommon risks involve infection, bleeding, and worsening of symptom. Fortunately, serious side effects and complications are uncommon.
Who should not have an Occipital Nerve Block?
If you are allergic to any of the medications to be injected, if you are on a blood thinner medication, if you have an active ongoing infection, or if you have poorly controlled diabetes or heart disease, you should not have an occipital nerve block performed. Consider postponing it until your overall medical condition improves.
What is a Sphenopalatine Ganglion Block?
The Sphenopalatine ganglion is made up of a large number of nerves which relay various messages from the face, head and neck to the brain. Pain messages from these areas are sent along these nerves to the brain where the pain is interpreted. In the past, a sphenopalatine block involved the insertion of cotton buds soaked in a local anesthetic into the nose. Currently, a small silicone catheter is injected into the area of the sphenopalatine ganglion. The medication blocks pain messages thereby reducing the pain. The block is usually temporary but the benefit can sometimes be prolonged. If you are female please tell your provider if you are pregnant to ensure there is no risk.
How long does it take?
It usually only takes minutes for the physician to administer the medication using the spehocath device. After the procedure the patient will need to lay flat for 10 minutes to experience maximum relief.
What are the possible side effects/complications of the procedure?
All procedures in medicine carry a risk of complications, this procedure has minimal associated side effects and low risks. Precautions are always taken to minimize the risk as far as possible. Generally injections are safe but occasionally the following risks may occur:
Failure of procedure to help
Worsening of pain (temporarily or permanently)
Bleeding/ bruising to the injected area
Hypotension (low blood pressure)
Numbness
Devices
Neuromodulation devices are a newer treatment modality in Headache Medicine. They are various FDA-approved devices that are used either daily for prevention, or as needed during individual migraine attacks.
Supra-orbital nerve stimulator
TMS (transcranial magnetic stimulation)
External vagal nerve stimulator
Pharmacologic
There are several prescription and over the counter medications used daily for migraine prevention, and as needed during individual migraine attacks.
