I did my first post about Botox for teens under 18 in July 2019, 3 years ago! My intention was to review our data and prepare for publication a paper supporting the use of Botox for those under age 18. The more academic publications there are available, the better to make the case with insurance providers for its use in this population.
Well, it’s been 3 years and I am just getting to this now. I guess I was distracted by other more pressing matters, like a pandemic. My NP colleagues and I are putting together data and analysis now of patients under age 18 from 8/2016 through 12/2021, a total of 32 patients now.
At the start, I was skeptical about the effectiveness of Botox for chronic migraine. I doubted whether our patients would actually go through with the 31-injection procedure more than once, in order to get full effect. In fact very few of those who met criteria have declined the Botox procedure. These teens with chronic migraine were suffering. I could make a case for trying it, after 5 years experience with many patients and much success.
The kids and families were not the challenge in this process. The challenge was and continues to be getting insurance approval, especially for those under 18 years. It has been daunting, many phone calls and appeals. We need to make sure the documentation in the clinical record is adequate and clear, indicating that they meet the criteria.
At this point I am doing the Botox for chronic migraine protocol about 25-30 times/month on average, depending on the timing of procedures (every 12 weeks). There are 32 discreet patients under age 18 (at the first procedure) for review, starting at age 13. We are now looking at the outcome data and planning to write up the results and our experiences for publication. (I know I said that in 2019). We are reporting on safety and efficacy for this population.
In published studies regarding adults with chronic migraine and Botox, it is reported that there is reduction in headache days (between 25-70% depending on the study), as well an improvement in quality of life and decrease in depression.
With all the new products available, why focus on Botox? All the new medications and modalities are not approved for those under age 18. There are ongoing clinical trials but it will be a while before they are approved. They are not without risk and consequences and expense. And the results are not miraculous. For teens with frequent migraine, the goal during adolescence is to reduce or reverse the chronicity before adulthood. We need every tool at our disposal- oral medications, injectable medications, occipital nerve and trigger point injections, neuromodulating devices, and Botox.
A look at our data has revealed about 80% of patients have had a positive result, a reduction in overall migraine pain and frequency. In the literature and anecdotally, it is reported that the biggest positive effect tends to be after the 2nd procedure. I have seen a few patients achieve minimal improvement. But I have also had plenty of patients with very significant positive effect after just one procedure. There has been at least a 50% reduction in migraine for many teenagers. There have been a few patients who went from having 3-5 migraine days/week to 1-3 migraine days/month, after 1 or 2 treatments. There have been a few who, after 1 Botox procedure, had not had any migraine at all before the next scheduled procedure.
We are looking at the data now for good statistical analysis, so my reporting here is just personal observations. I perform about 90% of the Botox procedures in the clinic, so I experience first-hand the positive results and life changing effects for our teens.
Insurance barriers remain the biggest hurdle and it can be discouraging to have to manage patients as best we can, until they reach the magic number of 18 years old. Since you never know when the insurance company will approve the procedure, we start making the effort for appropriate patients around age 16. With the advent of new medications, there is sometimes more openness to Botox or sometimes insurance companies insist they try a newer medication first (which they won’t approve and there are no financial assist available). You never know what is going to happen.
There have been few side effects, mainly neck soreness, flu-like symptoms for 48h max, and the occasional temporary eyelid droop. Most kids have no side effects and so far no long-term adverse effects. They know they will not be able to raise their brows, and often will comment that they know it is time to come back when they can move them again. And every single mother, every time, will ask if there are any leftovers for them, to smooth out their wrinkles……. followed by the obligatory eye roll from the patient……..
One of the questions I am asked is how does it really work. Well, not to get too much in the scientific weeds about it, it is more than just paralyzing the muscles that are injected. It works on the cellular level, within the same CGRP system (anti-CGRP) as the newer medications. Since Botox stays where you put it, rather than acting systemically, there are fewer long term effect concerns.
In my opinion, the reason it works well for adolescents is related to the years and level of chronicity of migraine. There is a huge difference between a teen chronic migraineur, who may have had increased frequency or chronicity for 1-2 years, and an adult who may have had chronic migraine for 10+ years. Adolescents are also going through a period of rapid brain development, which may help reverse/heal the chronic changes.
So while the hurdles are high, Botox for chronic migraine for teens is definitely worth the trouble. The clinical results have been great, with minimal long-term risks or side effects. In the words of my now-young adult patient, who started Botox right after her 18th birthday: “Botox changed everything and gave me a life!”
HeadFirst PNP 