When 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 the 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 to 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 a new neck pain. They are here in our office to find out why.

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

Summary transcript

  • I get a lot of inquiries from people who feel like botulinum toxin injections made them worse and then in fact it actually did.
  • When you get botulinum toxin injections it causes atrophy of muscles.
  • If you have an injection of botulinum toxin into a muscle in your neck, that muscle, being injected and prone to atrophy, maybe protecting you from cervical instability. It is relatively common for people to get botulinum toxin injections for headaches in the upper back of the neck and if the botulin toxin affects the obliquus capitis inferior muscle, that muscle is going to atrophy.
  • That muscle helps stabilize the C2 so when that muscle is weakened the C2 rotates out of proper alignment.

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.

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.

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.

  • 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 and  it can cause a pinching of the C2 nerve root which turns into the occipital nerve and give you occipital neuralgia.
  • These neck muscles are  needed to protect the stability of the C1-C2-C0 area. Botulin toxin can create weakness in these muscles and cause worsening cervical instability.
  • Worsening cervical instability is why many people have headaches and symptoms that worsen. The botulin toxin have atrophied the muscles.
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.

  • Treatment with onabotulinumtoxin A is safe and effective for chronic migraine. Several studies assessed possible predictors of response to treatment with onabotulinumtoxin A, but there is little knowledge on the frequency and predictors of sustained response.
  • 115 patients (84.3% female; average age 50 years had an average migraine duration of 30 years)  with chronic migraine were treated with onabotulinumtoxin A and followed up for 15 months.
  • Patients who achieved a more than 50% reduction in headache days during any three-month treatment cycle compared with the 3 months prior to initiation of onabotulinumtoxin were considered “Anytime responders.” So people who in anyone who had 50% reduction in headache during at least one three month period as compared to pre-treatment.
  • Patients who were “Sustained responders” are people who achieved a a more than 50% reduction reduction in headache days within the third treatment cycle and maintained response until the end of follow-up.
  • Non-responders were defined as those patients who never achieved a more than 50% reduction in headache days during the follow-up.
  • At the end of follow-up, 66 patients (57.4%) were classified as anytime responders.
  • Among the 51 patients who achieved a clinical response within the third month of treatment, 33 (64.7%) were sustained responders.

Success is seen as less 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.

There is also warnings issued with onabotulinumtoxin A injections. That warning comes from the United States Library of Medicine (Medline Plus)(2)

  • “Onabotulinumtoxin A injection is given as a number of tiny injections intended to affect only the specific area where injected. However, it is possible that the medication may spread from the area of injection and affect muscles in other areas of the body. If the muscles that control breathing and swallowing are affected, you may develop severe problems breathing or swallowing that may last for several months and may cause death. If you have difficulty swallowing, you may need to be fed through a feeding tube to avoid getting food or drink into your lungs.”

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: (3)

  • “In chronic migraine, botulinum toxin type A (Onabotulinumtoxin A ) may reduce the number of migraine days per month by 2 days compared with placebo treatment. Non-serious adverse events were probably experienced by 60/100 participants in the treated group compared with 47/100 in the placebo group. For people with episodic migraine, we remain uncertain whether or not this treatment is effective because the quality of this limited evidence is very low.”

“There is no headache in the world that is caused by botulism toxin deficiency.”
Treating with 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 vertabrae 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:

  • 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 and  it can cause a pinching of the C2 nerve root which turns into the occipital nerve and give you occipital neuralgia.
  • Botulin toxin can create weakness in these muscles and cause worsening cervical instability.
  • Worsening cervical instability is why many people have headaches and symptoms that worsen. Over time the botulinum toxin injections have contributed to muscle atrophy and continued 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 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.

  • The patient in this video suffered a whiplash injury in 2011.
  • The patient has migraine headaches everyday, horrible pain behind the eyes, terrible neck pain, he has clicking, grinding, and crunching in his neck.

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

  • As seen in the video, the DMX we see tilting of the C1 vertebrae, it is tilted through the full range of motion and this is one of the first signs that we see that a person has upper cervical instability.
  • In the DMX open mouth view (At 1:18) the video were looking for several things the first thing is symmetry of the C2 vertebrae this is where the Dens and the spinous process, the bony protrusion at the back of the vertebrae,  should be aligned with the Dens. In this particular patient the C2 is shifted to the left. This misalignment, caused by cervical spine instability, is the reason that the person has migraine headaches primarily on their left side. That shift can be corrected with Prolotherapy. (Prolotherapy is an series of injections of simple dextrose. Below we will discuss the treatment further as well as provide medical research findings supporting its use in selected patients). This patient had 4 Prolotherapy treatments, his headaches are at a minimum. He will need a few more treatments to stabilize his cervical spine and further reduce eliminate his migraines.

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

If this article helped you to understand problems related to cervical instability and botulinum toxin injections, you can get help and information from our Caring Medical Staff.

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. OnabotulinumtoxinA Injection at MedLine Plus United States Library of Medicine.
3 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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