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Mixing Botox to Treat Migraines
For some people, Botox will make their migraines go completely away. But, research shows that, on average, the result of treating chronic migraines with Botox is that they have two fewer headaches per month—only two. So, it is very important that you set the patient’s expectations to something real before you do the treatment. Though you are hopeful that their headaches may go away completely or almost completely, the more likely outcome is that they will have a decrease in the severity of their headaches (some of the time) and that they will have two fewer headaches per month.
When I do cosmetic Botox, I just put one cc. of bacteriostatic saline Into a 100-unit vial of cosmetic Botox. When I treat migraines, I want a broader spread (same number of units in more volume), so I add two ccs of bacteriostatic saline.
First, pull up one cc of bacteriostatic saline using a one cc syringe (more accurate than measuring 1cc with a ten cc syringe). Then I add that one cc to a 100-unit vial of cosmetic Botox. Then repeat the process with another one cc for a total of 2 cc added to the vial.
Botox comes vacuum-packed. If the vacuum doesn’t pull the plunger down when you add the first syringe, then the seal has been broken, and you should discard the vial. I have never had that happen, but that is the safety check on the vial.
The package insert tells you to use non-bacteriostatic saline, but non-bacteriostatic saline hurts more. So use the bacteriostatic, it works just as well.
After I add the saline, I take off the metal band holding down the stopper covering the opening of the vial using a regular beer bottle opener. There is a little knack for taking the top off using a beer bottle opener, but it is not that difficult and much more convenient. If you are doing botox regularly, keep a beer bottle opener on your key chain, and it will save you time and the inconvenience of looking for the opener.
We take off the top because you want the needle to touch nothing until it touches the person’s face—that keeps the needle sharp and greatly decreases the pain of the injection.
Also, as when you inject cosmetic Botox, when you inject Botox for migraines, there is no need to wipe off makeup or cleanse the areas. Research that you can go right through the makeup. When you do fillers, this is not the case because you are injecting an implant that can become infected. But, with Botox, you can just inject without cleansing the face.
How to Inject Seven Muscle Groups to Treat Chronic Migraines
The seven muscle groups to inject when you treat chronic migraines are as follows (listed in the order that I usually inject them):
- Procerus
- Corrugators
- Frontalis
- Occipitofrontalis
- Temporalis
- Trapezius
- Splenius Capitis
I will explain how to inject each muscle group. With all seven of the muscle groups, each injection point is five units.
Normally when we do cosmetic Botox, we put 1 ml of bacteriostatic saline into a 100-unit bottle of Botox, so five units on an insulin syringe (0.05 ml) contains five units of Botox.
But, as described above, when we treat migraines so that we get a better spread of the Botox throughout the muscle, add two ccs of bacteriostatic saline to a 100-unit vial; that makes it so that 5 units of Botox will be contained in 10 units (0.1 ml) on an insulin syringe.
For the most comfort, I prefer a 30-unit, BD brand, 31 gauge insulin syringe because I think they hurt less than any other insulin syringe, and there is no residual in the barrel of the syringe. Also, in addition to not touching the needle to anything before it touches the face, I try not to use one needle more than three times, four at the absolute most, because, after that, the needle starts to hurt.
As you inject for migraines, you might be tempted to inject based on where the muscles are tender. Research shows that injecting where the muscle is tender does not seem to make a difference; the main thing is to inject the muscles that will affect the trigeminal ganglion so that the afferent nerves from the meninges are blocked.
Remember, migraines are now thought to not be associated with somatic muscle tenderness. The headaches are thought to originate from the pain fibers of the meninges. Botox works by traveling along the axon and affecting the trigeminal ganglion to which the afferents from the meninges also connect. When I do cosmetic Botox, I do not inject wrinkles. I use the movement of the face and the associated wrinkles to find the individual muscles that I want to inject, but I do not inject the wrinkles. The same applies to both wrinkles and tenderness with migraines; you use both tenderness and wrinkles to help you find the muscles (the 7 groups you intend to inject), but you do not try to inject tender points.
