In a recent Facebook Live, our new director Nim Lalvani introduced herself to the migraine community. If you missed our Facebook Live, watch the recording below or read on to learn more about Lalvani’s personal connection to migraine and her plans for the Foundation. [embed]https://www.facebook.com/americanmigrainefoundation/videos/290329171553466/[/embed] In the short time that Lalvani has worked at AMF, she’s been impressed by the strong and vibrant community of doctors, patients and advocates. Lalvani’s background is in public health, and she has dedicated her career to patient engagement. She has worked in the nonprofit and patient advocacy spaces for more than 12 years, helping patients at both the national and international level. “I've specifically focused my career on designing and providing the rights tools and resources for patients at the times that they need it most,” she shared, adding that her goal is to amplify patients’ voices in research and therapeutic development.
The trapezius muscle is a large, triangular, superficial muscle. It attaches proximally in the medial third of the superior nuchal line, external occipital protuberance, nuchal ligament, and spinous processes of the C7-T12 vertebrae. Distal attachment of the trapezius occurs at the lateral third of the clavicle and acromion and spine of the scapula. The action of the muscle includes neck extension and stabilization of the scapula and support for the arm. The muscle fibers proximal to the inflection point of the neck (ie, necklace line) run vertically and are involved with neck extension. According to the PREEMPT injection paradigm, one injection of 5 units of onabotulinumtoxinA to each of three sites on either side of the trapezius, for a total of 30 units divided across six sites, is given. The first injection site can be identified by visually dividing the upper portion of the trapezius muscle in half, from the inflection point of the neck (ie the necklace line) to the acromion (acromio-clavicular joint); the midpoint of this location is where the injection should be administered. The second injection is located at the midpoint of the first injection site and the acromion. The third injection should be administered at the midpoint between the first injection site and the necklace line. Injections should occur in the supraclavicular portion of the muscle, lateral to the neckline, and medial to the deltoid and the acromio-clavicular joint. The injections into the trapezius should be administered horizontally and superficially to avoid injecting too deep.
It is not known whether BOTOX® is safe or effective to treat increased stiffness in upper limb muscles other than those in the elbow, wrist, fingers, and thumb, or in lower limb muscles other than those in the ankle and toes. BOTOX® has not been shown to help people perform task-specific functions with their upper limbs or increase movement in joints that are permanently fixed in position by stiff muscles. Treatment with BOTOX® is not meant to replace existing physical therapy or other rehabilitation that may have been prescribed.
If you think either of the FDA-approved anti-CGRP treatments might be right for you, speak with your primary health care provider, neurologist or headache specialist. If your medical provider isn’t aware of the treatments, don’t be afraid to let him or her know about them, or ask for a referral to a local neurologist or headache specialist. This is just the first step in advocating for the care that you deserve. To find a headache specialist in your area, consult our Find a Doctor tool. Dr. Starling believes that every person with migraine should be involved in advocacy, in order to bring awareness to the disease and break the stigma that surrounds it. She recommends that patients living with migraine get involved in advocacy organizations, such as our Move Against Migraine support community. You can also attend the annual Headache on the Hill event in which patients and providers go to Capitol Hill asking for more National Institutes of Health (NIH) research funding for migraine and other headache disorders. The next Headache on the Hill event is planned for February 11-12, 2019. Within the coming weeks, the American Migraine Foundation will be compiling a guide to all three anti-CGRP treatments. For additional information on anti-CGRP migraine treatment options, consult our doctor-verified resource library.
In May, hedge fund Appaloosa Management, run by David Tepper, received antitrust clearance from the Federal Trade Commission to potentially increase its stake in the Botox-maker. This means that Appaloosa now has more flexibility to push for further changes at Allergan. It remains to be seen if that happens, but if so, it could mean more changes are ahead for the drugmaker.

Allergan Plc engages in the research, development, and manufacture of pharmaceutical products. It operates through the following business segments: US Specialized Therapeutics; US General Medicine, and International. The US Specialized Therapeutics segment includes sales and expenses relating to branded products within the United States. The US General Medicine segment involves Central Nervous System; Gastrointestinal; Women's Health; Anti-Infectives; and Diversified brands. The International segment comprises of products sold outside the United States. The company was founded on in 1984 and is headquartered in Dublin, Ireland.

