Millions of chronic headaches sufferers look to the same injection that cures wrinkles to help their headaches – Botox. For many of these headache patients, Botox allows them to reduce their oral medications. However, is there a dark side to these headache shots? What are the long-term botox headache treatment side effects and should these patients be concerned?
I often write about topics prompted by patients that walk through the door. This past year I’ve seen several patients who get Botox injections every few months for chronic headaches. Interestingly, while they began the Botox to reduce their medication burden, they’re coming to me to see if regenerative medicine injections could possibly get them off the Botox as they’re legitimately frightened about what will happen if they stop “cold turkey”.
First, what is Botox and why would it help headaches? The brand name BoTox is actually short for Botulinum Toxin. When someone contracts the awful disease “Botulism” from eating contaminated food, they get paralyzed by the chemical released by a specific bacteria. That chemical is Botulinum Toxin. It works by shutting down the area where the nerves talk to the muscles (neuromuscular junction). In smaller amounts, it will partially disrupt this communication, causing a tight muscle to get looser and relax. Hence for headaches, the drug will relax the muscles around the head and neck that are frequently tight, thus making the patient feel better.
One obvious problem with the basic approach behind Botox headache treatment is that like many things in modern medicine, the treatment is designed to treat the symptoms of the headache (tight muscles) and not what’s causing the tight muscles in the first place! However, there is a darker side to this story, in that many of the patients I see who have been treated for years with Botox have evidence of muscle atrophy. Meaning the important stabilizing muscles that are supposed to keep the bowling ball we call a head aligned precisely on the neck are noticeably smaller and weaker on MRI. So they now have secondary problems being caused by this muscular instability, which means that the discs, joints, and nerves in their necks are getting overloaded and beaten up.
This past week I spoke to a patient like this and as I reviewed her films that showed clear signs of this lack of head/neck stability after years of Botox injections, I asked the obvious question – has anyone else reported on this long-term muscle damage issue? I wasn’t too surprised to find a bevy of recent research on the topic. For example, in one recent study of Botox injections into a muscle to treat back pain, MRIs showed a 40% reduction the thickness of the muscle as well as fatty atrophy (evidence that the muscle was dying off)! In another study, Botox muscle injections altered the important ability of the muscle to provide feedback to the brain about it’s proper length by messing with the sensors and metabolism of the muscle. Yet another study showed that these changes were happening at the genetic level in the muscle. Do these muscles recover once you stop the Botox? One 2013 study found that while the injected muscles could partially recover, there were permanent changes in the opposite non-injected muscle! Why? Because while we conceptualize the body as made up of individual muscles, it’s actually made up of muscle units and pairs that must work together to work at all, so damaging one part of that system by hurting it’s muscle – nerve connection may permanently alter the neurology of the rest of the system. Finally, if the nasty long-term effects on muscle weren’t enough, another 2013 study concluded that Botox has an effect on bones, because these weakened muscles reduce their pull on the bone and the body adapts by weakening that part of the skeleton.
The upshot? There is no such thing as a free lunch, meaning that if you ignore the common musculoskeletal causes of the tight muscles that lead to headaches (i.e. injured or painful neck facet joints, nerves, or muscle tendons) and just focus on a drug that relaxes muscles, it’s going to have consequences. In this case, the muscle atrophy and long term neck stability issues that I’m seeing in these patients seems to be quite real and well documented. So if you or a loved one is considering Botox headache therapy or have been using this approach, take the time to get the cause of the headaches properly diagnosed, rather than just covering up the symptoms and permanently damaging important stabilizing muscles!