Can botulinum toxin injections for headaches make your symptoms worse?

Ross Hauser, MD

When botulinum toxin injections for headaches make your symptoms worse

For some people, botulinum toxin injections (Botox®) will help relieve a good portion of their headache symptoms, headache severity, and headache frequency.  For some people, botulinum toxin injections will make their headache symptoms, headache severity, and headache frequency worse. In this article, I will discuss how botulinum toxin injections may affect you.

If you are reading this article you are likely someone who was recently recommended botulinum toxin injections for headaches and you would like to learn a little more, or, you are someone who had botulinum toxin injections and not only did the injections not help you, they made your situation worse and now you are looking for possible answers. You may also be someone who had botulinum toxin injections with great success and you are wondering why they are now “wearing off,” and your headaches have returned.

The people we see in our office are not the people who had great long-term success with botulinum toxin injections. We see the people for whom the headaches got worse and as the headaches got worse, so did other neurological problems such as vision difficulties, hearing difficulties, dizziness, and more.

Some people contact us after their first series of botulinum toxin injections. They had a treatment  “a few weeks back,” yet they still have terrible muscle spasms, their headaches are just as bad as they have been, and now they have developed new neck pain. They are here in our office to find out why.

Again, let me point out that many people have very successful botulinum toxin injections for their headaches. This article will be about some of the people we have seen, who did not.

In the video below I will explain some of the problems we see and give an introduction to our alternative options to botulinum toxin injections.

Summary transcript

At 1:10 of the video, Dr. Hauser describes how botulinum toxin injections can impact the obliquus capitis inferior muscle, the muscle that helps stabilize the C2.

What are we seeing in this still image from the video?

When you get botulinum toxin injections it can cause atrophy of muscles. If you have an injection of botulinum toxin into a muscle in your neck you may be limiting or preventing that muscle from protecting you from cervical instability. If the botulin toxin affects the obliquus capitis inferior muscle, the muscle that helps stabilize the C2, that vertebrae will rotate out of its natural position and can compress the vagus nerve it can cause a pinching of the C2 nerve root.

When you get botulinum toxin injections it can cause atrophy of muscles. If you have an injection of botulinum toxin into a muscle in your neck you maybe limiting or preventing that muscle from protecting you from cervical instability. If the botulin toxin affects the obliquus capitis inferior muscle, the muscle that helps stabilize the C2, that vertebrae will rotate out of its natural position and can compress the vagus nerve it can cause a pinching of the C2 nerve root.

What are we seeing in this image?

The possible impact of botulinum toxin injections at the location and relation between the suboccipital muscles to the C1 vertebra – the Atlas, and the C2 vertebra – the Axis and the path of the occipital nerve is illustrated. Upper cervical spine instability at C1-C2 can cause pressure on the base of the spine resulting in the contraction and spasm of the suboccipital muscle. This can cause headaches, migraines, and occipital neuralgia. 

The possible impact of botulinum toxin injections at the location and relation between the suboccipital muscles to the C1 vertebra - the Atlas, and the C2 vertebra - the Axis and the path of the occipital nerve is illustrated. Upper cervical spine instability at C1-C2 can cause pressure on the base of the spine resulting in the contraction and spasm of the suboccipital muscle. This can cause headaches, migraines and occipital neuralgia. 

Why were you or why are you being recommended to botulinum toxin injections then?

Botulinum toxin injections can help many people. These are typically the people we do not see in our office. We see the people as I mentioned earlier in this article who had botulinum toxin injections and continue to have headaches and worsening symptoms related to Cervical dystonia, also called spasmodic torticollis.

In an April 2020 study, researchers in Italy writing in The Journal of Headache and Pain (1) describe benefits that some may achieve with botulinum toxin injections. They also suggest to their fellow doctors which patients may benefit the most or the least from Botulinum toxin injections. Here are the summary learning points:

Two-thirds of people will get a more than 50% reduction in headache from botulinum toxin injections some of the time. One-third of patients will not.

Success is seen as fewer headache days within a 15 month period. For some people, any relief is seen as successful. But from most botulinum toxin injections, as successful as reported here, it is not curative.

Two late 2020 studies do however confirm success rates:

A December 2020 study in the journal Pain and Therapy noted outcomes at 24 weeks:(2)

“Treatment with onabotulinumtoxin A for 24 weeks was associated with clinically meaningful benefits beyond a reduction in headache days; including reductions in headache severity and headache-related impact, and improved quality of life. . .over 70% (of qualified participants) had clinically meaningful improvements on at least one outcome measure. (Reduction in headache days, severity, etc).”

