In the United States, more than 30 million people have 1 or more migraine headaches per year. Migraine is a complex disorder characterized by recurrent episodes of headache, most often unilateral and in some cases associated with visual or sensory symptomscollectively known as an aurathat arise most often before the head pain but that may occur during or afterward (see the image below). Several treatment principles, including taking medication early in an attack and using a stratified treatment approach, can help ensure that migraine treatment is cost-effective. BOTOX is not approved for fewer than 14 headache days a month. Scher AI, Terwindt GM, Picavet HS, Verschuren WM, Ferrari MD, Launer LJ. Typically, the associated headache affects one side of the head, is pulsating in nature, may be moderate to severe in intensity, and could last from a few hours to three days. Headache. [QxMD MEDLINE Link]. Interest in this theory has recently been renewed. Migraine, anxiety, and depression often occur together. U.S. patients were provided access to our medicines at no cost through our patient assistance program in 2021 92% of waste diverted from landfills in 2021. Applying sealants in school-based programs to the nearly 7 million children from low income households who dont have them could save up to $300 million in dental treatment costs, the CDC reported. ", The three gepants not only are similar in their mechanisms of action, but theyshare two additional important properties: they are all oral, and they all have favorable side effect profiles. These were the findings in 9 patients who had experienced spontaneous attack of migraine without aura. Migraine and biomarkers of endothelial activation in young women. 353:i2610. [65] However, those who have migraine without aura have the same risks as the general population. Find the latest business news on Wall Street, jobs and the economy, the housing market, personal finance and money investments and much more on ABC News 2003 Feb. 33(2):192-6. American Academy of Neurology. Krymchantowski AV, Jevoux C, Moreira PF. [Full Text]. Others, like Teri K., had a less favorable experience. Development and Evaluation of a Machine Learning Model for the Early Identification of Patients at Risk for Sepsis. Atogepant for the Preventive Treatment of Migraine. Cleve Clin J Med. Its effectiveness varies by dose and route of administration (Table 6).23 All triptans have strong evidence of effectiveness,8 but few head-to-head comparisons have been performed. [QxMD MEDLINE Link]. These include beta-adrenergic receptor blockers, antidepressants, calcium antagonists and anti-epileptics. [Full Text]. His slides and lectures were easy to understand and very helpful for my practice. 38 (6):1026-1037. U.S. patients were provided access to our medicines at no cost through our patient assistance program in 2021 92% of waste diverted from landfills in 2021. INTRODUCTION Migraine is a common episodic disorder, the hallmark of which is a disabling headache generally associated with nausea and/or light and sound sensitivity. [QxMD MEDLINE Link]. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. 10. Headache. 2012 Apr 24. Donations to the American Migraine Foundation are tax-deductible to the extent permitted by law. [QxMD MEDLINE Link]. Although some drugs that are effective for migraine inhibit neurogenic plasma extravasation, substance P antagonists and the endothelin antagonist bosentan inhibit neurogenic plasma extravasation but are ineffective as antimigraine drugs. Offer good only with a valid prescription for BOTOX (onabotulinumtoxinA). The cost of HIV treatment varies depending on which medicines you take and any other care you need. [28] : Opiates - Critical dose of exposure is around 8 days per month; the effect is more pronounced in men, Barbiturates - Critical dose of exposure is around 5 days per month; the effect is more pronounced in women, Triptans - Migraine progression is seen only in patients with high frequency of migraine at baseline (10-14 days/mo), In the study, the effect of anti-inflammatory medications varied with headache frequency. 