Cosmetic Surgery Tips

Botox for migraine injection sites

We’ve all heard of Botox, responsible for generations of smooth foreheads in Hollywood. But Botox has also brought relief to many people who suffer from chronic medical conditions. In 2010, Botox was approved for use with chronic migraine, and many patients are reporting success. What do you need to know before considering it?

In this guide, we review the aspects of Botox for migraine injection sites, does botox for migraines change your face, How do you dilute Botox for migraines, and What is the difference between Botox and Botox for migraines?

What Type of Headache Responds Best to Botox?

Botox is only FDA-approved for chronic migraines, which means headache on 15 or more days a month. “The more frequent the headaches, the better the patient does with Botox,” says Dr. Andrew Blumenfeld, Director, The Headache Center of Southern California. Botox is not recommended for patients who experience fewer than 15 headache days a month.

What is Botox?

Botox is a form of botulinum toxin, a neurotoxin produced by the bacteria that causes botulism. When the Botox botulinum toxin is purified and used in tiny doses in specific areas, it temporarily reduces muscle contractions for approximately 3 months.

How Does Botox Work?

Botox is injected around pain fibers that are involved in headaches. Botox enters the nerve endings around where it is injected and blocks the release of chemicals involved in pain transmission. This prevents activation of pain networks in the brain.

Botox prevents migraine headaches before they start, but takes time to work. “I look to the second and third treatments to maximize effects,” says Dr. Andrew Blumenfeld. “Patients see in

creasing benefit with an increase in the number of treatment cycles.” One treatment lasts for 10-12 weeks, and patients reported that two Botox treatments reduced the number of headache days by approximately 50%.

Who Uses Botox for Migraine?

The FDA approves the use of Botox to treat chronic migraine in adults who are age 18 or over. Botox is considered an “off-label” treatment if it’s used for children or adolescents. This means that a doctor can prescribe it, but insurance companies might not pay for it.

Finding a Doctor Who Treats Migraine with Botox

If you want to try Botox for migraine, you should look for a headache specialist or neurologist. We recommend using your insurance’s doctor listing, Yelp, or the American Migraine Foundation’s doctor database.

Dr. Laura Banks, neurologist at Natividad Medical Center, suggests asking prospective doctors where they learned to give Botox, and how many times they’ve given it. “You’re looking for a lot of experience,” she says. Dr. Andrew Blumenfeld suggests asking doctors how many injections they will give, and where they will give them.

Getting Botox Treatment Paid for by Insurance

In general, the FDA-recommended dosage of 155 units costs between $300 to $600 for each treatment. Because Botox is FDA approved for chronic migraine, it’s covered by most plans, including Medicare and Medicaid. Allergan offers a “Botox Savings Card,” which offers patients reduced fees.

Please note that before your insurance company will approve Botox as a treatment for your chronic migraine, you typically must have tried and failed to respond to two other preventative treatments. These might include anti-seizure medications, antidepressants, or blood pressure medications that are typically used to prevent migraine.

What is Botox Treatment Like?

When you receive your first Botox treatment, expect the appointment to take about 20 minutes. The doctor uses a very small needle that feels like a pinprick. He or she injects small amounts of Botox into shallow muscles in the skin. Each treatment typically involves 31 injections in seven key areas of the head and neck.

The most common side effect from the Botox shots is a sore neck, and we recommend using an ice pack to reduce the discomfort.

It can take up to six months to see the maximum benefit from Botox. In the meantime, you can continue your regular medications with no risk of a drug interaction.

Botox for migraine injection sites

Botox, or botulinum toxin, is a common remedy for migraines that you can’t get rid of by other means. Perhaps you’re scared of needles or curious about where your doctor will insert the needle for this treatment.

This article will explain how Botox alleviates migraine symptoms. We’ll also detail the procedure the doctor will use when providing the injection, including the locations they may use.

We make it easy for you to participate in a clinical trial for Migraine, and get access to the latest treatments not yet widely available – and be a part of finding a cure.

