Doctor on Call
Rachel, a 35-year-old female who lives in Washington, D. C. and works as project manager for one of the city’s countless nonprofit NGOs writes:
For years I had bad migraines so often that it was hard to hold a job. I tried one prevention therapy after another and more pills, shots and sprays for my acute headaches than I care to remember. Nothing worked. Not even a little. Not even for a short while.
Then, eight years ago, a neurologist started treating me with Botox injections, and within three or four months I was essentially headache-free. It was nothing short of a miracle! I returned for repeat injections every three months until at one visit she told me she was retiring. She referred me to another neurologist, but he was so booked up that I had to wait six months for my initial appointment. By the time I finally saw him I was three months overdue for Botox! Thankfully for me and my job security, my migraine remained quiet during the time spent waiting, and whatever few headaches I had were mild and relieved by Excedrin.
When I finally saw the new neurologist and told him I needed to restart Botox immediately, he just laughed and asked why. When I explained to him how bad my migraine had been before Botox and how much Botox had helped, he replied that it was great I responded so well but that at this point I no longer needed it.
What is he thinking? Do I need to see another neurologist and go another six months without Botox?
Confused&Frustrated
The Doctor’s Reply:
Rachel, first I must commend you for being a far more compliant patient than I am. And, to be fair, the issue you’ve identified still remains a topic for debate amongst headache subspecialists. That issue, specifically: when, if ever, can a successful migraine prevention therapy be discontinued in favor of as-needed therapy alone?
To begin with, the natural course of migraine in each individual can be quite variable. Significant spontaneous improvement is not uncommon, and when a new prevention therapy is evaluated in clinical research it is consequently important to conduct a randomized, placebo-controlled trial to better determine whether a research subject’s improvement is truly linked to the new therapy.
If migraine is in fact genetic in origin, to “cure” migraine will be impossible until we have the capacity to perform gene editing. Until then, providers will continue to use preventive and acute therapies to modify in a positive way what otherwise would be the natural course of a patient’s migraine. In doing so, although the “migraine gene” may still be present, the clinical expression of the genetic predisposition may be reduced, and that reduction may persist even after the therapy itself is discontinued.
In a prospective study we nicknamed “can Botox be stopped?”, my colleagues and I defined a strict clinical endpoint for clinical improvement sufficient to justify stopping Botox therapy in patients who reached that endpoint and followed those patients for up to five years. All the patients involved had chronic migraine, and many had been experiencing chronic migraine for years prior to beginning Botox. One year after renewed treatment with Botox had been discontinued, 90% of the patients were continuing to do well and had not required treatment with Botox or any other prevention therapy.
Your story, Rachel, provides a one-woman confirmation of our study results. Your migraine was almost totally suppressed by Botox while you were being treated, and that suppression was maintained for a long enough time that your headache disorder did not clinically reignite even after your initial neurologist retired and you received no Botox for the next six months. The odds are quite good that you will go for many more months or even years without the need for Botox or any other prevention therapy.
In short, it is the rare migraine patient who will require prevention therapy indefinitely. For most patients, commitment to prevention therapy is by no means a lifetime proposition.