12(3):249-54. Medscape Medical News. [QxMD MEDLINE Link]. OnabotulinumtoxinA for treatment of chronic migraine: pooled results from the double-blind, randomized, placebo-controlled phases of the PREEMPT clinical program. February 2010. The dopamine antagonists chlorpromazine, droperidol, metoclopramide, and prochlorperazine have moderate evidence supporting their use.8,11 They are often administered parenterally. Assessment aims to confirm diagnostic criteria, evaluate for alternative explanations, identify comorbidities that could complicate management (e.g., depression, chronic pain),8 and document the baseline pattern and severity of episodes. But don't attempt, If youve opted for conventional metal or ceramic brackets, youve got one more decision to make: What color will you choose? This article, Damon braces use a self-litigating sliding system to connect archwires to brackets instead of elastic ties. Lisa N. saysthe combination of Qulipta and Vyepti seems to be working better for her than Vyepti alone. In an ad hoc analysis presented at the American Headache Society(AHS) Annual Scientific Meetingin June 2022, headache specialists discussed a study in which nearly a quarter of participants taking Qulipta lost 7% or more of their body weight compared with people on other typical migraine treatments or a placebo. Nat Genet. 2004. Cephalalgia. Wendy Neri is an author and editor at Migraine Again. 333102420905132. In 2016, over 4.5 million procedures were performed using Botox and similar medication to fight wrinkles. 2001 Nov-Dec. 41(10):976-80. Practice guideline update summary: Botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: Report of the blepharospasm, cervical dystonia, adult spasticity, and headache: Report of the blepharospasm, cervical dystonia, adult spasticity, and headache: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Richter F, Lehmenkhler A. [QxMD MEDLINE Link]. 2018 May. All material on this website is protected by copyright, Copyright 1994-2022 by WebMD LLC. 2021. For comparison, the list price of Nurtec is about $900 to $960 for a pack of eight. Cephalalgia. The fact that sumatriptan reversed the concomitant increased rCBF in the cerebral cortex but not the brainstem centers suggests dysfunction in the regulation involved in antinociception and vascular control of these centers. [Full Text]. Offer valid only for BOTOX and BOTOX treatment-related costs not covered by insurance. Appropriate individualized use is critical. [30]. The fixed-dose combination pill is often reserved as second-line treatment because of its cost, but using sumatriptan (50 mg) plus naproxen (500 mg) has been found noninferior. Second, the headache must have had at least 2 of the following characteristics: Third, during the headache the patient experiences at least 1 of the following: In January 2018, the International Classification of Headache Disorders, Third Editionwas published. Author disclosure: No relevant financial affiliations. International Headache Society diagnostic criteria are that patients must have had at least 5 headache attacks that lasted 472 hours (untreated or unsuccessfully treated) and that the headache must have had at least 2 of the following characteristics: [QxMD MEDLINE Link]. Allergan, Inc., an AbbVie company, is the maker and marketer of BOTOX (onabotulinumtoxinA). In clinical studies, most people had quick pain by calling 1-800-44-BOTOX or click here to learn more, BOTOX prevents headaches and migraine attacks before they even start. 2019 Oct. 39 (11):1343-1357. [24] Nitric oxide released by microglia is a potentially cytotoxic proinflammatory mediator, initiating and maintaining brain inflammation through activation of the trigeminal neuron system. For questions about the program, please call 1-800-44-BOTOX. In the follow-up study, patients reported constipation at a higher rate: up to 10.9%, as compared with 6.9%to 7.7%in the initial study. Allergan, Inc., an AbbVie company, imposes no obligations on these physicians relating to the manner in which they provide medical care to their respective patients. Patients who have migraine without aura seem to have an increased ratio of matrix metalloproteinase9 (MMP-9) to tissue inhibitors of metalloproteinase1 (TIMP-1), in contrast to a lower MMP-9/TIMP-1 ratio in patients who have migraine with aura. Medscape Medical News. Again note the visual loss in the center of vision. The term migraine is derived from the Greek word hemikrania. Anderson P. Neuropeptide May Be Biomarker for Chronic Migraine. 