1. Injecting Procerus
The glabella region includes the corrugators and procerus. Start by putting five units right in the center of the procerus. I like to start with the procerus because it is the least painful to the patient when you inject it. Procerus may also be the easiest to find.
To find the procerus, imagine a line that goes from the corner of one of the patient’s eyes to the medial end of the opposite brow.
Imagine that line (from the corner of the eye to the opposite medial brow) with both eyes. Then, inject five units right in the center of the X formed by those two lines.
2. Injecting Corrugators
First, ask the patient to knit their brows together. When she does, you will see a dimple on each side just above the brow with “pleats” medial to the dimple. That dimple (one on each side) represents the insertion site of the corrugator.
So the insertion site of each corrugator pulls the skin toward the midline of the face. I like to put the index finger of my nondominant hand into the insertion site. Then, I can both see and get a feel of the muscle belly. I imagine the medial end of each corrugator attaching to the same place where I injected the procerus. I realize this may not be the exact anatomy, but it helps me see where to inject.
After you ask the patient to knit her brows together and you find the corrugators, then ask her to relax her face before you do the injection. If I were doing Botox for cosmetic purposes, I often use 7 to 15 in each corrugator-divided into two injections into each corrugator. But for migraines, just put five units in the center of the muscle belly (which will be 10 units (or 0.10 ml) on your insulin syringe.
Do that whole process (knit the brow, finger in the dimple, find the corrugator, relax the brow, inject the corrugator) with each side—a total of 10 units to treat both corrugators.
So that’s a total of 15 units, for the whole glabella region (5 in procerus, 5 in each of the 2 corrugators). After the three injection points, then lightly massage the area for a few seconds to spread the material throughout the muscles.
Note: With all of the injection points, if you see bleeding, hold light pressure until the bleeding stops. If the bleeding is brisk, it can take up to a minute, but usually, you only have to hold each area for a few seconds.
If the skin looks like you need a bandaid, you are making a bruise. So, stop and hold pressure.
3. Injecting Frontalis
So if you look at the distribution as diagrammed in the research, they avoid the center of the frontalis. The reason for that is that many people have a split frontalis, but not everybody. And I think you can make the case for putting an extra five in the center if they do not have a split.
To inject the frontalis, first say to your patient, “Lift your brow as high as it will go.”
Then, you can see the distribution of her frontalis (and if she has a split); you can see the muscle belly. You are looking for the muscle; the wrinkles are a guide, but so is the protrusion of the muscle and the depression where there is no muscle. And when she lifts, you can see that there’s a roundness to the muscle belly.
Your patient does not die if you put Botox in the depressed area where there is no muscle, but it wastes her money.
Each injection point is five units—four injection points for a total of 20 units in the frontalis.
Put the most lateral injection just slightly lateral to the color of her eye and near the top of the frontalis. Put the next injection of 5 units near the medial corner of her eye. Then repeat on the other side.
And I would always do these injections in the same order so that you get a routine that makes sure you do not forget something and that you are more time efficient. I like the order I am showing you, starting with the procerus, because oftentimes, they do not even feel it when you inject the procerus, and that reassures them. Then, it seems logical to finish the face before moving to the other muscles, so I next do the corrugators and then the frontalis.
And I like to massage the muscles after each injection (which I do not do when I inject the face except with the frontalis and the glabella region). I message the muscles injected when treating migraines because it is comforting to the patient, and in all seven of these locations, it helps to spread the Botox.
Then I stop and look to see if anything’s bleeding, and only when I see no bleeding do I go to the next muscle group.
4. Injecting Occiptofrontalis
In some books, you will see this labeled as simply the frontalis, which makes no sense because this part of it is not in the front—it is in the back. So, it is the occipital, occiput version of the frontalis.
The way I like to find it is to go just above their ear and just lateral to the midline, basically covering the posterior 20% of the occiput and sparing the center.