In a separate December 2020 paper, the same research team added, that onabotulinumtoxin A worked better than a placebo. (3)

Still some uncertainties and concerns

There are also warnings issued with onabotulinumtoxin A injections. That warning comes from the United States Library of Medicine (Medline Plus)(4)

Study: “For people with episodic migraine, we remain uncertain whether or not (Botulinum toxin) is effective.”

Researchers at the Institute of Applied Health Research, University of Birmingham wrote (June 2018) in The Cochrane Database of Systematic Reviews: (5)

“There is no headache in the world that is caused by botulism toxin deficiency.”
Treating botulism toxin is not a long-term resolution of the problem.

Your neck does not become unstable because you are deficient in botulinum toxin. You do not get headaches because of botulinum toxin deficiency. You get headaches and muscle spasms because the muscles are trying to hold your neck in proper ailment because you may have cervical capsular ligament damage and weakness. Botulinum toxin does not treat this problem.

In the illustration below we see a great variation at C1 – C2 in the flexion (head bent forward, chin in chest) and extension (head bent backward, chin in air) positions.  This is a demonstration of cervical instability caused by cervical ligament damage or weakness. It is the ligaments that hold the vertebrae in place. When the ligaments fail, the muscles then try to take over the job of maintaining cervical stability. It is a difficult job for the muscles because that is not their intended job. That is why muscles become fatigued and tired and go into spasm.

As I discussed above:

What are we seeing in this image?

In the illustration, we see a great variation at C1 – C2 in the flexion (head bent forward, chin in chest) and extension (head bent backward, chin in air) positions. This is a demonstration of cervical instability caused by cervical ligament damage or weakness. It is the ligaments that hold the vertebrae in place. When the ligaments fail, the muscles then try to take over the job of maintaining cervical stability. It is a difficult job for the muscles because that is not their intended job. That is why muscles become fatigued and tired and go into spasm.

In the illustration we see a great variation at C1 - C2 in the flexion (head bent forward, chin in chest) and extension (head bent backward, chin in air) positions.  This is a demonstration of cervical instability caused by cervical ligament damage or weakness. It is the ligaments that hold the vertebrae in place. When the ligaments fail, the muscles then try to take over the job of maintaining cervical stability. It is a difficult job for the muscles because that is not their intended job. That is why muscles become fatigued and tired and go into spasm.

In this video, Ross Hauser, MD explains and demonstrates the use of Digital Motion X-ray (DMX) to help identify cervical neck and spine instability in the C1-C2 region in a patient with severe migraines.

The summary transcript of this video, with explanatory notes, is below the video.

Summary transcript:

I am going to demonstrate how we diagnosis and plan treatments for a patient we suspect of upper cervical spine instability as the cause of migraine headaches. In this video Digital Motion X-ray DMX is utilized to demonstrate the clues and signs of cervical spine instability, especially that surrounding the Dens or the C2 vertebrae.

At the 1:00 mark of the video, the Digital Motion X-ray DMX of the patient’s cervical spine instability is demonstrated.

Prolotherapy injections for upper cervical c1-c2

This is the treatment we offer as an alternative to botulinum toxin injections. Prolotherapy does not address muscle spasms by causing a shut down of the spams, it addresses cervical instability by addressing and repairing the damaged cervical ligaments.

Related articles:

If you are seeking information on botulinum toxin injections for a specific diagnosis. I invite you to continue your research on these pages dedicated to your diagnosis

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

We hope you found this article informative and it helped answer many of the questions you may have surrounding your headaches. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Please visit the Hauser Neck Center Patient Candidate Form

References

1 Ornello R, Guerzoni S, Baraldi C, Evangelista L, Frattale I, Marini C, Tiseo C, Pistoia F, Sacco S. Sustained response to onabotulinumtoxin A in patients with chronic migraine: real-life data. The Journal of Headache and Pain. 2020 Dec;21:1-0. [Google Scholar]
2 Diener HC, Dodick DW, Lipton RB, Adams AM, DeGryse RE, Silberstein SD. Benefits beyond headache days with onabotulinumtoxinA treatment: a pooled PREEMPT analysis. Pain and Therapy. 2020 Dec;9(2):683-94. [Google Scholar]
3 Silberstein SD, Diener HC, Dodick DW, Adams AM, DeGryse RE, Lipton RB. The impact of onabotulinumtoxin A vs. placebo on efficacy outcomes in headache day responder and nonresponder patients with chronic migraine. Pain and Therapy. 2020 Dec;9(2):695-707. [Google Scholar]
4 Onabotulinumtoxin A Injection at MedLine Plus United States Library of Medicine.
5 Herd CP, Tomlinson CL, Rick C, Scotton WJ, Edwards J, Ives N, Clarke CE, Sinclair A. Botulinum toxins for the prevention of migraine in adults. Cochrane Database of Systematic Reviews. 2018(6). [Google Scholar]

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