S2 E4: Botox and Nerve Blocks

A National Migraine Centre Heads Up Podcast transcript

Botox and Nerve Blocks

Series 2, episode 4

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[00:00:00] Did you know Botox has been used to treat migraine in the UK since 2012? When migraine becomes chronic, injections may help. Welcome to the Head’s Up podcast brought to you by the National Migraine Centre, the only UK charity treating migraine and headache.


Dr Jessica Briscoe [00:00:23] Hello and welcome to this episode of the Heads Up Podcast. I’m Dr. Jessica Briscoe and I’m joined by Dr. Katy Munro.


Dr Katy Munro [00:00:31] Hello.


Dr Jessica Briscoe [00:00:32] And Dr. Naz Manukyan.


Dr Naz Manukyan [00:00:34] Hello.


Dr Jessica Briscoe [00:00:35] So you’ve got three of us today and today we’re talking about injectable treatments, so not the CGRP medications. We’ll cover that in another episode, but we’re talking about Botox and nerve blocks today. I think we’ll probably start off by talking about when they are used these types of treatments. So it tends to be in chronic migraine, doesn’t it?


Dr Naz Manukyan [00:00:55] Yes. So chronic migraine is a bit different from episodic migraine when we would prefer using rescue treatments and recommend lifestyle changes. Chronic migraine is a term reflecting frequency of headache episodes at least 15 or more days over a month, for over three months. And the majority of those cases are also associated with medication overused headache. Probably about 80% of secondary care referrals overuse medication. And those injectable are good options to calm migraine down and prevent use of medication.


Dr Katy Munro [00:01:33] Yes, it’s quite difficult to have a hard and fast line, isn’t it, between episodic and chronic, because some people get so many episodes, but they’re not quite at 15 days a month. So we sometimes call that high frequency migraine and it’s really a judgement call as to whether the acute medications are having to be taken too frequently, and that’s going to push people into that more relentless sort of background headache that doesn’t respond very well. But chronic migraine is sadly very common and has a huge impact on people’s lives, doesn’t it?


Dr Jessica Briscoe [00:02:05] Absolutely. And even when they’re not actually having the sort of actual migraine headache attack, they can be quite disabled in between, actually, if they were in the postdromal period of time when you can be quite confused and it can be quite debilitating.


Dr Katy Munro [00:02:19] It just lingers on at a lower level and then ramps up every now and then. So we would possibly look at using injection techniques if people have tried preventative medications and haven’t got on very well with them. And there’s other situations that we might use injections, just initially to start people off on trying to reduce their acute medications. And they’re very useful, aren’t they?


Dr Jessica Briscoe [00:02:44] Absolutely. I think we’re going to start off by talking about Botox, actually. It’s quite interesting how Botox was discovered because a lot of people associate Botox with cosmetic treatment. Which is actually how it was discovered to be useful for migraine, wasn’t it?


Dr Katy Munro [00:02:58] Yes, it was one of those sort of coincidental things back in the mid-nineties when it was beginning to be used to make people look more youthful and they suddenly also felt a bit better if they had migraine. A sharp doctor discovered this and decided that they would do some studies on it and it was gradually founded on what would be the best protocol. And in about July 2010 it was licenced in the UK for use for the prevention of chronic migraine. So the PRE-EMPT study was the key study done by Professor Blumenfeld in America, and that’s the one we tend to use here at the National Migraine Centre.


Dr Naz Manukyan [00:03:37] Yes, they included a protocol of 31 injections and it’s a specific brand of botulinum toxin used Botox by Allergan, which is approved for chronic migraine and was used in PRE-EMPT study. So you inject 31 five unit Botox into different muscle groups of the head. It will be forehead, temples, back of the head, neck and shoulders.


Dr Jessica Briscoe [00:04:07] And they’re quite specific actually aren’t they?


Dr Katy Munro [00:04:08] Yes. Very specific and I think quite often when you mention to patients so it’s going to be 31 injections, they look a bit alarmed, but they’re quite superficial. They’re a bit stingy though.


Dr Jessica Briscoe [00:04:20] Yeah, I think it’s actually quite an acidic substance. So people who have chronic migraine often have a ramp up of their pain fibres anyway, so they can often feel pain a lot more severely than other people would do.