Individuals with peripheral motor neuropathic diseases, amyotrophic lateral sclerosis (ALS), or neuromuscular junction disorders (eg, myasthenia gravis or Lambert-Eaton syndrome) should be monitored when given botulinum toxin. Patients with known or unrecognized neuromuscular disorders or neuromuscular junction disorders may be at increased risk of clinically significant effects including generalized muscle weakness, diplopia, ptosis, dysphonia, dysarthria, severe dysphagia, and respiratory compromise from therapeutic doses of BOTOX® (see Warnings and Precautions).


Study 2 compared 3 doses of BOTOX with placebo and included 91 patients [BOTOX 360 Units (N=21), BOTOX 180 Units (N=23), BOTOX 90 Units (N=21), and placebo (N=26)] with upper limb spasticity (expanded Ashworth score of at least 2 for elbow flexor tone and at least 3 for wrist flexor tone) who were at least 6 weeks post-stroke. BOTOX and placebo were injected with EMG guidance into the flexor digitorum profundus, flexor digitorum sublimis, flexor carpi radialis, flexor carpi ulnaris, and bic eps brachii (see Table 27).
Once the protein stops functioning at the neuromuscular junction, it is broken down into its harmless components (amino acids) and either recycled for use in other proteins or excreted by the kidneys. "The bigger the muscle, the quicker you'll see motion return," says Rowe. "Likewise, the smaller the muscle, the longer the effect of botox lasts." It doesn't have a tolerance effect, either—your body never gets used to Botox.
The correct way to inject Botox is to always customize the treatment plan to solve the aesthetic issues that bother the person. Some patients need only limited areas injected such as the vertical lines between their brows, their “crow’s feet” at the outer aspects of their eyelids, the “bunny” lines that radiate on the sides of their nose, vertical and horizontal lip lines and rarely patients request a correction of their “gummy” smile where their upper gums show when a person smile. Yes, you usually can pay for specific areas of treatment or by the number of units injected. But if you only want single line or area of your forehead injected you may not be satisfied with the results in the end. Why? -because when Botox or Dysport is injected it will weaken only the muscles that are treated, there may be muscles that were not treated that are pulling in an opposite direction that will produce undesirable results(an example of an undesirable  effect occurs when treating just the glabella “11” lines between your eyebrows that may produce an overarched brow contour that resembles Mr. Spock.) Therefore, a complete treatment plan that includes all muscle groups should be treated to balance the pull and counter-pull of facial muscles.In addition, injections around the mouth must be performed by an experienced injector because there is the potential for the mouth to droop afterwards which can cause you to drool or may impact your ability to eat, pucker and smile. These adverse effect  may last several weeks.

There are numerous areas where Botox may be used, including the forehead, crow's feet, gummy smile, chin, neck, and other areas of the body. Many of these are under investigation at this time for approval by the FDA. Additionally, topical forms of botulinum toxin (Revance) are under study at present. With time, these will likely come to market and be absorbed into the body of treatments for which Botox is used.


In November, the FDA held a two-day hearing asking for expert comment on the agency's rules concerning off-label drug use and marketing. Some said the practice paves the way for scientific progress and gives doctors and their patients much needed alternatives for hard-to-treat medical conditions. Others said that off-label drug use is primarily financially motivated and that it poses a serious threat to public health, particularly when drugs are used experimentally on children.
Lastly, a Botox treatment does not offer permanent results. Botox is most effective when treatments are carried out at regular intervals before the results fully wear off. On average, the results last for three to four months,  although Botox metabolizes at different rates in different individuals. The first ever Botox treatment you receive may not last as long as subsequent treatments, plus you may require touch-ups two weeks after the procedure as your injector determines the right dosage for you. Over time, however, many patients notice that they can wait longer intervals between treatments as their treated facial muscles weaken.

