Friday, October 19, 2012


Botox Therapy for Chronic Migraine

What is migraine?
  • Migraine is a condition, characterized by repeated episodes of headache.
  • Headache can be on one side or both sides of head.
  • Headache typically lasts for more than four hours, but usually resolves in less than 72 hours.
  • Nausea (a sensation to vomit) or vomiting may be present during headache episodes.
  • There may be photophobia (headache becomes more in bright light or sunlight) or phonophobia (headache becomes more in noise).
 What is chronic migraine?
A person, who has been suffering from migraine, for a period of more than six months, is said to be suffering from chronic migraine.

What is the impact of chronic migraine on the sufferer?
Chronic migraine leads to a number of problems in the sufferer:
  • Recurrent headache interferes with job or studies, leading to poor performance at work or in studies.
  • It leads to frequent absenteeism at workplace or in college.
  • People suffering from chronic migraine can not enjoy social functions, as slight triggers such as music can trigger the headaches.
  • They need to avoid road travel, as it can trigger headaches.
  • Patients are frequently forced to take multiple analgesics (pain-killers) every month, leading to significant adverse effects.
What are the treatment options for patients with chronic migraine?
Patients with chronic migraine, who get three or more than three episodes of headache in a month, require preventive therapy (medications to prevent repeated episodes of headache).

What are the commonly used medications to prevent headaches in a migraine patient?
Following medicines (with their brand names) are available for use in chronic migraine:
·        Amitryptiline (Tryptomer)
·        Flunarizine (Sibelium)
·        Propranolol (Betacap TR, Ciplar LA)
·        Divalproex (Divaa OD, Dicorate ER)
·        Topiramate (Topamac)
·        Botulinum toxin (Botox) injections

What are the disadvantages of oral medications?
1.      Lack of efficacy- many people do not adequately respond to these medications. They continue to get recurrent headaches despite taking them for long periods.
2.      Adverse effects- Significant adverse effects are noted with oral medications.
·        Amitryptiline- drowsiness
·        Flunarizine- drowsiness, weight gain
·        Propranolol- aggravation of asthma, depression
·        Divalproex- weight gain, tremors of hands, hair loss, pregnancy-related complications,
·        Topiramate- tingling of feet, weight loss, glaucoma in rare cases, renal stones in rare cases.
 3.      Need to take them on a daily basis

What are the advantages of Botox injections over oral medications in migraine treatment?
1.      Efficacy of botox in migraine has been proven in research and clinical practice.
2.      Botox is fairly safe and the side effects are negligible.
3.      Botox injections need to be repeated once in 3-6 months, so, the patient compliance is better and they can get rid of daily tablets.

Facts regarding Botox injections in a patient with migraine
·        There are fixed points over the scalp, where the injections are given (irrespective of the site of head pain).
·        These locations include front of head, over eyebrows, temple region, back of head and neck muscles.
·        Injections are given by a neurologist, who is trained in the botox procedure.
·        It is given by insulin syringe and needle, and is given in the superficial tissues (scalp muscles, which are hardly a few mm beneath the skin).
·        Topical (surface anesthetic) creams are used, so, the injection does not hurt much and is almost painless.
·        The whole procedure can be completed in an office (Outpatient) set up and is completed in 15-20 minutes.
·        Patient can leave for office or home immediately after the botox procedure.
·        A total dose of 155 units of botox is used in chronic migraine.
Are there any side effects of botox injections?
·        This is the same botox that is used in cosmetic procedures and several million patients have received botox for neurological problems as well (such as writer’s cramp, dystonia, blepharospasm, post-stroke spasticity, hyperhidrosis, etc).
·        It is among the safest injections, and has no serious side effects.
·        Mild pain at the injection site may be felt (just as is felt with any injections).
·        Mild bruising (and redness) and swelling may occur at the injection site.
·        Mild eyelid droop may occur, which improves in a few days on its own.

My experience with Botox in migraine
  • I see about 15-20 new cases of migraine per month, and have seen thousands of patients in the past 18 years of my medical practice.
  • About 20-30% of them either do not improve with oral preventive tablets or they have side effects with them. Some people find it difficult to take tablets on a daily basis for a long period of time.
  • For this group of patients, botox injection therapy is the most ideal. I see 2-3 patients per month, who are eligible to receive botox therapy in chronic migraine. About 1-2 per month receive them. In the past two years, I have given botox to about 40 patients with chronic migraine.
  • About 95% patients report benefit after botox therapy and in most cases, oral tablets are not required after botox.
  • None of them reported any adverse or side effects with botox.
I would like to share an interesting experience with one of the patients. Mrs Nazia (name changed) from Dubai came in June 2012 for botox therapy in migraine. I gave her the injections on OP basis on the usual sites, including forehead. She had no side effects with botox. She came back for review three months later and reported that she was totally headache-free. However, she wanted a repeat botox injection. I was surprised. I asked her if she has no headache, then why does she want botox! She said, after botox, her husband has started to give her more attention and love, as her face has also improved (then, I realized that she wanted it for cosmetic effects). She also told me that three of her colleagues at her office want the botox to be given by me (but only for cosmetic reasons). I had a tough time, referring them to a cosmetic surgeon for the same.