Botox for migraine

Most people have heard of Botox, but we often associate it with celebrities and others looking to reverse the effects of aging. While the substance is most famous for its cosmetic use, it has several medicinal uses. Let’s take a closer look at Botox and how it works.

What is Botox?

Botox is a specific type of botulinum toxin, and it’s the same toxin found in food that causes botulism. Botulinum toxin has several subtypes, which we’ll discuss later. The term toxin might sound scary, and without the aid of a medical practitioner, it can be.

However, the injections doctors give you are a small enough dose that they won’t harm you. Instead, these injections target neurotransmitters that are causing unwanted effects in the body. These toxic effects are temporary, making the treatment safer than it would be otherwise, but it also means you’ll need repeated doses to continue feeling the benefits.

How does Botox prevent migraine?

The exact method of interaction between Botox and migraine pain isn’t fully understood. Scientists know that the substance is a potent neurotoxin. Researchers believe that Botox works by preventing the release of certain peptides responsible for migraine pain and blocking neurotransmitters responsible for pain sensation.

Types of botulinum toxin for migraine

There are seven primary types of botulinum toxin. These are labeled A through G. Doctors only use A and B in a medicinal capacity. The different types are related but distinct from one another.

Other than type C, all types are neurotoxins. They have different strengths and preparations that prevent them from being used interchangeably.

The A group has four subtypes, and there is one B-type in clinical practice:


This is the botulinum toxin under the brand name Botox. Doctors commonly use onabotulinumtoxin/A for treatments, perhaps because it has the highest safety profile of all botulinum toxins. This type of botulinum toxin uses crystallization to form a powder, which healthcare providers mix with a liquid to make an injection.


Most commonly known under the brand name Dysport, abobotulinumtoxin/A has the second-best safety profile of the major botulinum toxins used in clinical settings. While Botox relies on crystallization to separate it, Dysport uses a process known as chromatography. The procedure dissolves a substance into a solvent and carries it through various materials.

Because of the way different chemicals react to various materials, separation occurs.


The final common A-type of botulinum toxin is incobotulinumtoxin/A under the brand name Xeomin. Like Dysport, Xeomin uses chromatography. This type has fewer side effects than Dysport but has lower efficacy than both Dysport and Botox.


Prosigne is a Chinese formulation of A-type botulinum toxin. It uses¹ bovine gelatin, which can result in allergic reactions or immunological responses. Prosigne isn’t FDA-approved, so doctors cannot use it in the United States.


The only B-type botulinum toxin commonly used in clinical settings is rimabotulinumtoxin/B under the brand names Myobloc and Neurobloc. This type fell just after abobotulinumtoxin/A in the safety profile test. While the other types mentioned come in powder form, this type comes in a liquid form.

Researchers believe its acidic pH is responsible for the increased discomfort of this type versus the others.

Injection sites

Typical Botox treatment for migraine pain involves several injections across seven sites. The most common treatment involves 31 injections. Some treatment options call for additional injections to better target the areas where the pain occurs. This could result in up to 39 injections for full treatment.

Here are the sites doctors typically choose:

The lower part of your forehead, right above your nose

The procerus is a small muscle between your eyebrows and above your nose. This is the muscle you use when you’re angry and pull your eyebrows downward. Your doctor will make a shallow into this thin muscle right between the eyebrows. Often, this is the first injection that a doctor will make during the treatment.

The lower part of your forehead, near the inside edge of each eyebrow

The corrugators are muscles above each of your eyebrows. Like many other muscles in your face, these are very shallow muscles, so the injection will not be very deep. Your doctor will use one injection on each side of the face, close to the inside of your eyebrow. For safety, your doctor will inject upward, away from the eyelid.

Between your shoulder and neck on your right and left

Your trapezius muscle is the big muscle that sits between your shoulders and your neck. The doctor injects three of the shots into your trapezius. They will visually divide the muscle into three parts and inject each one. Your doctor will repeat this process on the other side of your body, resulting in six total shots in this location.