57(10):1805-11. For prevention, Nurtec istaken once every other day. Ann Emerg Med. Quiz: Are you Experiencing Chronic Migraine? The female-to-male ratio increases from 2.5:1 at puberty to 3.5:1 at age 40 years. Neurology. [QxMD MEDLINE Link]. Silberstein SD, Freitag FG. [53] This increase in iron deposits may be explained as a physiologic response induced by repeated activation of nuclei involved in central pain processing or by damage to these structures secondary to the formation of free radicals in oxidative stress (possibly the cause of the disease becoming chronic). Tell your doctor about all your muscle or nerve conditions, such as ALS or Lou Gehrigs disease, myasthenia gravis, or Lambert-Eaton syndrome, as you may be at increased risk of serious side effects, including difficulty swallowing and difficulty breathing from typical doses of BOTOX. N Engl J Med 2021; 385:695-706. The price ranges from $2,000 to $8,500. Curr Opin Neurol. Phase 3 randomized, placebo-controlled, double-blind study of lasmiditan for acute treatment of migraine. Accessed: March 27, 2013. [Guideline] Solomon GD, Cady RK, Klapper JA, Ryan RE Jr. Standards of care for treating headache in primary care practice. I had the first injection and I had really kind of overthought everything and made it seem much worse than it was going to be. 322(7277):19-22. Migraines are less frequent and less severe. Instead, the flow is reduced because the spreading depression reduces metabolism. April 28, 2017; Accessed: May 9, 2017. April 24, 2018. From the Editor in Chief (interim), Subhash Banerjee, MD. International Headache Society criteria for migraine without aura. When being injected between the brows, do not lie down or bend over for three to four hour. All rights reserved. Medscape Medical News. Bigal ME, Lipton RB. In the follow-up study, atogepant was studied in two dosages (60 mg once a day, and 30 mg twice a day) in participants with at least a one-year history of chronic migraine. Barbas NR, Schuyler EA. [Full Text]. [17], Increased net activity of matrix metalloproteinase2 (MMP-2) has been demonstrated in migraineurs. Combining the triptan with 500 mg of naproxen or choosing a triptan with a longer half-life may reduce recurrence rates.24 In a randomized, placebo-controlled trial comparing sumatriptan plus naproxen (Treximet) with each medication alone, the combination was superior for partial pain relief at two hours, complete pain relief at two hours, and sustained pain relief at 24 hours.2426 The fixed-dose combination pill contains 85 mg of sumatriptan, a dose not available in sumatriptan alone. According to the American Dental Association, braces are typically given to children or adolescents between the age of 8 to 14. (2016). Neurology. Preventive treatment of migraine in adults is discussed separately. [QxMD MEDLINE Link]. Neurogenically induced plasma extravasation may play a role in the expression of pain in migraine, but it may not be sufficient by itself to cause pain. Diclofenac is available as a powder or tablet and is as effective as ibuprofen.18 Naproxen has a slower onset of action but longer half-life. Migraine and risk of haemorrhagic stroke in women: prospective cohort study. Study: Efficacy, Safety, and Tolerability ofAtogepantfor the Prevention ofChronic Migraine. The results shown may not be inclusive of all physicians who may have experience with BOTOX or therapies like BOTOX in your area. 2009 Nov. 29 Suppl 2:1-6. Migraine occurs with increased frequency in patients with mitochondrial disorders, such as MELAS (mitochondrial myopathy, encephalopathy, lactic acidosis, and strokelike episodes). Read articles and watch video on the tech giants and innovative startups. The cost of Qulipta depends on your insurance coverage, but the average list price ranges from around $968 to $1,197 for a 30-day supply. [QxMD MEDLINE Link]. BMJ. [Full Text]. Cost and Savings Patient Information Healthcare Professional Site. If youre concerned about pain or discomfort, a topical anesthetic or ice can numb the treatment area. 60(7):S21-3. 7. Patients in each of the non-placebo groups experienced a decrease in mean monthly migraine days over the12-week treatment period of up to four days, with slight differences among the dosages. Some of the GLP-1 drugs have been shown to reduce the risk of further heart disease in people who have had a heart attack. JAMA. All Rights Reserved. Botulinum toxin injection for facial wrinkles. Offer good only in the USA, including Puerto Rico, at participating retail locations. In our podcast interview with 'Today Show' nutritionist Joy Bauer, RDN, we asked her about some of her favorite migraine prevention recipes. In general, braces get more expensive the longer you wear them. One study showed that among women, 20.4% of whites, 16.2% of African Americans, and 9.2% of Asian Americans met International Classification of Headache Disorders (ICHD) criteria for migraine. 2012 Apr 24. Approximately 44.5 million U.S. adults (18% to 26% of women and 6% to 9% of men) have experienced a migraine, according to 2009 data.1 Estimated annual U.S. direct costs for migraine are more than $17 billion; the costs of lost productivity and reduced quality of life are significantly higher.2 More than one-half of migraines are treated in primary care, and they are the fourth most common cause of emergency department visits.3, Migraine has well-established diagnostic criteria4 (Table 15 ). 