Dr Katy Munro [00:04:35] They have a bit of allodynia, that sort of hypersensitivity of the skin. It can be a bit sore, but it’s very variable. Actually. I’ve had some people who don’t flinch at all and other people who are kind of pulling faces while we’re doing them, but they’re done quite quickly within a consultation. Takes about, what, 15 minutes?


Dr Naz Manukyan [00:04:50] Yes. Preparing the actual injection, diluting the Botox, it’s a bit longer or explaining side effects, but the actual 31 injections can be done quite quickly. And that pain response does improve with time. So with subsequent injections, you know, when migraine comes down and patients get used to them, they can be less bothersome, you know, in some severe sensitivities, we could use some topical gel of anesthetic, just mainly on forehead. Sometimes it could be helpful. So it’s not that bad. But the outcome, calming down chronic migraine could be very effective.


Dr Katy Munro [00:05:26] Very helpful. And then of course, there is the other extension to the PRE-EMPT protocol called the ‘Follow the pain’, which enables us to use an extra up to 8 injections in the sites of maximum pain during the migraine attacks. So I sometimes do anything between 2 and 8 extra ones, depending on what the patient says.


Dr Naz Manukyan [00:05:46] The vial of Botox, 200 units. So it’s above the PRE_EMPT protocol amount so the leftover can be used additionally. Though there were no studies to clarify how useful they are, but they can be used individually just for greater benefit.


Dr Jessica Briscoe [00:06:04] And they’re given at quite specific times as well, aren’t they? So you do the first administration of the Botox at the beginning, and then you do them at 12 weekly intervals, which can be quite difficult in busy NHS clinics actually.


Dr Katy Munro [00:06:18] Yes, we try very hard to make it exactly 12 weeks because of this thing called ‘wind up’. If you leave it too long, especially at the beginning of a course of Botox, then you’re actually almost back to square one with suppressing the irritation inflammation of the brain. So we try and keep it every 12 weeks and we always say to patients, you must have at least 2 sets of injections, preferably 3, before we can fully decide whether or not that’s going to work for you, because a number of people don’t have very much benefit on the first set.


Dr Jessica Briscoe [00:06:50] Absolutely.


Dr Naz Manukyan [00:06:50] So NHS criteria will be 2 sets of injections before judging benefit. And if there is no improvement, it would be abandoned. But we had Botox for a long time and there are now studies showing that even the first two responses were not good. If you using them much longer, patients would report improvement at the second or third year. So the overall calming effect of Botox is beneficial, you know, for a longer period of time. And the initial response, usually when there is a daily headache, they can still be daily without clear days. But the impact of that severity is much, much less so people can regain their function. The disability improves and headache is more manageable.


Dr Katy Munro [00:07:38] So the quality of life can improve even if they are actually still having a headache. Because if you have a headache that scoring ten out of ten and you manage to improve that to five out of ten, it makes a heck of a difference to what you can do in the day.


Dr Naz Manukyan [00:07:49] And switching to episodic pattern, you know, it may take longer to happen maybe one or two years.


Dr Jessica Briscoe [00:07:58] And so I think this is another advertisement for keeping diaries. It’s really important to keep the diaries during Botox treatment because the criteria are fairly strict, actually, from the NICE guidelines, you have to show a 30% improvement in migraine frequency, it’s quite difficult to sometimes monitor the severity, for the Botox to continue.


Dr Katy Munro [00:08:23] There are very strict NICE criteria in the UK. So the NICE guidelines is an organisation that looks at cost effectiveness of treatments and they say that to be eligible in the NHS to have it. You need to have tried and failed three oral preventative medications. You need to have been having a look at whether there’s medication overuse as part of the problem and that needs to have been addressed, which is open to interpretation.


Dr Jessica Briscoe [00:08:54] Slightly wooly term ‘address medication overuse headache’.


Dr Katy Munro [00:08:56] And you need to have had chronic migraine for at least three months. So I think the other thing is if you improve a lot, then they consider that it has worked and it can be withdrawn. So it’s a little bit tricky sometimes, in the NHS, to keep going.


Dr Naz Manukyan [00:09:11] Also Botox has shown that it’s one of the treatments reducing use of acute medication, even if you don’t address it from the start actually calming the migraine patients find they use less and less. They don’t have to treat that headache at all and they can cope with it on the day.


Dr Katy Munro [00:09:31] Yes, I think that’s true. And I think being aware of medication overuse, you don’t have to have actually got rid of all the medication use because that’s really very challenging for somebody with chronic migraine.


