My name is Dr Ziv Peled. Welcome to the blog for my practice, Peled Migraine Surgery. My work as a Plastic Surgeon at Peled Migraine Surgery.has given me the experience needed to treat nerve and migraine issues here in San Francisco.

Several people have recently asked about the long-term effects of Botox treatment.  Happily or unhappily (depending on your perspective) this will be a relatively short post as very little is known about the long-term effects of repeated Botox injections.  There are likely a number of reasons for this fact. First, keep in mind that Botox is used for many different clinical conditions such as chronic headaches, blepharospasm (spams of the eyelid - the condition for which Botox was first developed and studied), spastic paresis in cerebral palsy and of course for cosmetic reasons. Secondly and because of the first reason, Botox is used in many different doses, places and frequencies making its long-term effects hard to study.  Even for chronic migraines, there are many different treatment algorithms (i.e. dosages and patterns of injection) amongst clinicians using Botox. Third, there are now three FDA approved versions of botulinum toxin type A (Botox® made by Allergan, Dysport® made by Ipsen, and Xeomin® made by Merz) each with slightly different formulations and hence clinical properties.

One of the few truly long-term follow-up studies I have found regarding botulinum toxin type A (in this case Botox®) was out of Jordan, Turkey and the University of Cincinnati.  In this study, chart reviews were performed on 32 patients who were being treated for hemi-facial spasm and blepharospasm and had had at least one Botox injection annually for at least 10 years (some patients had been treated for 20 years).  The findings demonstrated a need for a slightly higher dose of Botox to be effective over time and a decrease in the number of adverse effects (i.e. complications) over time. No life-threatening or systemic complications were reported, only localized ones likely relating to the function of the drug at the site of injection. Several other studies with follow-up between 6-15 years have found similar results.  The latter finding is likely a function of greater experience treating patients after many years and improved injection techniques.  The former finding can be related to a number of potential causes.

Prolonged treatment with botulinum toxin type A has been shown to result in the development of neutralizing antibodies which are thought to decrease the efficacy of the toxin.  Risk factors for the development of such antibodies are the formulation of the toxin, the frequency and dosage of the injections and the conditions for which the injections are being used.  Decreased efficacy (and hence the need for higher doses) may also be a reflection of the progressive nature of the disease being treated.  In other words, if the nerves are progressively injured by the disease process, they may require higher doses of Botox for clinical effectiveness. The take home message would be that Botox appears to be relatively safe and effective in long-term use although very few studies have been done to test this concept formally and none with occipital neuralgia.  Therefore, in my hands botulinum toxin type A remains a diagnostic test which, if effective, means that no more botulinum toxin type A needs to be injected - the patient is a candidate for decompression.  After all, in ON we are talking about a mechanical compression of the nerve(s) by a physical structure (muscle, fascia, blood vessels) and no amount of medicine will make that go away.

For more information on the effects of Botox, and how Migraine Surgery can help relieve Migraine symptoms and pain, visit www.peledmigrainesurgery.com today, and call (415) 751-0583 for an appointment.  Contact the author at This email address is being protected from spambots. You need JavaScript enabled to view it..