Botox is a very well-known and popular drug approved by the FDA for the treatment of a variety of muscle-imbalance problems and for the elimination of wrinkles of the brow. It is effective for these purposes because it weakens muscles wherever it is injected. This effect of Botox is its only known action. Weakness typically lasts 2-3 months; permanent weakness is not a reported risk of this drug, and it seems to have no direct pain-relieving ability like morphine or Demerol. However, many patients with chronic head pain have reported relief when Botox is used to weaken the muscles of the brow and/or those at the base of the skull. These muscles contain branches of nerves that provide feeling to the face and scalp. They are part of the “nerve system” that also signals the pain of headache. If we can reduce or eliminate your head pain by weakening these muscles, we are justified in strongly suspecting that your pain is arising from chronic muscle-related irritation of those nerves. Essentially, a Botox block gives you a “preview” of how life might be if those muscles were not able to compress and irritate the nerves they contain.

Steroid-containing nerve blocks have been used for many years to treat a variety of problems, ranging from back pain to carpal tunnel syndrome. Many plastic surgeons and other hand specialists have had extensive experience with these drugs in treating common hand disorders, and success rates have been so high that many insurance companies and HMOs will not authorize surgery for carpal tunnel surgery until steroid blocks have been tried as a first means of treatment. Steroids are anti-inflammatory drugs that don’t weaken muscles in the doses we use, but they reduce swelling and irritation surrounding nerves and nearby tissue. . Our steroid blocks also contain a local anesthetic, which usually lasts 6-8 hours. It is very similar to the anesthetic your dentist might inject for uncomfortable dental procedures. This drug is used to make your nerve block more comfortable but it also gives us a view, for a few hours, of how you might feel when the sensory nerves in the region of your nerve block are not allowed to signal pain. In that regard, this period of 4-6 hours after a steroid/anesthetic block is a sort of preview of how you are likely to feel when those nerves are not irritated.

We use Botox blocks to test for nerve irritation in areas where compression is most likely due to muscle action or spasm, and we use steroid blocks to test for nerve irritation in areas where muscles are not suspect but other irritation can occur. Often we will first suggest a steroid block if the pain appears to arise from the back of the head or the upper neck, as these blocks are less-expensive and the likelihood that they will be helpful is quite high. If a steroid block is not effective in eliminating head pain here, we will often suggest a Botox block to test the possibility that the problem is arising from muscle-related nerve compression. In the forehead, the likelihood is high that the muscles of the brow are causing nerve compression, and we will often use Botox first in that region.

While the actions of Botox and steroids are quite different, it is important to understand that they are similar in the fact that they both typically take 5-7 days to completely show their effects. Botox blocks in the forehead region have the extra advantage of improving “worry lines” of the brow, and that improvement is often seen within a few days, but elimination of pain is often slower. It is important to record your progress in the headache log you keep, allowing us both to accurately understand your response to your nerve block. If you received a steroid block, which also contains a local anesthetic, your pain status in the first 4 hours after your block is also particularly important to note.

After your nerve block, whether you received Botox or steroids, your injection site(s) will probably be moderately painful for 1-2 days. This is usually similar to the pain experienced after a tetanus shot. You may use ice packs or heat (both are worth trying) in the regions, though neither should be used for 6-8 hours if we have used a local anesthetic and the region is numb. You will be able to drive and perform all of your usual activities immediately after your block, but you may wish to plan a restful day and concentrate on your comfort. All of your usual medications may be continued without interruption, and your block should not interfere with any other aspect of your health care. We will schedule a return appointment to review your response to the block, but invite you to contact us sooner if you have questions or concerns.

Your response to nerve blocks is very important, as it gives you, and us, the best possible preview of how you might feel if the external branches of the sensory nerves of your face and head are functioning normally. In addition, your response tells us which specific type of the surgery we offer is most likely to give you more-permanent relief. If you benefit from a steroid block, we will suspect that your head pain is arising from an area in the back of the head where muscles are absent, but nearby blood vessels and lymph nodes can “pinch” nerves. Therefore, we will discuss a “superficial occipital neurolysis” with you. If steroids aren’t helpful to you, but Botox gives you significant relief, we’ll discuss a “deep occipital myomectomy” or a “corrugator muscle resection” with you. These are the technical names of the procedures we perform in the back of the head and/or the forehead to remove small muscles that surround the small nerve branches we are addressing.

In summary, we use both Botox and steroid blocks as diagnostic tests to give us, and you, a preview of how our surgical procedures could be helpful to you. If we can’t give you significant relief of your head pain with these blocks, this will be apparent to you: for us to consider a block result “favorable”, improvement is quite dramatic. You will be very impressed by the difference we have made.

FREQUENT QUESTIONS REGARDING NERVE BLOCKS

Are Botox and steroid nerve blocks painful?

They do hurt, usually about the same level of pain as a flu shot or a tetanus shot. However, some patients find them to be more uncomfortable. This may be related to adding a new pain stimulus to a region that is already sending strong pain signals to the brain. The whole blocking procedure only takes a few minutes, though, and we're very experienced with it: Dr. Austad has placed over 4,000 blocks for patients with head pain, and has never experienced a serious complication.

Can I take my own pain medication before my steroid or Botox nerve block?

Yes, though you should avoid anything containing aspirin or other drugs that might cause bleeding problems for at least two weeks before your blocks. If your medication contains codeine or other narcotic drugs, you must have someone drive you to and from the office to assure your safety.

Can I be “put to sleep” for my nerve block?

Yes, though this requires the services of an anesthesiologist and is significantly more expensive. Moreover, undergoing any type of anesthesia adds a slight risk of problems related to the drugs involved, and we prefer to avoid these when possible. If you’re highly concerned, we’ll discuss anesthetic options with you.