Dr Jessica Briscoe [00:09:43] Really difficult.


Dr Katy Munro [00:09:43] So the Botox can be used in conjunction with trying to reduce that acute medication.


Dr Naz Manukyan [00:09:48] So we offer Botox in our clinic and we are aware that in the NHS there’s very patchy availability of this three month procedure is maybe not followed. So we have some patients who don’t get it for maybe 4 to 6 months. So sometimes they have to come between their NHS appointments to have injection here. We’re also aware of other cosmetic practitioners who do Botox for headache, but it’s very important to emphasise it should be a headache trained specialists giving allergan Botox in the doses which were studied in the trial.


Dr Katy Munro [00:10:28] Yes, I’ve come across some dentists give it, but what they tend to do, either cosmeticians or dentists tend to give smaller doses or only partially.


Dr Naz Manukyan [00:10:39] There is also botox given by dentists for bruxism into the masseter muscle.


Dr Katy Munro [00:10:46] For jaw tension and things.


Dr Naz Manukyan [00:10:47] But you know, it’s not licenced for chronic migraine sufferers but may be helps the actual jaw clenching.


Dr Katy Munro [00:10:55] Of course Botox is used in the NHS for other things including a sort of dystonia a sort of cramping like, painful spasms of the muscles and I’ve know somebody who has that for her neck dystonia.


Dr Naz Manukyan [00:11:09] Or overactive bladder.


Dr Katy Munro [00:11:10] Yeah overactive bladder, sweating, excessive sweating it’s used for.


Dr Jessica Briscoe [00:11:15] Hyperhidrosis.


Dr Katy Munro [00:11:16] It’s a very useful intervention but for headache it needs to be following the PRE-EMPT protocol and a headache specialist needs to be doing it, that could be a nurse it’s not necessarily a doctor.


Dr Jessica Briscoe [00:11:29] Absolutely.


Dr Naz Manukyan [00:11:30] So how does it work?


Dr Jessica Briscoe [00:11:32] Yeah I was going to say, do we know how it works? So actually the real reason why it helps with migraine isn’t really fully understood at the moment. It’s actually thought to sort of interfere with the sensory nerves that carry pain impulses. So a lot of people think that Botox works in migraine by paralysing the muscle, don’t they. Actually, there probably is a little bit of effect with the neck and shoulder administration because a lot of people get neck and shoulder tightness. But that’s not really how it helps to help with chronic migraine because obviously that’s not always where the pain is.


Dr Naz Manukyan [00:12:08] Migraine mechanism is very complex and the way Botox works is probably by paralysing the release of the acetylcholine in the synapses between muscle and the nerve. That also stops the impulse of pain signals into the central neurones in the brain and overall has calming effect. But this is a very simplistic explanation. I’m sure with time we’ll find out the full mechanism and there’re still, you know, ongoing studies.


Dr Katy Munro [00:12:41] And we’re going back to neurochemicals aren’t we. It all comes back to neurochemicals when you’re talking about migraines, these little chemical messengers that carry pain signals around the brain, in some way the Botox seems to reduce the release and transmission of those.


Dr Jessica Briscoe [00:12:57] So are there any side effects that people should be aware of?


Dr Katy Munro [00:13:00] I think the one that people most commonly worry about is that they’re going to look a bit funny. Am I going to look like those film stars with their flattened foreheads? And the answer is, well, yes, you are going to have a bit of a flattening of the forehead. Most people don’t find that too bothersome.


Dr Jessica Briscoe [00:13:18]  Some people like it.


Dr Katy Munro [00:13:19] Yes, to some people it’s like a helpful thing. But I do have a group of patients who I’ve seen who are psychotherapists, who are actually not allowed to have Botox because it can slightly change the way that their facial expression shows their empathy with their clients. So it will change things a little bit in the facial expression, but it’s not a major problem for most people.


Dr Naz Manukyan [00:13:40] We don’t do too many injections in the forehead like cosmetic injections are done, and most of it are away from forehead, in the deep muscles in the temple, back of the head. So the cosmetic effects are not obvious. Even with perfect technique, there are some side effects with drooping over the eyelid, maybe 1/100 patients. I haven’t had that experience with our patients.


Dr Katy Munro [00:14:03] No, no.


Dr Naz Manukyan [00:14:04] But that’s fully reversible. 8 to 12 weeks after Botox injections, the muscle function comes back.