If you want any further information regarding botox therapy in migraine, please email me at

Dr Sudhir Kumar MD (Medicine) DM (Neurology)
Senior Consultant Neurologist
Apollo Hospitals, Jubilee Hills, Hyderabad

Friday, October 12, 2012




Neurology is one area, where we see patients who are critically ill, and require emergent and aggressive medical care for better outcomes. This branch of Neurology is also called NEURO CRITICAL CARE. I have a lot of passion for neuro critical care. Here, time is crucial. One has to make the diagnostic and treatment plans as fast as possible, so as to start the best treatment at the earliest, and I love that.


IVIG belongs to the group of medicines, called as immunotherapy. This is used in illnesses, which are due to involvement of immune system. In many conditions, antibodies are produced in the body, which can harm, leading to diseases. In these diseases, IVIG treatment can be life-saving.

IVIG Treatment in Neurology

IVIG is required in the following neurological diseases:

1. Guillain Barre syndrome (GBS)- In this illness, patients have paralysis of both hands and legs and may get difficulty in breathnig also.

2. Myasthenia Gravis- In this condition, patients have drooping of eyelids, difficulty in speaking and swallowing, weakness of hands and legs and breathing problem.

3. Multiple sclerosis (MS)- In severe cases of MS, IVIG is useful.

4. CIDP- Chronic inflammatory demyelinating Polyradiculoneuropathy- In this condition, there is weakness of both legs and hands. When steroids do not work, IVIG may be required.

5. Epilepsy- In certain cases of epilepsy, such as West syndrome (seen in children), refractory status epilepticus (where fits do not respond to usual treatment), etc, IVIG therapy can be life-saving.

My Experience with IVIG Therapy

I have been using IVIG since 1995 (about 17 years now). I have given IVIG in all the above-mentioned indications and my experience with this medicine has been very good.
I remember several patients who came in states of severe disability and they recovered well.

One case, I would like to share with you. There was a young 25-year-old software professional Ms Reena (name changed) from Chennai, who had developed severe GBS. She rapidly worsened, became totally paralysed in whole body, and could not breathe. She was put on ventilatory support for the same. As she was not responding to the treatment, their family consulted me. I advised them to shift her to Apollo Hyderabad under my care. She was treated with a course of IVIG, ably supported by our excellent ICU doctors and nurses. She showed gradual improvement and was discharged from hospital after one month. She had little movements of hands and legs at discharge, could not speak, and required feeding through a nasal tube. I advised them to continue physiotherapy. She came back after two months to my OPD for a review. I was pleasantly surprised to see her totally normal. When I asked her if she had any problem, she replied- "yes- my nails have become dark, what to do to make them better?" I could not stop smiling to see the extent of recovery.

There are several similar cases that come to mind, when I look back at more than 500 patients during the past 17 years, who were treated with IVIG under my care and showed excellent recovery.

Dose of IVIG

The standard dose of IVIG is 0.4 grams per kg body weight per day for five days (a total of 2 grams per kg body weight). For ex- a person with body weight of 75 kg would require 150 gms total dose of IVIG (30 grams per day for five days).

It is given as drip (infusion) in the hand veins, slowly over 4-6 hours (just how we give glucose or saline drip).

Cost of IVIG

IVIG is costly, as it is prepared from the plasma (a part of blood) of healthy volunteers. As the source of healthy plasma is scarce, IVIG also is scarce product. A typical vial of 5 gm would cost Rs 15000-20,000/ (USD 300-400). So, a person requiring 150 grams may need to spend Rs 4,50,000-Rs 6,00,000 (USD 9000-12000).

Side effects of IVIG

IVIG is fairly safe product. In some cases, minor allergic reactions may occur. This can include fever, chills, etc. This can be well managed with simple medicines and decreasing the rate of IVIG infusion.

If you require any further information about IVIG treatment, please send an email to me-

Dr Sudhir Kumar MD (Internal Medicine) DM (Neurology)
Senior Consultant Neurologist
Apollo Health City, Jubilee Hills, Hyderabad
Phone- 0091-40-23607777/60601066