Between the back of your head, behind each ear

The occipitalis muscle is on the back of each side of the head. It’s between the bony prominence (occipital protuberance) and the back of each ear. Your doctor will give three injections on each side into this muscle: The first will be in the middle of the muscle, and the next two are above and to either side of the first injection, forming an imaginary V shape on each side.

Cervical paraspinal muscle group

The cervical paraspinal muscle group is in the neck region. Your doctor will give you four more injections in this area, two on each side. The first injection is just off the midline of the cervical spine below the bony prominence of the occipital bone. The second is diagonally above that, toward the ear.

Although the muscle in this area is thicker than the facial muscles, your doctor will likely use a shallow injection to avoid weakness or pain in the neck.

The middle of your forehead, above each eye

Most of your forehead contains the frontalis muscle. This is the site for the next set of injections. There are two shots on each side, for four shots total. Each injection is near the top of the forehead.

Your doctor will place the first injection in the upper third of the forehead, above the corrugator injection sites. The second injection will be to the side of it, in line with the outer edge of the cornea (the transparent front part of the eye).

Behind each temple, above the ear

Covering your temples is a muscle known as the temporalis. At this location, above the ear, your doctor will give you four injections on each side of the head for eight total injections.

The first injection will be above your ear, with a second slightly above that. The third injection will be between those two positions vertically but closer toward your temple in the front. The final injection will be behind the second one. The doctor repeats the process on the other side.

Botox side effects

Although the word toxin in the name may be intimidating, studies² show that Botox injections for migraines are well-tolerated. Compared to similar treatments, Botox has a low discontinuation rate due to side effects. However, like all drugs, the potential for side effects exists.

Common side effects include:

Injection site pain or discomfort

These symptoms usually go away shortly after the treatment. Contact your doctor if you feel that something isn’t right after receiving your Botox injections.

Some people experience allergic reactions to Botox. More severe side effects can occur in rare cases when the toxin spreads beyond the desired location and causes symptoms similar to botulism. The most common sign of toxin spread is difficulty swallowing and muscle weakness.

If you experience swelling of your tongue or throat, blurry vision or difficulty speaking or swallowing, get immediate medical help.

Receiving Botox injections

Typically, because of the inconvenience and expense of receiving dozens of shots, Botox injections are a choice you and your doctor will make after trying easier and more affordable methods, such as over-the-counter or prescription painkillers.

If you and your doctor decide that Botox injections are the right treatment for your migraines, you’ll be able to get all of the injections in one sitting. However, it may take 2-3 treatments before you notice a reduction in migraine severity. You’ll typically have treatments every 12 weeks.

does botox for migraines change your face

Botox’s effect on migraine attacks was discovered coincidentally when people who were having Botox injections to lessen lines and wrinkles in their foreheads noticed that their headaches were improved. That’s when so-called off-label uses of Botox began, and its manufacturer began pursuing approval by the U.S. Food and Drug Administration (FDA) and insurance reimbursement for medical uses.

Dubbed as the “little neurotoxin that could” by USA Today, Botox now boasts sales of well over $1 billion for its manufacturer, Allergan. Many of us who start to see our migraine-furrowed forehead lines show up in our thirties think: Hey, maybe Botox for migraine could help me too.

Botox for migraine is the same medication as Botox for wrinkles, but before you say, “Heck yes!” at the next Botox party or med spa, be sure you know what you’re getting into. (Especially since unscrupulous people try to sell counterfeit Botox!)

Now widely used for more than a dozen different conditions, from teeth grinding to sweaty palms to spasticity to vaginal spasms, Botox is a megadrug. And to think that not so long ago, botulinum toxin meant a bulging can of poison. It’s now deemed quite safe in the hands of a medical professional, and about half of all uses are cosmetic.

Not Just for Wrinkles: What to Expect From Botox for Migraine

If you’re struggling with chronic migraine and want to know whether to try Botox, it’s wise to know what not to do. Here’s what you need to know:

1. It’s Approved Only for Chronic Migraine

“Why can’t I get Botox for migraines?” asks a woman who loses 10 days a month to her attacks. Good question. Whether or not it will help you really depends on the frequency of your attacks.