Dr Jessica Briscoe [00:14:10] And sometimes you just have to slightly alter where you place the injections as long as it’s in the right muscle group.


Dr Naz Manukyan [00:14:17] Just away from those danger points.


Dr Katy Munro [00:14:19] Yes. I’ve had a couple of people who had had that happen where they had had their Botox in another clinic. And so they were very keen not to have the injections in their forehead at all and wanted them much higher into the hairline. And so, you know, we had a discussion about that.


Dr Naz Manukyan [00:14:34] It’s possible to alter a bit and you don’t have to do, you know, all those muscle groups exactly and individually it’s possible to change. One off side effects also, there is a worsening of headache. So first, two weeks before the actual paralysing effect of Botox kicks in, it’s quite common if you’re already a migraineur to have some worsening pain at the sites of injection. That doesn’t mean the Botox failed and it’s going to be effective. Good effect kicks in two weeks later and sometimes it wears off earlier than 12 weeks and patients notice their headache.


Dr Katy Munro [00:15:06] That’s definitely a thing, isn’t it. People saying, ‘oh, I was great for ten weeks but now I’ve got my migraine coming back again’. And neck pain and stiffness. Aggravation of headaches fairly soon after the treatment is quite a common thing I think. The other thing that it does sometimes cause a bit of pain in the wallet especially if people are coming and having to pay for it. And the problem with the availability of Botox on the NHS is I had a patient yesterday who was saying, ‘well I’ve been approved for it, but there’s now a 45 week waiting list’. So she was looking into having it done privately and it is an expensive treatment, which is why it is so regulated on the NHS. It’s costly.


Dr Jessica Briscoe [00:15:44]  Again, as we mentioned at the beginning, that can be a problem having the 12 weeks in between. So again, I’ve seen patients who will say I was supposed to have it a month ago and I’m still waiting for my appointment and that can be really difficult.


Dr Katy Munro [00:15:57] Yeah, yeah.


Dr Naz Manukyan [00:15:59] If it’s group of patients who are already disabled and with chronic migraine, they lost their jobs…


Dr Katy Munro [00:16:04] I was just going to say that. Financially they’re often very impacted by the migraine itself. So it is very hard.


Dr Jessica Briscoe [00:16:17] And some people ask us about the use of Botox in children, actually. What do you think about that?


Dr Katy Munro [00:16:23] I haven’t been using it in children and I’m not aware of many headache specialists in the UK but looking on to various forums and things, it’s quite widely used in the United States in children.  Have you used it on kids, Naz? It’s not generally done here.


Dr Naz Manukyan [00:16:41] Maybe a nerve block in teenagers but not Botox under 18s. I haven’t come across that. We had some cases referred to Great Ormond Street.


Dr Jessica Briscoe [00:16:51]  Yes, absolutely.


Dr Katy Munro [00:16:53] It would probably be more of a specialist paediatrics.


Dr Jessica Briscoe [00:16:56] That would be a specialist centre and also which probably mentioned Botox in pregnancy.


Dr Katy Munro [00:17:01] Yes.


Dr Jessica Briscoe [00:17:02]  So a lot of people worry about- we will discuss pregnancy more in a later episode, but people worry about the effect of pregnancy and whether they’ll be able to continue with their Botox treatment. Now, at present, we don’t give Botox in pregnancy because we don’t actually know if there are effects of giving that potentially harmful substance on pregnant women and what the effect will be on the foetus. At present, we don’t know if there are any harmful effects, and I believe there are actually some studies going on at the moment looking into that. So hopefully we’ll have a bit more definitive information about that in the future.


Dr Katy Munro [00:17:39] Yeah, yeah. It’s back to that old thing of it’s very difficult to try anything out on pregnant women. Not surprisingly.


Dr Jessica Briscoe [00:17:48] Yeah. Lots of ethical issues.


Dr Naz Manukyan [00:17:51] Nerve block will be an effective option for pregnancy, we’ll cover that.


Dr Katy Munro [00:17:55] So I think we’ve covered everything about Botox and Naz and I are going to talk a bit about greater occipital nerve block after this little break. So I’m now with my colleague, Dr. Naz Manukyan. And we’re going to talk about how we use greater occipital nerve blocks here at the National Migraine Centre and also what we found out that other people do in other places. Greater occipital nerve blocks. We use them quite a lot, Naz, don’t we.


Dr Naz Manukyan [00:18:23] Yes.


