A few days ago I was asked to give a talk at a nearby prestigious university – grand rounds in fact, in the department of plastic surgery on Botox for chronic migraine. Now, let me explain, being asked to give grand rounds is a great honor, the kind of thing you put in your CV, and it has special attraction in this case because we are a little competitive with the institution who invited me – and I know if they had anyone there who was close to as qualified as me, they would have chosen them.
After some deliberation I responded:
I would be happy to speak about chronic migraine, and botulinum toxin use in the context of a very complex disease. I believe anyone injecting toxin for chronic migraine should be prepared to manage the full extent of the disease, including recognizing mimics, understanding and prescribing alternative treatments, diagnosing medical and psychiatric comorbidities, treating these and referring if appropriate. They should also be prepared to manage the abortives, and recognize and treat medication overuse. If this is the lecture you want, I'll be glad to give it, but I don't think physicians without a deep knowledge and interest in this disease should be treating it.
I doubt my offer will be accepted.
In medicine, procedures pay much more than cognitive work such as talking to a patient, understanding their disease, understanding the impact of the disease on the patient, its’ triggers, and finding the abortives, preventives, and non-medicine treatments that work best for the patient. What I hear in this request is that the plastic surgeons are suddenly interested in treating migraine because they might make some money doing it. There are many neurologists and primary care doctors, and even a few ENTs who have spent years learning about migraine, and who are therefore much more appropriate people to perform this procedure, and who are not just in it for a buck. Are we going to see fly-by-night operations spring up, run by people who could care less about treating the person with migraine, and just want the opportunity to do the little piece that makes money, while letting everyone else (or nobody) do the rest of the work?
On the other hand, the Botox era offers the chance to bring more people into the practice of headache medicine if it is not so very difficult to keep a practice afloat in this field. Ironically, since patient pain and suffering is apparently not enough, as treatments become more expensive to insurance companies and to government, it also could bring welcome attention to our field, putting emphasis on preventing the chronification of migraine and learning how to measure long term treatment outcomes.
We need to think about the future of headache medicine. I am not sure what the answers to the challenges of the Botox era are, but advocacy organizations like the AHDA, and groups like the American Headache Society will need to actively confront them.
William B. Young, MD, FAHS, FAAN
Vice President, Alliance for Headache Disorders Advocacy
Jefferson Headache Center; Philadelphia, Pennsylvania