The Headache of Navigating Insurance for Migraine Treatment

Latest Device Now FDA Approved for Teens with Migraine

18 Natural Migraine Remedies

“If you are looking for evidence-based data to support Botox for episodic migraine or tension-type headache, it doesn’t exist,” said Robert Cowan, MD, FAAN, professor of neurology and chief of the Division of Headache Medicine at Stanford University, in an interview with Migraine Again.

The FDA has approved Botox only for chronic migraine (15 or more headache days per month), which affects about 2 million people. Episodic migraine (fewer than 15 headache days per month), on the other hand, affects more than 40 million people.

Clinical Evidence for Botox for Chronic Migraine

The FDA’s decision to approve Botox for chronic migraine (but not episodic) was based on the existing evidence, namely two clinical trials called PREEMPT. The two PREEMPT trials included only patients with chronic migraine.

These two pivotal, placebo-controlled trials showed that Botox was associated with two fewer headache days a month (6 to 7 days vs. 8 to 9 days for placebo) for people with chronic migraine and chronic daily headache.

Real-world evidence confirms the results in the PREEMPT studies, too. More than half the people who used Botox for CM in this study reduced headache and migraine days by at least 50% and reported improvements in pain-free days and quality of life.

Botox may be a good option for adolescent patients who haven’t had success with other treatments, too. Although Botox is not FDA approved for patients under 18, it has been shown to be safe for patients ages 11 to 18 in clinical trials, and some doctors have used it with their pediatric patients with migraine.

For episodic migraine or tension-type headache, on the other hand, the clinical proof just isn’t there. A recent meta-analysis of 17 studies looked at data from nearly 3,650 patients, of whom 1,550 (46%) had chronic migraine and the remaining had episodic migraine.

Some Clinicians Will Prescribe Botox for High-Frequency Episodic Migraine

“I think clinical experience trumps any meta-analysis,” said Cowan. “High-frequency episodic patients who failed multiple preventive therapies were not specifically studied in the PREEMPT trial, but my clinical experience has shown Botox to be equally effective for HFEM and chronic migraine.”

What about tension headaches? Cowan warns, “However, I strongly doubt Botox would be effective or appropriate for episodic tension-type headache.”

Our Advice

Track your attacks so you know exactly how many days per month you’re losing to migraine and headache symptoms.

2. The Clinical Benefit Is Comparable to CGRP

Botox is considered a preventive, not abortive, medication for debilitating migraine attacks. Even for those with chronic migraine, though, the effect may only be “small to modest” when compared with placebo, says Jeffrey Jackson, MD, author of a 2012 study.

“In terms of efficacy, my clinical experience with Botox and CGRP monoclonal antibodies has been roughly the same,” said Cowan. “Once the monoclonal antibodies have been around longer, we will know more, but it is too early to tell.”

If Botox and CGRP monoclonal antibodies are such good preventive treatments on their own, do they work better together? After all, experts often recommend layering treatments as part of a multimodal treatment plan for people whose CM has been resistant to improvement with single preventive treatments.

The answer is complicated. Right now, there are no large-scale studies proving that Botox and the CGRP monoclonal antibodies are safe to use together. Smaller peer-reviewed real-life studies and anecdotal reports from headache centers suggest that the combination is successful for many people with CM and has few side effects. If you want to try both treatments at the same time, talk to your doctor about your potential risks and benefits.

One big hurdle may be insurance coverage for both treatments at the same time. If your doctor can document your responses to other treatments, you may have a stronger case for having both Botox and a CGRP monoclonal antibody covered simultaneously.

Our Advice

Read the research for yourself. Compare those clinical results with the new anti-CGRP preventive medications.

3. Botox for Migraine Side Effects Include an Aching Neck

Botox for migraine side effects aren’t widespread (less than 10% of patients are affected), but they’re painfully real.