Dr Katy Munro [00:18:24]  And you’re particularly keen on them. So tell me a bit about the greater occipital nerve. Where is it?


Dr Naz Manukyan [00:18:31] Greater occipital nerve block is a branch of our cervical nerve C2 segment and it comes out of scalp and becomes superficial nerve just next to the bump on the back of the head on both sides left and right. And there’s also lesser occipital nerve, which goes slightly more lateral to that. And injecting that nerve is procedure called greater occipital nerve block. We frequently use for quite bad runs of migraine, chronic migraine, medication overuse headache. It’s just a useful skill and quite nice because the benefit to the patient could be quite significant and an additional measure to help migraine sufferers.


Dr Katy Munro [00:19:13] Yes, it’s one of those things that we can just decide to do and do it within the course of a consultation, because it’s quite straightforward, isn’t it? So the nerve block that we’re using here at the moment is a depo-medrone injection, which is a dose of steroid and a local anaesthetic and it’s pre-mixed. So we usually do one each side, don’t we.


Dr Naz Manukyan [00:19:34] Yes.


Dr Katy Munro [00:19:34] Sometimes we use it for people who are maybe trying to reduce the amount of acute medication that they’re taking so that they can sort of do a bit of a detox. And we use it for chronic or high frequency migraine. I sometimes say to people who’ve got a lot of neck pain with their migraine that it can help with that.


Dr Naz Manukyan [00:19:53] Yes, when migraine becomes more and more frequent, I think neck pain becomes more troublesome and in between migraine episodes. So when they have lots of stiffness, tenderness or maybe had some whiplash and lots of muscle spasm which feeds into their migraine, nerve block can be also very beneficial clearing these pains.


Dr Katy Munro [00:20:15] The other thing is of course, it is quite safe in pregnancy, so people are sometimes in pregnancy. Migraine settles down and disappears, but sometimes actually ramps up depending on the individual and depending on the type of migraine, it’s a bit unpredictable. But if people are going through the first few months of pregnancy and getting more and more migraine, we do use this injection.


Dr Naz Manukyan [00:20:35]  It’s another drug free approach, avoiding chemicals and triptans in pregnancy. And it’s quite safe procedure. It may work for eight weeks or longer. And through that bad phase of pregnancy, when migraine deteriorates, it just can cover them.


Dr Katy Munro [00:20:54] Yeah, you can have it more than once, can’t you, in a year. So how many times would you advise people to have it roughly?


Dr Naz Manukyan [00:21:01] Average may be up to three, four times a year, more than that there’s risk of accumulation of steroid. But if you avoid steroid in injection, use only local anaesthetic, you can have it more frequently. You could consider a couple of them in a row, maybe every four, six or eight weeks at the start just to calm migraine down and stabilise the pattern. But overall you don’t go on with it all the time, month after month, year after year.


Dr Katy Munro [00:21:30] Yes, yes. It’s more of a kind of shorter term measure, isn’t it? So I’ve been in the habit of saying to patients, well, if you have one and it doesn’t work, there’s not really any point in having another one. But doing some research for this podcast episode, I was reading a study that looked at lots of evidence and it did seem to very strongly say that it’s worth having at least two, and that seems to be something to do with the local anaesthetic calming down the inputs from the nerve and that reduces the irritability of the brain and that can build up if you have more than one injection.


Dr Naz Manukyan [00:22:00] Yes, it’s worth trying again, some patients come here they’ve already tried, maybe only on one side. Or they was different technique or maybe different anaesthetic. In studies we reviewed they’re using all variety of local anaesthetics. It could be only long acting, only short acting or mix of both. Some of them had steroids added to that different type of steroid like triamcinolone or depo-medrone. And the problem is that there is no standardisation of the procedure.


Dr Katy Munro [00:22:31] Yeah, that’s the thing, isn’t it? One thing that came out very clearly from reading these studies was that everybody who’s looked at it has done it slightly differently or used different techniques or different mixes of medication. In America, they use a lot of bupivacaine, which is a longer acting local anaesthetic just on its own. And they sometimes, I’ve come across that being used sort of as an emergency procedure. So if people come in with a really severe migraine, they have a local anaesthetic injection to try and help, but we’re not really geared up for that over here and I don’t think that’s widely used here in the UK.


