BOTOX in Headache Clinic
Who is eligible?
-Patients with chronic migraine - experiencing >15 days a month of headache, with >8 meeting criteria for migraine, AND patients must have trialed AT LEAST 3 preventive therapies and still have frequent headaches >15 days a month
-Triptans/NSAIDs/tizanidine do not count as they are not preventives
-This information must be clearly documented in your progress note in order to apply for insurance authorization
-If you think the patient is a candidate for botox, please discuss with the patient during neurology clinic first to determine if the patient is amenable, and then refer to headache clinic
-If the patient was just recently seen in general neurology and being referred to headache clinic, allow for at least 2-3 months after your visit before scheduling, as authorization for botox is a slow process that takes time
How to Obtain Botox Authorization for Patients:
-At the end of each clinic before you leave, you should email the following information to Kristy Archer kristy.archer@mountsinai.org and Erica DaCosta erica.dacosta@mountsinai.org, and cc Dr. Pace and Dr. Green. This is for both new botox auth as well as a reauth to continue botox for a patient. Please when asking Kristy/Erica to obtain auth specify if the patient is a new botox auth or a repeat auth:
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Can you please obtain reauth for the below patients? Please see information below:
Name:
MRN:
DOB:
Botox Dose: 200 units every 3 months [this is the same for everyone]
Failed medication trials: [this should be a list of every preventive failed, ie topiramate, propranolol etc - triptans do not count]
Dx: Chronic Migraine without aura, ICD-10: G43.711 [this is the same for everyone]
Next Clinic Appointment: [so that auth can be including their next appointment date]
This should be done no later than 24 hours after headache clinic as authorization takes time to obtain, and the nurses need to send the info and documentation immediately after clinic.
How to Document Botox in EPIC:
1. All notes for patients who are on botox should have a documented list of past preventives used and current preventives/abortives used. This is important for obtaining authorization.
All botox patients should have documentation in their notes of some improvement in headaches while on botox, or if applying for the first time, the patients should have a documented frequency of >15 days per month for 3 months prior to botox.
For the procedure note, use “dot botoxres” phrase in your progress note, which should look like this:
PROCEDURE:
Botulinum Toxin Injections
The risks, benefits, and alternatives of Botox injections for headaches have been discussed and reviewed with the patient, and all questions have been answered to the patient's satisfaction. The patient agreed to proceed and informed consent was obtained. Time out performed.
The patient was placed in the seated position in a chair. 200 units of Onabotulinum Toxin A were reconstituted in preservative-free saline and drawn up into 1mL syringes such that the final concentration was 5 units per 0.1mL.
200 unit administration protocol of Onabotulinum Toxin A.
Lot # 1:
Lot # 2:
Designated areas were prepped using an alcohol swab prior to injection.
Standard injection sites:
Corrugator 10 units divided in 2 sites bilaterally
Procerus 5 units in 1 site
Frontalis 20 units divided in 2 sites bilaterally
Temporalis 40 divided in 2 sites bilaterally
Occipitalis 30 divided in 2 sites bilaterally
Cervical paraspinals 20 units divided in 2 sites bilaterally
Trapezius 30 units divided in 2 sites bilaterally
Follow the Pain:
Temporalis 0 units divided into 2 sites bilaterally
Occipitalis 0 units divided into 2 sites bilaterally
Trapezius 0 units divided into 2 sites bilaterally
Total Units:
The patient tolerated the procedure well and it was performed without complication. Verbal discharge instructions for the procedure were given.
Advised the patient on precautions and side effects post Botox procedure:
Advised there may be some redness/swelling/mild bruising and pain at the site of injections, that can last hours to a few days. Can use analgesic medication as needed.
Advised may experience a mild amount of tenderness or a stinging sensation following injection.
Advised to wait 24 hours prior to yoga, any prolonged inverted positions, any strenuous activity or exercise that may induce sweating, to avoid rubbing the forehead.
Advised to avoid rubbing or massaging the forehead for 24 hours.
Pre and post procedure diagnosis: chronic migraine
Procedure safety checklist completed: yes
Specimens sent: none
Estimated Blood Loss: <1 ml