2010 Jan. 11(1):48-52. Antihypertensive therapy seeks to prevent the complications of high blood pressure, such as stroke and myocardial infarction.Evidence suggests that reduction of the blood pressure by 5 mmHg can decrease the risk of stroke by 34% and of ischaemic heart disease by 21%, and [QxMD MEDLINE Link]. Copyright 2022 American Academy of Family Physicians. The benefit outweighs the pain for sure. BOTOX (onabotulinumtoxinA) is a prescription medicine that is injected into muscles and used to prevent headaches in adults with chronic migraine who have 15 or more days each month with headache lasting 4 or more hours each day in people 18 years and older. 47(5):614-24. Brandes JL, Klise S, Krege JH, Case M, Khanna R, Vasudeva R, et al. Bothell, WA: Lundbeck Seattle Biopharmaceuticals, Inc. February 2020. Fast Five Quiz: How Much Do You Know About Migraines? [59], The World Health Organization (WHO) estimates the worldwide prevalence of current migraine to be 10% and the lifetime prevalence to be 14%. [42] The mechanisms by which these genetic vasculopathies give rise to migraine are still unclear. FHM may be associated with cerebellar ataxia, which is also linked to the 19p locus. Please visit the Allergan site for your country of residence for information concerning Allergan products and services available there. [QxMD MEDLINE Link]. Martins-Oliveira A, Speciali JG, Dach F, Marcaccini AM, Gonalves FM, Gerlach RF, et al. The incidence of migraine without aura peaks in boys at age 10-11 years and in girls at age 1417 years. Nestoriuc Y, Martin A. Efficacy of biofeedback for migraine: a meta-analysis. [QxMD MEDLINE Link]. Neurology. Once were done, I go on with my day. Stewart WF, Linet MS, Celentano DD, Van Natta M, Ziegler D. Age- and sex-specific incidence rates of migraine with and without visual aura. 354(14):1489-96. Some of the symptoms associated with migraine headaches, such as nausea, vomiting, yawning, irritability, hypotension, and hyperactivity, can be attributed to relative dopaminergic stimulation. Share cases and questions with Physicians on Medscape consult. You should be able to resume normal activities immediately in most cases. PubMed Journals was a successful Headache. It can also be used on the forehead between the eyes. 63(12):2240-4. 2013 Jan 16. If you choose to get a more expensive type of braces, many providers like Delta Dental have you pay the difference. Neurology. Weiner et al. 2009 May. Neurology. The mechanisms of migraine remain incompletely understood. Migraine is characterized most often by unilateral head pain that is moderate to severe, throbbing, and aggravated by activity. JAMA. They will inject the targeted area between the eyebrows. Medications considered safe during lactation include acetaminophen, ibuprofen, metoclopramide, droperidol, prochlorperazine, diphenhydramine, and sumatriptan.12 Aspirin should be avoided during pregnancy and lactation.12, Triptans and other vasoconstrictors are contraindicated in patients with coronary artery disease and in specific migraine syndromes, such as hemiplegic and basilar migraines. BMC Complement Altern Med. Get clinically-studied, premium vitamins and supplements and lab tests from the people whove spent 40 years passionately pursuing healthy living. 2008 Jun. [QxMD MEDLINE Link]. 2009 Sep. 29(9):1517-27. FDA allows marketing of first device to relieve migraine headache pain [press release]. Different circulating metalloproteinases profiles in women with migraine with and without aura. 2002 Jun. Its relatively safe and noninvasive. Find the latest business news on Wall Street, jobs and the economy, the housing market, personal finance and money investments and much more on ABC News Medscape Medical News. INTRODUCTION Migraine is a common episodic disorder, the hallmark of which is a disabling headache generally associated with nausea and/or light and sound sensitivity. The vascular risk associations with migraine: relation to migraine susceptibility and progression. As a rough guideline, you can expect to pay anywhere from $3,000 to more than $10,000. Accessed: March 17, 2014. [QxMD MEDLINE Link]. All dopamine antagonists carry a risk of extrapyramidal adverse effects. Yarnitsky D, Dodick DW, Grosberg BM, Burstein R, Ironi A, Harris D, et al. [50], Migraine with aura for women in midlife has a statistically significant association with late-life vascular disease (infarcts) in the cerebellum. Latest health news. Effect of Ubrogepant vs Placebo on Pain and the Most Bothersome Associated