Dr Naz Manukyan [00:23:02] The effect can be obvious on the day if you’re coming with a big attack of migraine. It may just calm it down within hours. And it’s one of the effects to check if the numbness kicked in on the day and, you know, migraine headache disappeared. And other symptoms even it’s used to abort persistent aura. And that effect on the day could be wonderful.


Dr Katy Munro [00:23:29] Yes, It is nice to do that.


Dr Naz Manukyan [00:23:31] And then it may be short lived, maybe three weeks or less, but sometimes it could work much longer. So situations when patients want to stabilise migraine and switch their preventive, start a new one or go through detoxification when they have a painkiller overuse, it could be a very good short term measure.


Dr Katy Munro [00:23:52] I think one of the studies looked at how many people benefited and it was actually higher than I thought was about 80%, with about 50% saying that they really had a significant improvement. But of course, like everything in migraine, nothing works for everybody. But it’s worth considering if people are struggling and don’t want to just keep taking more and more acute medications.


Dr Naz Manukyan [00:24:16] Yes. And if they had side effects with preventive or preventive take long to work. We had some group of patients like teenagers, those who are doing exams, A-levels or GCSEs and it’s quite good short term measure when they are stressed and they have bad runs of migraines during the exam season and we just had a good benefit injecting them during those time.


Dr Katy Munro [00:24:40] Just to carry them through that difficult time. I think I spoke to somebody the other day who was planning her wedding in September and we discussed whether or not it might be a good idea for her to to have a greater occipital nerve block before that. Just to talk about the practicalities of of having it. So I normally say to patients that one of the things that people comment on is that they can hear it when it goes in and they find that a little bit disconcerting.


Dr Naz Manukyan [00:25:05] Yes. Injection is like having a dental block. I explain. So you have just a needle at the back of your head. It’s between the skin and the scalp and just going through because it’s just very close to ear and the bone conduction is greater so you could hear a bit of a noise and cracking or the medicine just going in under the skin.


Dr Katy Munro [00:25:27] It’s not unpleasant.


Dr Naz Manukyan [00:25:28] No, the numbness, you know, of anaesthetic kicks in more or less immediately and yeah it’s quite good tolerated procedure. There are some side effects associated with that, you know fainting.


Dr Katy Munro [00:25:41] Well, some people faint even at the thought so hopefully we’re not worrying anybody by even talking about it.


Dr Naz Manukyan [00:25:44] It’s useful asking you know if they’re prone to fainting with some procedure or blood taking so best if they are in, you know, lying on the couch before you inject them. And some side effects also include loss of pigmentation at the site of injection, more commonly associated with a steroid and maybe loss of fat tissue there. And in long term, it could be reversible.


Dr Katy Munro [00:26:08] Yeah. And sometimes people get a small patch of hair loss, don’t they. So although we don’t see that very often.


Dr Naz Manukyan [00:26:14] No, not that frequent. In the first few days after injection that could be mild stiffness and soreness after anaesthetic wears off and positive effect kicks in maybe towards a week, one week after injection.


Dr Katy Munro [00:26:28] I think sometimes people have come back and said, well, I feel a little lump where the injection was, I feel a bit bruised or a tender little spot there and that is quite common and that just normally settles down over time, doesn’t it? Gradually the kind of effect builds up hopefully if it’s working over the first two or three weeks. But occasionally I’ve had people say that they got worsening neck pain and worse headache and it’s a little bit unpredictable. Again, we can’t look at people and know what is going to help them, but it’s quite unusual that that happens.


Dr Naz Manukyan [00:27:00] Yes, you know, the most disappointing that it may not work fully or it was very short lived. Patients I had maybe just one week of some sort of a gap when they don’t use medication and then they have to go back to, you know, over using their triptans or painkillers.


Dr Katy Munro [00:27:17] And of course we know that there are reasons why you wouldn’t do a greater occipital nerve block and one of those, of course, is if a patient was allergic to any of the contents of the injection. But the other thing is, if people had a sort of defect in their skull, if they had a sort of a soft spot on their skull bones or something, which I have to say I haven’t come across.


Dr Naz Manukyan [00:27:38] Or some scalp infections you’re trying to avoid with any other minor surgical procedure. There are some other nerve blocks exist, the peripheral nerve block. So some patients in tertiary neurological centres who don’t respond to greater occipital nerve block having other multiple cranial nerve blocks and sometimes it could be more beneficial than GON block.