Inject the occipitofrontalis with three separate injections of 5 each, then repeat on the other side for a total of 30 units.
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5. Injecting Temporalis
To find the temporals, I like to start by finding the zygoma. It is pretty easy to find; just find their cheekbone and then feel just above the posterior section of the zygoma, and you will find the temporalis muscle.
It is easier to find if you ask them to clench their teeth.
Remember you grind your teeth with your masseters, but you go up and down with your temporalis. So you ask her to clench her teeth, and you can feel this muscle mound.
It is very big. You can’t miss it.
And then, just go just above the cheekbone and inject 5, then posteriorly and inject another 5. Imagine a rhombus and inject the corners (think of a rectangle with the upper edge moved back a 1/2 to a full centimeter and then inject the corners).
You do that on each side, so it’s going to be another 20 units per side.
6. Injecting Trapezius
We have two more to go, the trapezius and the splenius capitis.
For the trapezius, come down to right about where the vertical part of the neck starts to go horizontal and turn into the shoulder—find that inflection point.
Inject the inflection point, slightly posteriorly on the neck, and about an inch or two above it and an inch or two lateral to it—5 units in each injection point. That’s 15 units total which will be all of one of your 30-unit insulin syringes.
Then repeat with the other shoulder, with another 15 units distributed into 3 injection points.
7. Injecting Splenius Capitis
The splenius muscle is the label used in the Mayo Clinic research listed below this description. The name splenius capitis is what you’ll see on some muscle diagrams. If you look at the FDA chart regarding the treatment of migraines with Botox, it labels this area as simply the paraspinal muscles.
But I’m going to show you how I was taught to inject this area. I used to work with an internist mentor (when I was an intern) who suffered migraines. And because he suffered from migraines, he had the motivation to know a lot about migraines. Some thought he was the best migraine doctor in Birmingham, Alabama at the time.
Sometimes he would just put his head down at the nurse’s station and say, “Charles, inject me right here.” And what he would take my finger and he would come down off the occiput, near this notch, near the juncture between the bone and the muscle, that’s where he would ask me to inject. That is a good way to find the splenius capitis.
First, find the notch just postauricular. Then, move your finger laterally, then move your finger caudal until you feel the pressure change from the hard feel of the skull to the softer feel of muscle. At the juncture is where you put the first injection (5 units).
Then you come another one inch more medially and another 2 inches more caudally and inject another 5 units.
And now we have just treated those seven muscle groups for Botox.
A Word about Cash vs. Insurance
When people see me for other problems and ask me if I can treat their migraines with Botox, I tell them I could, but that their neurologist can charge insurance, and they can get it for free (and I don’t charge insurance). But, if they want me to treat their migraines, then I will make it pretty and treat their migraines.
And surprisingly, many people, without treating anything other than the procerus, the corrugators, and the frontalis, will enjoy complete relief from their migraines. So that is worth a try since it is much less expensive to them than paying for the complete migraine protocol, and if you add in crows feet and a brow lift, they will see a great cosmetic effect as well.
An Extra Injection to Keep It Pretty
When you do the strict migraine protocol and treat the frontalis and stop there without lifting the brow, you could droop her brows. So, with women, I always add in an extra three units to lift the brow even if I am treating just for migraines. The brow lift likely does not help with the migraines, it is only because I don’t want to droop her. If the neurologists were doing this, probably wouldn’t do the brow lift because it’s not part of the migraine treatment.
For this part, I use my usual dilution of one cc to a hundred units, which gives me one unit of Botox per one unit on my syringe. If I use the more voluminous dilution that I use to treat migraines, I am more likely to cause ptosis when the botox spreads down onto the lid.
First, I find the anterior protrusion of the zygoma or what I call the “corner of the head.” And then I put my finger medial to that, grab the brow, and put five units between my fingers.
This is the part that would make her eyelids droop if she rubbed on that. So I tell her to wait 4 hours before she touches her brows.
Now, we are done. We treated migraines, and I threw in some extra so her eyebrows don’t droop.
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