Symptom in the Acute Treatment of Migraine: The ACHIEVE II Randomized Clinical Trial. Offer valid for up to 5 treatments over a 12-month period. Martin VT, Fanning KM, Serrano D, Buse DC, Reed ML, Lipton RB. Don't perform computed tomography imaging for headache when magnetic resonance imaging is available, except in emergency settings. Are Dental Hygienists Allowed To Do Botox? [QxMD MEDLINE Link]. All the currently available triptans (see Medication) are selective 5-HT1B/D full agonists. Is craniosacral therapy effective for migraine? In 1944, Leao proposed the theory of cortical spreading depression (CSD) to explain the mechanism of migraine with aura. The Washington Post mentioned in 2014 that knee injections of PRP can cost anywhere from $500 to $1,200 per treatment. See Migraine in Children for a pediatric perspective on migraine. Migraine. Here are others. Some providers offer an add-on orthodontic insurance plan that may offer coverage. 2003 Oct 28. Migraine headache in middle age and late-life brain infarcts. [44] pregnancy, and ovulation, Medications (eg, vasodilators, oral contraceptives 24 Suppl 1:9-160. [QxMD MEDLINE Link]. Dodick DW, Turkel CC, DeGryse RE, Aurora SK, Silberstein SD, Lipton RB, et al. [QxMD MEDLINE Link]. Certain rarer syndromes with migraine as a clinical feature generally show an autosomal dominant inheritance pattern. Though not yet approved by the U.S. Food and Drug Administration for the preventive treatment of chronic migraine, these new data offerhope for those with chronic migraine, which is defined by more than 15 headache days per month for more than three months, with at least eight of those days per month including features of migraine. Accessed: September 8, 2014. GLP-1 drugs can be used as an add-on treatment to improve glucose control when insulin treatment is not acceptable. These findings have been confirmed in a population-based study by Bigal et al. Development and Evaluation of a Machine Learning Model for the Early Identification of Patients at Risk for Sepsis. Ailani notes that the usual time from enrollment to results and submission to the FDA for approval can take 1 to3 years, depending on how long it takes for the last patient to complete the trial and how much data needs to be evaluated. Five tips on how to cook and eat to live below your migraine threshold. Although CSD is the disturbance that presumably results in the clinical manifestation of migraine aura, this spreading oligemia can be clinically silent (ie, migraine without aura). Conway S, Delplanche C, Crowder J, Rothrock J. Botox therapy for refractory chronic migraine. This disorder is caused by mutations in the CACNA1A gene located on 19p13, which codes for a brain-specific calcium channel. Botox treatments also resulted in lower costs of oral preventatives for the patients, at $313 vs. $413. Migraine treatment involves acute (abortive) and preventive (prophylactic) therapy. BMJ. Her work has been published in The Arizona Republic, America West Airlines Magazine, San Jose Mercury News, Silicon Valley Home, Spaces magazine, The Scottsdale Republic, East Bay Home & Design, and the National Migraine and Headache Awareness Month blog. 2019 Jul 1. This patient reported that these visual auras preceded her headache by 20-30 minutes. Migraine headache. Acute management of migraine: highlights of the US Headache Consortium. Medication overuse headache can occur with any analgesic, including acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen, and aspirin. How Do I Prevent the Next Migraine Attack? [23]. "This may help patients decide which gepant preventive is right for them if both are on the market at the same time. Unlike metal and ceramic braces, they can easily be removed for eating or brushing your teeth. 47(5):654-61. Acute treatment aims to eliminate, or at least prevent the progression of, a headache. Neurology. high quality, cost effective, and innovative treatments; new diagnostic techniques, and; other topics related to the prevention, diagnosis, and treatment of disorders of the skin, hair, and nails; More. By participating in the BOTOX Savings Program, you acknowledge and agree to the terms and conditions of this program. Offer valid only for BOTOX and BOTOX treatment-related costs not covered by insurance. [QxMD MEDLINE Link]. Research suggests people hesitate to tell their doctor, but that you can find relief with treatment, including cognitive behavioral therapy or biofeedback. 