Dr Katy Munro [00:28:01] So there are nerves all around the scalp that can feed in stimulatory signals into the centre of the brain where the migraine process seems to kick off. And some people do the two nerves, which are above the eyebrows, so the supraorbital nerve and the supratrochlear nerve, are both just above the eyebrows. So you can have a nerve block into there. There’s one around the ear, isn’t there? The auricular nerve, auricular temporal nerve.


Dr Naz Manukyan [00:28:30] Sphenopalatine nerve. I think this is used for trigeminal neuralgia.


Dr Naz Manukyan [00:28:36] Also GON block is very useful measure for treating cluster headache bout.


Dr Katy Munro [00:28:41] Yes.


Dr Naz Manukyan [00:28:42] Very effective.


Dr Katy Munro [00:28:42] We mentioned it I think when we did our cluster headache episode. And if people are interested in cluster headache, have a look back at our third episode in the second series, which is all about cluster. But yeah, we use that very commonly to help people through a cluster bout.


Dr Naz Manukyan [00:28:57] But yes, cluster bout can be sometimes very short eight weeks and at the start of it, if you do injection, the duration of that injection will cover them for cluster bout maybe until next episode, six months later or a year later.


Dr Katy Munro [00:29:11] It doesn’t necessarily cure the cluster bout, but it can sometimes mute it down and make it more manageable, can’t it. Looking at the studies of things that people have done worldwide, it seems that there’s quite a lot of debate still about greater occipital nerve blocks and the best way to do it. So it may be that one injection on one side is better, or it may be that some people need one each side. Some people prefer just using anaesthetic and not steroids. But the main thing to say is that we can’t really look at you and decide whether it will work for you or not. It’s just a question of discussing it with the doctor and seeing whether you think that might be a good choice.


Dr Naz Manukyan [00:29:48] Probably depends on everyone’s, you know, the specialist expertise, what you comfortable doing and what feedback you get from your patients. But maybe in future it will be standardised, similar to Botox procedure, which we using only one protocol because it’s been proven in the study and we’re following the PRE-EMPT.


Dr Katy Munro [00:30:08] So I just realised that we haven’t really talked about how does it actually work. So without being too technical, Naz, how would you explain to patients how a GON block works?


Dr Naz Manukyan [00:30:18] I usually try to explain the mechanism of migraine and how it all activated gone out of control and it’s usually overflow and increased traffic of sensory signals. They usually go through occipital nerve and trigeminal nerve and become centralised into the brain. So by blocking greater occipital nerve calming down all this afferent impulses, it’s some sort of negative feedback and calming down central mechanism of migraine or such a term we use central sensitisation. So it has some anti-inflammatory effect on this neurogenic inflammation and it just stops production and release of inflammatory chemicals and overactive migraine centres.


Dr Katy Munro [00:31:04] Yeah. So it has a general quieting down effect and that hopefully will lead to reduction in the neurochemicals that we know are really important in migraine and one of which is of course the CGRP, calcitonin gene related peptide, which we will be talking about more. Hopefully we’ll get some advice about that as an injection technique when NICE has decided whether or not we can use that in the UK. Currently only available in Scotland at the time of this recording. But neurochemicals, including CGRP are the key transmitters of the pain messages in the brain, aren’t they?


Dr Naz Manukyan [00:31:37] Yes. And in chronic migraine very important.


Dr Katy Munro [00:31:41] Yeah. So in terms of prevention, we’ve talked in other episodes about migraine preventative medication, about the lifestyle things which are always really, really important. Greater occipital nerve block and injection techniques like Botox are very useful and will be coming on later in another episode about CGRP injections and also about the devices. Neuromodulation devices. So tune in later to hear a bit more about those.


Dr Naz Manukyan [00:32:08] Thank you for listening to our Heads Up podcast. I hope you like our episodes. We’ve done lots of topics on migraine, cluster headache and the various situations we covering today, nerve block and Botox, and we’re very excited about new ideas and new topics to cover during the year. If you would like to support us, please donate on our Virgin Giving page. You can find a link on our website and Facebook page.


Swati Raina [00:32:39] Hi, Caroline. Thank you for joining us on our Heads Up podcast. Just wanted to understand it for our listeners. What is your migraine diagnosis? What have you been diagnosed with?


Caroline [00:32:48] So I have chronic migraine, which I’ve had for probably 25 years now.


Swati Raina [00:32:53] Okay. And when did you get this diagnosis?


