Chronic migraine: when headache becomes a constant companion
Migraine is more than an ordinary headache. Typical features include attack-like, mostly one-sided, pulsating pain, often accompanied by nausea and sensitivity to light and sound. When headaches occur on at least 15 days per month over a period of more than three months, and at least eight of those days show migraine-typical symptoms, specialists refer to chronic migraine.
For those affected, this often means a considerable reduction in quality of life: work, family and leisure all suffer from the frequent attacks. Finding an effective headache treatment therefore becomes a central concern – and this is where botulinum toxin has come into focus in recent years.
What is botulinum toxin?
Botulinum toxin type A is a protein produced by certain bacteria. In very small, controlled doses it has been used in medicine for decades – for example to treat muscular tension, spasticity or certain neurological conditions. In aesthetic medicine the substance is best known for treating expression lines.
In the field of chronic migraine therapy, botulinum toxin type A has been approved as a treatment option in several countries – including Austria – since 2011. Important: its use in migraine differs significantly from aesthetic treatment, both in dosage and in the distribution of the injection sites.
How does botulinum toxin work in migraine?
The exact mechanism of action in migraine is not yet fully understood. According to current knowledge, several factors play a role:
- Inhibition of nerve signal transmission: Botulinum toxin can reduce the release of certain messenger substances at the nerve endings that are involved in pain development.
- Modulation of pain receptors: There is evidence that the substance influences the sensitivity of pain fibres in the scalp, neck and forehead area.
- Reduction of muscular tension: An indirect effect arises from the relaxation of the muscle groups involved, which can reduce triggers.
The result: in some of those treated, the frequency and intensity of migraine attacks decreases.
Who may be suitable for botulinum toxin migraine therapy?
Treatment with botulinum toxin is not a first-line option. It is usually considered only when other therapies do not work sufficiently well or are poorly tolerated.
Requirements include, among others:
- a confirmed diagnosis of chronic migraine by a specialist in neurology
- previous, documented attempts at medicinal prophylaxis (e.g. certain beta-blockers, anticonvulsants or antidepressants)
- insufficient effectiveness or intolerance of these prior therapies
- no known contraindications such as certain neuromuscular diseases, pregnancy or breastfeeding, or acute infections in the injection area
For episodic migraine (i.e. fewer than 15 headache days per month) botulinum toxin is not approved. The evidence base also differs for tension-type headache or cluster headache.
How the treatment is carried out
The therapy follows a standardised scheme that has been investigated in studies (the so-called PREEMPT protocol):
Before treatment
- Detailed initial consultation: taking the medical history, reviewing previous therapies and an up-to-date headache diary.
- Information and consent: discussion of effects, possible side effects, alternatives and expectations.
The injections
- Botulinum toxin type A is injected in very small quantities at several predefined points.
- The sites are distributed across the forehead, temples, back of the head, neck and upper shoulder area.
- A total of around 31 to 39 injections is usually planned.
- The treatment normally takes 15 to 30 minutes and is performed on an outpatient basis.
After treatment
- Usual activities can generally be resumed quickly.
- An onset of effect is often described after two to four weeks.
- If well tolerated and effective, the treatment is repeated approximately every 12 weeks.
- A final assessment of treatment success usually only makes sense after two to three treatment cycles.
What do studies say?
Several controlled studies suggest that botulinum toxin type A can reduce the number of headache days per month in chronic migraine. Accompanying symptoms and the need for acute medication also decrease in some of those treated.
However, it is important to note: botulinum toxin is not a cure. It can contribute to relief and complements established therapies, but it does not replace careful diagnostic work-up or a comprehensive treatment strategy. Not all patients respond equally – in some, the desired effect does not occur.
Possible side effects
Like any medical treatment, therapy with botulinum toxin can have side effects. Reported effects include, among others:
- temporary pain or a feeling of pressure at the injection sites
- mild swelling or small bruises
- neck stiffness or muscle weakness in the treated area
- headache immediately after the injection
- rarely: drooping of the eyelid or temporary changes in facial expression
Serious side effects are rare when the treatment is carried out properly. Careful information beforehand and application by experienced doctors are essential.
Botulinum toxin as part of an overall concept
Effective migraine treatment rarely relies on a single measure. A multimodal approach is usually advisable:
- regular sleep and eating habits
- stress management, e.g. through relaxation techniques or behavioural therapy
- moderate physical activity
- identification and avoidance of individual triggers
- targeted acute and prophylactic medication
- in suitable cases, supplementary botulinum toxin or other innovative therapies
Which components are appropriate in each individual case should be discussed together with the treating doctors.
Conclusion
Botulinum toxin type A has become established as a supplementary therapy option in chronic migraine when other treatments do not work sufficiently well. The method is well studied, is performed on an outpatient basis and can contribute to a reduction in headache days in some of those affected. Whether it is suitable in an individual case depends on careful diagnostics, the previous treatment history and individual factors.
Anyone suffering from frequent, severely impairing headaches should seek a conversation with a specialist to plan the appropriate next steps.
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This article does not replace medical advice.