2001 Jan 6. Efficacy of coenzyme Q10 in migraine prophylaxis: a randomized controlled trial. [QxMD MEDLINE Link]. Accessed: July 15, 2013. Please see the Terms & Conditions for additional details. [QxMD MEDLINE Link]. [Full Text]. eNeura Therapeutics. [QxMD MEDLINE Link]. Antihypertensives are a class of drugs that are used to treat hypertension (high blood pressure). [Full Text]. [QxMD MEDLINE Link]. A BOTOX Savings Program check will be provided upon approval of a claim and may be sent either directly to you or to your authorized healthcare provider who provided treatment. Strong evidence supports the use of acetaminophen and oral NSAIDs such as aspirin, diclofenac, ibuprofen, and naproxen as first-line treatments for mild to moderate migraine attacks.8,11,12 In placebo-controlled trials, acetaminophen was less effective than NSAIDs but did not cause gastric irritation or antiplatelet effects.12,15 The recommended dose is 1,000 mg. Aspirin is effective at doses of 1,000 mg but has the greatest risk of gastric irritation.12,16 Ibuprofen is often chosen for its availability and tolerability. 289(1):65-9. Mutation in the neuronal voltage-gated sodium channel SCN1A in familial hemiplegic migraine. The neurochemical basis of the CSD is the release of potassium or the excitatory amino acid glutamate from neural tissue. Assigning your BOTOX Savings Program benefit to your healthcare provider is not required to participate in the program. Our experts continually monitor the health and wellness space, and we update our articles when new information becomes available. The initial randomized placebo-controlled phase 3 study enrolled nearly 900 episodic migraine patients who experienced, on average, about eight migraine days per month. Here we break down the process and examine who makes a good candidate. One study showed that among persons who had migraine during childhood, 62% were migraine free for more than 2 years during puberty and as young adults but that only 40% were still migraine free at age 30 years. [QxMD MEDLINE Link]. AbbVie also looked at cost differences between Botox treatments for migraines and CGRP mAbs. If you log out, you will be required to enter your username and password the next time you visit. Kelman L. Women's issues of migraine in tertiary care. The risk of migraine is increased 4-fold in relatives of people who have migraine with aura. This corresponds to approximately 18% of females and 6% of males. [46] Instead, it has been hypothesized that ingestion of chocolate may be in response to a craving brought on at the start of a migraine, as a result of hypothalamic activation. [14] One can draw a parallel with the patient with epilepsy who similarly has interictal neuronal irritability. Acute treatment aims to reverse, or at least stop the progression of, a headache. Pain Med. Available at http://www.eneura.com/clinical_trials.html. Available at http://www.medscape.com/viewarticle/831261. [Guideline] American Academy of Neurology. [QxMD MEDLINE Link]. Nutr Rev. [19], In an experimental study, acute hypoxia was induced by a single episode of CSD. Vyepti (eptinezumab) [package insert]. During the procedure, your provider will use a thin needle to administer 3-5 injections of botulinum toxin type A. In the current International Headache Society categorization, the headache previously described as classic migraine is now known as migraine with aura, and the headache that was described as common migraine is now termed migraine without aura. But with Qulipta, again, the key difference is the dosing flexibility. Klein E, Spencer D. Migraine frequency and risk of cardiovascular disease in women. (See "Preventive treatment of episodic migraine in adults".) Migraines without aura are the most common, accounting for more than 80% of all migraines. Latest health news. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. Neurology. 2013 Aug 23. MacGregor EA. [Full Text]. People who suffer from migraine headaches are more likely to also have cardiovascular or cerebrovascular disease (ie, stroke, myocardial infarction). 2004 Jan. 44(1):2-7. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. [QxMD MEDLINE Link]. FHM type 1 is characterized clinically by episodes that commonly include nystagmus and cerebellar signs. The pharmacologic properties, potential adverse effects, cost, and routes of administration vary widely, allowing therapy to be individualized based on the pattern and severity of attacks. : Janssen Pharmaceuticals, Inc., Titusville, NJ. Get medical help right away if you have any of these problems any time (hours to weeks) after injection of BOTOX: There has not been a confirmed serious case of spread of toxin effect away from the injection site when BOTOX has been used at the recommended dose to treat chronic migraine. 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