About a year ago, I hit a wall in my migraine treatments. After five years of working with a neurologist, I had quietly given up. I'd tried everything from cognitive behavioural therapy to anticonvulsants to prevent them; I avoided potential triggers like the plague. But nothing was truly effective, and my neurologist suggested I instead shift my focus to de-stressing, which is like telling water to please try being less wet.
There was, however, one last-ditch migraine treatment I'd always been curious about: botulinum toxin, the most potent neurotoxin on the planet — a.k.a. Botox, the injectable treatment known for its use in reducing fine lines and wrinkles by paralysing the muscles responsible for them. Botox was approved by the U.S. Food and Drug Administration for treating chronic migraines, defined as more than 15 headache days per month, in 2010. A fellow migraine sufferer had recently gotten it, and suggested that I switch neurologists and pursue the treatment.
I had nothing to lose, so I reached out to Risa Ravitz, M.D., a neurologist at Downtown Neurology in New York City who is board-certified by both the American Academy of Psychiatry and Neurology and the American Board of Pain Medicine, to learn more.
It’s complicated to explain the physiological mechanism behind why Botox works, because migraines aren’t fully understood to begin with. People with migraines have "overly excitable" brains, meaning a small, seemingly innocuous trigger (such as changes in barometric pressure, dehydration, or hormone levels) could cause a migraine, Dr. Ravitz told me. "A person with migraines is just on the threshold of setting off this big cascade of chemical and electrical events," she said. And for about 25-30% of people who get migraines, this wave of electricity causes four incapacitating stages: a visual aura, a piercing headache, and nausea and vomiting, ending with a hangover-like comedown.
Botox, experts believe, blocks a very specific type of neurotransmission that sends a signal from a neuron to a muscle and releases pain transmitters, Dr. Ravitz said. "Botox completely paralyses this whole process, so that neuron can’t talk to the muscle," she explained. "It’s like that whole process of pain-pain-pain is sort of quieted down." But again: This is just a theory as to how it works, she said. When injected into the scalp, neck, shoulders, temples, and forehead every three months, Botox can reduce the number of migraines people get by up to 50%.
Even people like me, who don't get "chronic" migraines but do get a few horrific migraines a month, can benefit from Botox. Dr. Ravitz said she's seen patients who get hemiplegic migraines, a rare form of migraine that causes people to feel paralysed or numb on one side of the body. Others find themselves in the emergency room every month with a migraine because they're scared. "It's completely reasonable to be using Botox, because I don't want those patients getting any headaches — I want them getting none," she said. "As a doctor, I want to advocate for patients, as well as the people who will likely benefit from Botox, even if they don't necessarily fit the exact definition."
After a consultation and trying two more preventative drugs (to prove that, yes, I'd tried everything), the Botox was approved by my health insurance. I settled the $50 copay for the appointment and sat nervously sweating in Dr. Ravitz’s office. I wanted this treatment to work, badly, and I worried I would be back to square one if it didn’t.
The prospect of getting 26 injections in my head and face was also slightly jarring. I watch a lot of reality TV, so I’m well aware of the visible effects of cosmetic Botox. I also grew up with a vanity-averse mum who doesn't believe in painting her nails, let alone getting plastic surgery. That internalised stigma admittedly made me concerned I would be judged for getting Botox, even though it was for what I saw as a "legitimate" medical reason. Also, I already have a natural "resting bitch face," so I needed to be able to express some emotion afterwards. Dr. Ravitz reassured me that my face would be fine.
Surprisingly, the injections didn’t hurt at all, which Dr. Ravitz told me is a common reaction from migraine sufferers, who tend to have a high pain tolerance. The ones that went in my shoulders instantly relaxed my perpetually tight upper back. I had a few bloody pinpoints on my forehead after, but they went away after showering. I took approximately one billion selfies that night, raising and furrowing my eyebrows, waiting to see a noticeable change in my face. Days after the injections, my forehead finally froze, which was funny for everyone, including my mum. And honestly, although I'd never been drawn to anti-wrinkle skincare products or treatments, I'm really into not having any wrinkles. My forehead is as smooth and uniform as a Krispy Kreme glazed donut — and I love it.
But a motionless forehead was not what I came for; what really mattered was how Botox affected my migraines. A month after receiving the injections, I had no migraines. Zero. When one was eventually triggered by a dramatic change in the weather and a lot of stress, it was much less severe than my pre-Botox migraines. I used to have to cancel my entire life when I got a migraine, but the pain was tolerable and I was able to get through it (though I still have to take a dose of prescription rescue medication and three Excedrin when I get one). And more importantly, knowing that the Botox is in my body serving as a kind of traffic crossing guard to stop unnecessary electrical activity has given me a sense of control over my migraines that I never had before.
It's also worth mentioning that, while Botox used to be the only solid preventative solution for migraines, a promising new migraine drug called fremanezumab was approved by the FDA in 2017. It’s also an injection, and although it works in a different way (it works specifically on an antibody called CGRP), it has a similar success rate as Botox.
Botox worked for me, but migraines are as individual as the people who get them; it’s up to you and your healthcare provider to determine the best choice for you. To that same point, if you are struggling with migraines, it’s best to see a headache specialist who is comfortable with and experienced in diagnosing and treating head pain disorders. (For patients who don't live near a headache specialist, Dr. Ravitz created a telemedicine platform called Modern Migraine MD, which can connect you with a neurologist and headache specialist from anywhere.) There are also subsets of headache specialists who administer Botox.
Regardless, every patient should be informed about their options, and feel comfortable telling a doctor what they are and aren’t willing to do, Dr. Ravitz says. It can feel intimidating to advocate for yourself at a doctor’s appointment, especially when you’re describing pain, but it’s always worth it. And as for anyone who says getting Botox is vain and frivolous? Well, at least they can't see what my face is really trying to tell them underneath all this Botox.
No Filter is a week-long series of frank, honest stories about cosmetic procedures — without judgment, sugar-coating, or stigma.