Botox has saved my life. Went from chronic every day for four and half years to 4 a month now. Been on them 5 years and I’ve never looked back. Only thing is the first bout did nothing, so if you do try and they don’t work at first try again. —Geraldine W.

It, unfortunately, didn’t work for me. It had the opposite effect and increased the frequency and severity to all day every day. It took almost 2 years to get back to where I was before the injections. —Michelle L.

Helped the actual head pain, but not any other chronic migraine symptoms. Migraine hijacks so much more than pain in my head. —Jennifer M.

I have been doing it for a year I have gone from 5 migraines a week to 1 to 5 a month!!! I literally can’t begin to explain the life-changing difference it has made for me. —Megan M.

Work great at first but it really doesn’t work anymore two years later it’s not doing much. —Carolyn G.

I have been having Botox for migraines for about 4 years now and it certainly helps, I still get them but not as bad or as long, occasionally I get a killer one but nothing like as often as I used too, I do know when I am close to being due for Botox as my head starts getting bad again. It doesn’t stop them but it makes them bearable and livable. —Virginia C.

Our Advice

Read the comments from the community on Migraine Again’s Facebook page. And remember: every person can have a different response to the same medication.

4. You May Look a Bit Different

Many people are drawn to Botox for the perceived cosmetic benefit, but the Botox for migraines injection sites are different from those used for cosmetic purposes. So you can’t count on looking like a movie star if your goal is migraine prevention.

As anyone who’s tried Botox for migraine (or wrinkle reduction) will tell you, your forehead may feel heavier after the injections are done, where the nerve endings are in essence frozen.

In my case, my usually expressive face didn’t track with my emotions: no raised eyebrows of surprise or delight or shock. So people told me I looked tired, overlooking the grape-sized purple bruise smack dab in the center of my forehead (see No. 5 below).

“Yes, I have noticed my eyelids have drooped, I can live with that for now but am looking into surgery for that since it is a ‘medical’ issue,” said Silja P. on Migraine Again’s Facebook page.

If it works, though, looking a bit tired or different is a small price to pay for a few more days each month of migraine freedom and function.

5. Physician Experience Matters

Sadly, I learned this lesson the hard way. First, I tried Botox in the hands of my neurologist when it first came on the market, and he didn’t have much experience administering it (hence the big bruise).

Later, I tried a highly recommended plastic surgeon, wrongly assuming that his extensive Botox experience trained him to treat migraine, too.

At each American Headache Society meeting, Allergan invests in educating the attending physicians on the most effective injection sites and methods for chronic migraine patients. Find one here.

Who trains those doctors on Botox for chronic migraine? World-leading experts like Bronwyn Jenkins, MD, in Australia and Andrew Blumenfeld, MD, in the United States. Discover the proper procedure and much more during their Migraine World Summit interviews in 2018 and 2019, respectively.

Our Advice

Find one of those Allergan-trained doctors and ask them exactly how many Botox for migraine procedures they’ve done.

6. It Takes Six to Nine Months to Give It a Fair Trial

To give Botox for migraine a fair trial, you’ll need to undergo the injections two to three times over a six- to nine-month period. It takes some time for the muscles to relax, apparently, and change the way the pain receptors work.

Some patients report that their side effects vary each time they have it done. But relative to oral preventive medications like Topamax (topiramate) and Elavil (amitriptyline), Botox for migraine has very few side effects.

Even better, there is good evidence that when it does work, Botox has a cumulative effect and works better and better with each cycle. What’s the success rate of Botox for migraine? It may help more than half the people who use it to reduce their number of headache days by 50% or better.

How do you dilute Botox for migraines

Let’s talk about Botox for migraines. Botox (Onabotulinum Toxin A) has been a game changer for the treatment of chronic migraine. I’ve frequently seen it give people their life back (as they often tell me), restored their ability to function normally in all aspects of life, and pulled them from the dark rut of chronic migraine that people get stuck in as described here. It can assist in stopping medication overuse headache (rebound headache), which often accompanies and drives chronic migraine. Once Botox is working, patients can often wean off daily pills being used for migraine prevention.

