Headaches in children and young adults are more common than people think — and, in younger patients, they can also be tough to treat. When other therapies fail, doctors may consider an interesting therapy: Botox® (onabotulinumtoxinA) injections.
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Headaches in younger patients can vary in type. Among 15- to-17-year-olds, about 10 percent have migraines — severe headaches that cause sensitivity to light and noise, nausea and vomiting.
A rarer, even more debilitating condition that can affect young people is chronic daily headache (CDH). While this affects only about 2 percent of this age group, CDH can cause more than 15 headaches each month. Roughly 40 percent of young patients who seek specialty care for headaches suffer from this condition.
Lifestyle modifications are the first line of defense in CDH treatment. But when those don’t work, doctors may turn to medication, including Botox injections.
“Botox injections should never be the first option to treat CDH. Our criteria for using it in children is that the patient has had a good trial with other medications, but they’ve failed,” says A. David Rothner, MD, Chairman Emeritus of the Section of Child Neurology and Head of the Pediatric/Adolescent Headache Program at Cleveland Clinic. “Then, we consider Botox.”
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Other therapies come first
Dr. Rothner encourages young patients to focus on getting more sleep, adequate exercise and being mindful about drinking enough water.
To supplement that, he also relies on four medications to relieve pain. Most often, he prescribes cyproheptadine (Periactin®) or topiramate (Topamax®). Less frequently, he turns to amitriptyline (Elavil®) or gabapentin (Neurontin®).
In most cases, these drugs relieve either all or most headache pain, but when they don’t, doctors, parents and patients can consider Botox as an alternative treatment, he says.
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How well does it work?
It’s actually unclear how Botox works, Dr. Rothner says. But, doctors do know it interferes with impulse transmission between nerves and muscles, causing the muscles to relax.
It’s also possible, he says, that the nerves absorb some of the Botox, and it travels backward to the brain and interferes with some pain impulses.
To treat CDH, doctors administer a series of injections into the patient’s head and neck. The doctor tailors the dose to each patient’s needs. The medication usually offers relief within seven to 14 days. Impact on CDH ranges from full relief to no change, he says.
Some children need no further treatment; others require up to three or four follow-up injections, Dr. Rothner says.
The severity of a child’s CDH often directly impacts how effective Botox treatment is. Children with a long history of CDH that affects their social lives and ability to attend school often find less relief from this therapy, he says.
Good news on side effects
The good news with Botox, Dr. Rothner says, is that it produces almost no side effects when used in the proper dosage. Once in awhile, some patients might see some eyelid drooping. Difficulty swallowing and generalized weakness both occur rarely.
Still, doctors, parents and patients should have a thorough conversation about this treatment before moving forward, he says.
“We always exercise more caution and restraint,” Dr. Rothner says. “We go more slowly and less aggressively than you would with adults with chronic daily headache.”
Currently, the FDA only approves the use of Botox to treat CDH in adults, age 18 and over. Use in children or adolescents is considered “off-label,” Dr. Rothner says. This means the drug is being used for a reason your doctor finds medically appropriate, but not specified in the FDA’s approved packaging label or insert.
While prescribing medications off-label is a common practice, it also means insurance companies are less likely to pay for it.
Be sure to talk to your doctor or pediatrician. He or she can help your child or teen find the best ways to address chronic headaches.