Caroline [00:32:56] Probably five years ago now, when I first came to National Migraine Centre, I got a pretty good diagnosis. I had a diagnosis of migraine for many, many years now through my GP.


Swati Raina [00:33:06] Okay. And have you tried the injection therapies for your current condition?


Caroline [00:33:12] I’d had medications previously and then at the National Migraine Centre, originally I had the greater occipital nerve blocks and I had a few of those. And then after that I tried Botox as well. They were really good as well.


Swati Raina [00:33:27] What was the experience in general getting the injections? I know there are two injections in the back of your head. What was the whole experience of it? If you could share that with us?


Caroline [00:33:36] Okay. I mean, the first time I had them, it was actually on my first visit to the centre and I was I was really nervous about going and what was going to happen, which I think is really understandable for people. I was just so thrilled to be seeing a doctor that was understanding of how I felt and the position I was in at that time. I couldn’t even make the visit on my own. I had to have someone come with me. So to have that nerve block done at that time it was just immediate relief. It was just an immediate relief of pain.


Swati Raina [00:34:09] So it did help you?


Caroline [00:34:11] Usually so, yeah.


Swati Raina [00:34:13] So why did you switch from nerve blocks to Botox? Did it stop helping?


Caroline [00:34:18] It’s not so much that it stopped helping. It’s that it was recommended by Dr. Munro that it would be a better option for me going forwards with the nerve block being steroids, to move forward with that, to have a more long term basis for the next bit of my treatment to have the Botox.


Swati Raina [00:34:40] And hows your experience with Botox been. I understand it’s 31 to 36 injections.


Caroline [00:34:46] There’s a lot of injections, but they are very small needles and it was fine. They were a different treatment from the nerve blocks. A nerve block is two needles in the back of your head. It’s over with really quickly and the anaesthetic goes in as you’re doing it so it’s just a little bit tender afterwards, the following day. The Botox, it’s kind of a stingy pain, the most painful ones probably being across the face and the forehead. And then the ones in my neck and my shoulders I have to be honest, I didn’t really feel. It’s probably not as bad as going having a flu jab each year. I don’t find that particularly bad either. And the care that I received has been outstanding, great rapport with my doctor. So as they’re being done, we can chat and take my mind off of what’s going on and it’s over and done with very quickly.


Swati Raina [00:35:47] And how many times have you had Botox?


Caroline [00:35:50] Probably four. And I’ve now got to a stage where I’m feeling that I don’t need to keep having that done. I’ve gone from a position, when I first came, of having five migraines a week to maybe now having one every three weeks, maybe less, sometimes maybe more but usually less.


Swati Raina [00:36:11] That’s quite a change.


Caroline [00:36:13] Yeah. I mean, it’s absolutely life changing for me.


Swati Raina [00:36:16] What’s been the impact of it in general in your life? Have they had any life changing impact? I mean, I understand in terms of the number of headaches and number of migraines you’re getting, it’s reduced. Has it helped the overall improving the quality of life?


Caroline [00:36:35] In terms of quality of life, it’s helped. It’s things that people with migraine really empathise with in terms of making plans to go out or not worrying about when you’re out as to are you’re going to get a bad head? What contingency plans do you have put in place or are you going to let people down and just being able to go out and do more things? For me, I love driving my motorhome and being able to go and drive that and go out in it and go and enjoy with my child. Who Dr. Munro’s also seen that the link for migraine being hereditary, of course, in running through families and being able to enjoy that family time without that constant pain running through me.  So much more liberating, much more life, more energy and coinciding with other life changes. For me, going back to being a student, being able to really participate in that and being able to think more clearly to enjoy and participate in that study as well. It’s really good, positive effect.


Swati Raina [00:37:34]  That sounds really good. Well, thank you so much for sharing your experience with us, Caroline, and thank you so much for joining us on our podcast again.


Caroline [00:37:42] Thank you for having me.


Dr Katy Munro [00:37:46] We hope you’ve enjoyed listening to this particular episode of Heads Up podcast. Our next episode will be on migraine in pregnancy and breastfeeding, and we’ll give you some tips about how to prevent it and how to treat it if you do get it.


[00:38:04] You’ve been listening to the Heads Up podcast. If you want more information or have any comments, email us on info@NationalMigraineCentre.org.uk. Till next time.

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This transcript is based on a past episode of the Heads Up podcast and reflects information available at the time of broadcast – some facts may have changed or new treatments become available since.

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