Study 3 compared 3 doses of BOTOX with placebo and enrolled 88 patients [BOTOX 360 Units (N=23), BOTOX 180 Units (N=23), BOTOX 90 Units (N=23), and placebo (N=19)] with upper limb spasticity (expanded Ashworth score of at least 2 for elbow flexor tone and at least 3 for wrist flexor tone and/or finger flexor tone) who were at least 6 weeks post -stroke. BOTOX and placebo were injected with EMG guidance into the flexor digitorum profundus, flexor digitorum sublimi s, flexor carpi radialis, flexor carpi ulnaris, and biceps brachii (see Table 27).
They affect 39 million folks in the U.S., 4 million of whom deal with daily pain. Chronic migraines can severely inhibit daily life, and when I started to feel like my bad days were outnumbering my good, I knew I needed to find a solution. Botox had been suggested to me multiple times before by friends, family, and doctors, and though it took quite a while to get it approved by insurance and find a provider I trusted, my migraines were making it hard to live a normal life, so I decided to try it out.
It may be necessary for the patient to have additional procedures, such as the use of filler substances (for example, Restylane, Perlane, Juvederm, Sculptra, or Radiesse) in order to plump up the wrinkles that are now relaxed. Additionally, it may be necessary to have two or three sessions of Botox treatment for deeper wrinkles before results become optimal. The area of the crease between the eyes is a particularly ideal area for Botox use in conjunction with filler as these fixed wrinkles don't always respond optimally to Botox alone. There is some controversy about using filler in that area as it may block veins or arteries and result in loss of blood and a scar to the area. Generally, the smaller particle fillers, such as Restylane or Juvederm Ultra, are best in the area between the eyes for this reason.
The recommended dose is 50 Units per axilla. The hyperhidrotic area to be injected should be defined using standard staining techniques, e.g., Minor's Iodine-Starch Test. The recommended dilution is 100 Units/4 mL with 0.9% preservative -free sterile saline (see Table 1). Using a sterile 30 gauge needle, 50 Units of BOTOX (2 mL) is injected intradermally in 0.1 to 0.2 mL aliquots to each axilla evenly distributed in multiple sites (10-15) approximately 1-2 cm apart.
This product contains albumin, a derivative of human blood. Based on effective donor screening and product manufacturing processes, it carries an extremely remote risk for transmission of viral diseases and variant Creutzfeldt-Jakob disease (vCJD). There is a theoretical risk for transmission of Creutzfeldt-Jakob disease (CJD), but if that risk actually exists, the risk of transmission would also be considered extremely remote. No cases of transmission of viral diseases, CJD, or vCJD have ever been identified for licensed albumin or albumin contained in other licensed products.
The most common side effects of Botox injections are neck pain and stiffness at the injection site. You may develop a headache afterward. You may also experience temporary muscle weakness in your neck and upper shoulders. This can make it hard to keep your head upright. When these side effects occur, they usually resolve on their own within a few days.

Laser tattoo removal has minimal side effects. Lasers break up the pigment of the tattoo with a high-intensity light beam. During the procedure, the patient wears protective eye shields and may be giving anesthesia. The pulse of the laser feels like the snapping of a rubber band against the skin. Possible side effects include a risk of infection, hypopigmentation, and hyperpigmentation.

On November 23, 2015, Allergan and Pfizer announced their intention to merge in a $160 billion transaction, the largest pharmaceutical deal and the third largest merger in history.[19] On April 5, 2016, after the Obama administration announced its plan to ban tax inversions, Pfizer terminated the acquisition and paid Allergan a $150 million breakup fee.[20]


According to the PREEMPT injection paradigm, a total of 5 units of onabotulinumtoxinA is injected into each corrugator muscle. To confirm the location of the muscle, the patient is asked to furrow the brow in order to activate the corrugator. Once the muscle has been located, the muscle should be palpated and pinched by holding it between the thumb and index finger. Five units of onabotulinumtoxinA is injected at an approximate 90° angle with the bevel of the needle pointing upward into the medial belly of the muscle. As the needle is inserted, there is skin resistance, which lessens when the muscle is penetrated. This decrease in resistance is termed a muscle pop. Once the muscle pop occurs, inject into the superficial muscle. If the injection is too far superior or above the corrugator muscle, brow ptosis can occur due to depression of the medial brow as the frontalis elevating function is lost and the corrugator depressing function remains unopposed. Whereas weakening the corrugator muscle will cause elevation of the medial eyebrow, alternatively, if the corrugator injection is done too low, then diffusion to the levator palpebral muscle could lead to lid ptosis.
Can you use Botox under your eyes? Botox is often used to treat lines and wrinkles around the eyes and mouth. Can it also reduce dark circles or bags under the eyes? Using Botox under the eyes is not approved in the U.S. and researchers are unsure how well it may work and what side effects may occur. Here, learn about the procedure and its alternatives. Read now
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