If someone mentions the word ‘Botox’ to you, I suspect the first image it conjures up is of people desperately trying to hold back the consequences of ageing. In doing so they may end up looking like a Thunderbirds puppet.
But as a family doctor I increasingly have discussions with patients about non-cosmetic applications of Botox, more accurately described as botulinum toxin A. Often these can have dramatic benefits.
The main conversation is about migraines that have resisted all the treatments I have thrown at them, often over many years. A paper just published in the British Medical Journal has highlighted the fact that women who get migraines are also more likely to develop heart conditions such as heart attacks and strokes, and are also slightly more at risk of dying from them compared to women who do not get migraines. The link between migraines and heart health remains unclear but we are now advising that migraines could be considered a risk factor for heart disease.
While I have never experienced a migraine attack myself, I see the effects every day in my patients. Treatment is usually focused on trying to turn off an acute attack or using preventive treatment to reduce the chances of one developing. Some patients appear resistant to all treatments, or cannot tolerate the treatments, and this is where Botox can help.
However, only patients with chronic migraine — defined as headaches occurring on 15 or more days each month, at least half of which have migrainous features — are eligible for this type of therapy, which consists of a number of cycles of treatment where fixed doses of Botox are injected into various points of the scalp.
The exact reason it works is unknown, although one possibility is that the toxin inhibits migraine pain by reducing the expression of certain pain pathways involving nerve cells in the trigeminovascular system — the sensory pathway thought to play a key role in severe headaches. At present there are only a few specialised centres offering this type of treatment on the NHS, but for the patients under my care who have undergone this treatment it has revolutionised their lives.
Other medical conditions that can benefit from Botox injections include excessive sweating, urinary incontinence, spasms linked to multiple sclerosis, Bell’s palsy, squints and twitching eyes. Unlike its use in migraine treatment, these conditions are helped by the impact of Botox on relaxing overactive muscles. In excessive sweating (also called hyperhidrosis — a miserable condition for those afflicted by it), Botox works by blocking signals the brain sends to sweat glands and the benefit often lasts many months before it needs to be repeated.
The problem of urinary incontinence caused by an overactive bladder affects about 20 per cent of people over the age of 45, with women being affected more than men, and injecting Botox into the wall of the bladder is one treatment option in severe cases. One study found that people treated this way found their need to suddenly pass urine falling from several times a day to once daily, although the benefit started to wear off after about six months.
In Bell’s palsy, one side of the face droops badly because of a facial nerve problem and Botox can help relax muscles that have become tight or are twitching here. Such twitching can also occur in the eyelids without any other medical problem being present and injecting these muscles can relieve this irritating spasm for many months. For similar reasons, people with muscle problems linked to multiple sclerosis can be helped by Botox, which stops their muscles contracting when they don’t want them to.
In all these cases, specialist appraisal is required rather than a GP being able to treat in this way, but what was once seen as a purely cosmetic treatment is rapidly becoming a mainstream way of helping to improve the quality of life of many.