Botox is a neurotoxin made by the Clostridium botulinum bacteria. When ingested, it is the same toxin that causes botulism, a severe form of food poisoning. Yes, this concept freaks many patients out. However, the amount used for chronic migraine is a much lower potency and dose, and when used correctly, can be an amazingly helpful medication.

Botox is produced by Allergan (now an AbbVie company), and was FDA approved for the treatment of chronic migraine in October 2010 following this study. Since that time, it has technically remained the only truly FDA-approved treatment specifically indicated for the treatment of chronic migraine prevention. With that said, the array of standard preventive migraine treatments as well as the CGRP monoclonal antibodies are also commonly used for all spectrum of migraine from episodic migraine (14 or less headache days per month) to chronic migraine (15 or more headache days per month).

Most insurances will generally require a failure of at least 2 categories of standard preventive medications before they will approve Botox coverage. With that said, 98% of commercial insurance plans cover Botox, and it’s actually fairly easy to get it approved through Medicare and Medicaid. In addition, Allergan provides a Botox Savings Program which will cover $1000 of any out of pocket costs per treatment and $4000 per year. So for most patients, Botox treatments can be covered 100% between this savings program and insurance coverage.

It is my hope that this blog can provide the education and guidance in optimizing Botox procedure precision and technique (based off the PREEMPT chronic migraine protocol with tweaks) for medical providers to give optimal results, as well as a great educational overview on Botox for patients so they have a better idea of how Botox works, the best pattern to get (which can be shared with their doctors), and what to expect in terms of how long it takes to work, suggested duration of use, side effects, and safety in pregnancy and breastfeeding.

How does Botox work for chronic migraine?

The primary and most important mechanism of how Botox works for chronic migraine is by disrupting the electrical communication signals of pain between nerves involved in migraine pathophysiology and ultimately stopping these signals from reaching the pain circuitry of the brain. Thus, it prevents the activation of pain and migraine networks in the brain, including disruption of CGRP activity, which has become a central focus in most of the new migraine medications on the market such as the gepants and CGRP monoclonal antibodies.

Botox does this by entering the nerve endings and cleaving a specific protein called SNAP25. The inactivation of this protein leads to the inhibition (stopping) of neurotransmitter and neuropeptide release from the nerve endings and the prevention of the electrical pain signals from firing off. It also causes temporary (3 months) paralysis of the muscle being innervated by those nerve endings. Thus, it also causes the muscles to chemically relax (by chemically paralyzing them). For example, this muscle relaxation is why Botox works for facial wrinkles. It causes the thin muscular layers to relax to where they can’t contract (and wrinkle the skin), and wrinkles go away. Interestingly, one of the early clues that led to Botox being studied for migraine treatment was that women who were getting Botox were also noticing that they would have much less migraine headaches. This eventually led to further trials looking at Botox treatment to prevent migraine.

How long does it take for Botox to work, how long should Botox be used for chronic migraine, and how effective is Botox?

Botox typically starts to kick in within 1-2 weeks, but many times patients say they feel it working within a day or so after they have been getting it for a while. Botox lasts about 3 months. Patients commonly notice some gradually increasing migraines 1-2 weeks or so before getting to the 3-month wear-off window. I have quite a few patients that can actually get a good 4 months out of a treatment, but that is not common. If patients consistently start to come in for their 3-month Botox appointment and migraines are not starting to increase significantly as it is wearing off, I will often try to extend the next treatment to 4 months. If they are still doing well at that time, I suggest that we try stopping it to see if the migraines have entered and sustained into a more infrequent episodic pattern. It can always be restarted if needed in the future. It should be avoided from repeating much earlier than 3 months because early dosing before the prior dose has worn off can lead to cumulative medication and subsequent side effects. This can also increase the risk of antibody formation against Botox which can make it less effective over time.

