The Neurologist/Pain Doctor’s Approach
Pain doctors and neurologists have used Botox to treat and prevent chronic migraines for some time. Their injections are often based on the FDA guidelines which is in turn based on old literature from neurology journals. Per the Botox website, “BOTOX® is injected into shallow muscles, not too deeply beneath the skin. Each treatment involves 31 injections in 7 key areas of the head and neck.”
This injection technique utilizes somewhat of a shotgun approach, injecting small amounts of Botox into lots of areas. Some of these areas may very well be contributing to the patient’s headaches, while others may not. Importantly, however, these “shallow” injections often do not reach the particular muscles that are compressing the nerve- particularly in the back of the neck. If an injection of a small amount of Botox is even a few millimeters away from a problematic compression point on the nerve, the constricting muscle will remain tight and that nerve will remain irritated. Similarly, the injection of a nerve block agent in the vague region of a problematic nerve may or may not affect the target and therefore may or may not provide desired effects. Additionally, in some cases, it is not muscle causing compression on a nerve, but instead an artery or possibly even some firm tissue or scar. In these cases, the mechanism of Botox may not provide the needed decompression of the nerve even if injected in the region of the problem.
This is NOT to say the medical approach to nerve blocks and the injection of Botox is ineffective- these techniques work for some migraine patients. For those patients who find improvement of their headache pain with this approach, we recommend continuing to have these treatments. If, however, a patient has found that the neurologist approach to injections has not improved their headache symptoms, they may still benefit from having a surgeon evaluate them and try a nerve block or Botox therapy in a different manner.
The Surgeon’s Approach
So what exactly does this mean? Some patients have had previous nerve blocks or Botox injections by neurologists or pain doctors and have not found relief. This does not mean that a nerve block or Botox injection by a surgeon will be similarly unsuccessful. Dr. Lowenstein’s surgical experience allows him to provide a very specific, directed injection to the problematic region. It should not be surprising that despite previously failed nerve blocks and Botox treatments, a headache patient may find Dr. Lowenstein’s approach remarkably successful. It is important to restate that the purpose of this discussion is NOT to discount the medical or neurologist’s approach to Botox injections which can be effective. Surgeons and medical doctors (such as neurologists and pain doctors) have different experiences and certainly different skill sets which allow each of them to provide different therapies, even when utilizing the same tools- in this case, Botox or local anesthesia. Because a peripheral nerve surgeon has had the experience of actually visualizing the nerves in question as well as the muscles surrounding these nerves in problematic areas, our approach to the use of Botox is more directed to the specific regions where targeted muscle relaxation can decompress the nerve. Dr. Lowenstein’s administration of nerve-blocking agents is based on the detailed anatomic knowledge of the nerve locations.
In the long term, this difference between injection techniques can have very profound implications. Patients who have had previous nerve blocks and Botox injections by other doctors may be mistaken in the belief that they are not candidates for migraine surgery. Until a patient has been evaluated by a surgeon such as Dr. Lowenstein, nerve decompression surgery for occipital neuralgia and migraine headaches should not be ruled out as a potentially life-changing option. The specialized injection approach of the headache surgeon may provide surprising success in patients who have failed injection treatment by other physicians.