It is recommended to give the Botox a minimum of 2 rounds 3 months apart to get a good sense of how much benefit one can likely expect. The reason for this is that in the trials after the 2nd round, there was continued upwards improvement. With that said, I typically expect (and usually see) good improvement with the 1st round. Some doctors advocate for giving a full year (4 rounds separated by 3-month intervals) to see the full effect. However, I typically tell patients if they have gotten absolutely no benefit after the 2nd round that we should move on to another treatment option. On average, Botox decreased chronic migraine days by 8-9 days per month, as opposed to placebo which was 6-7 days per month.

What are the Botox side effects?

A great thing about Botox is that it is so well tolerated with much lower side effect risks compared to many of the medications used for migraine prevention. I’ve done thousands of Botox treatments and have never seen someone have a bad reaction or an allergic response. In general, I tell patients there may be some tenderness in the injection sites temporarily. It is a very tiny needle injected just under the skin in a specific standardized dosing pattern and takes only a few minutes. Infrequently, patients can have a temporary flu-like muscle achiness for a day or so after the Botox. If the Botox spreads into some of the muscles in the forehead, I always mention that there is a risk of eye lid droopiness (ptosis), although I have not seen this occur. A more extensive list of potential side effect risks (which are extremely rare and I’ve not seen), can be read on the Botox for chronic migraine Allergan website. Caution is also advised if Botox is mixed with bupivacaine or other “caine” medications as this can be a fairly common allergy of some patients to these medications.

Can I get Botox with the Covid-19 vaccine?

The short answer is that we need to gather more data on this, so check back periodically for updates. However, this hasn’t been a reported issue thus far. There is no current evidence for an interaction between the Covid-19 vaccine and Botox injections, the same as any other vaccine. This has also been stated by the American Migraine Foundation. Patients receiving Botox were not excluded from the Covid-19 vaccine trials. There is no evidence at this time that Botox can not be used along with receiving Covid-19 vaccination, nor does it need to be delayed or timed any differently in relation to receiving Covid-19 vaccination. Most physicians feel that there should theoretically be no interaction or contraindication to receiving both because they are entirely different proteins with different mechanisms of action. The Covid-19 vaccine stimulates the immune system to form antibodies against the virus, should you encounter it. However, Botox does not have any significant influence on the immune system (it does not cause immunosuppression, etc). Rarely, the immune system of some patients can form neutralizing antibodies against Botox, and this can weaken Botox’s effectiveness in decreasing migraine frequency and severity. However, this issue really has nothing to do with the mechanism and how the Covid-19 vaccine works. So, it is not felt that the Covid-19 vaccine will lessen the effectiveness of Botox, nor will Botox lessen the effectiveness of the Covid-19 vaccine. The topic of Covid-19 headache, Covid-19 vaccination, and the use of Botox or CGRP monoclonal antibodies (Aimovig, Ajovy, Emgality, Vyepti) is discussed further here.

Notably, there have been just a few isolated reports of dermal fillers used in dermatology causing some facial swelling in association with Covid-19 vaccination. These reports were with the Moderna Covid vaccine and resolved with steroids and/or antihistamines.

Is Botox safe in breastfeeding and pregnancy?

Historically, Botox has generally been avoided and saved as a last resort option in these scenarios, and often still is. The longstanding concern for using Botox during breastfeeding is based in theoretical concern that the Botox could seep into the breastmilk and effect the baby, although this really hasn’t been reported. It has been shown that Botox is not detectable in the blood after intramuscular use, so excretion into breast milk is considered unlikely. In fact, there was a reported case of a lactating woman who had foodborne botulism. However, when the breastmilk and infant were analyzed, neither showed any botulinum toxin at all, and the infant was safely breastfed. With this in mind, the doses of Botox used medically are much lower than those that cause botulism. Therefore, the amounts ingested by an infant, if any, are suspected to be small and not cause any adverse effects in breastfed infants. Regardless, for extra precaution, it is suggested to breastfeed before the Botox treatment, store some milk, and then 24 hours after the treatment before breastfeeding again (so plenty of milk should be saved ahead of time).

Similar to breastfeeding, there are no published studies on Botox use during pregnancy. So, it is still often avoided if possible and saved as a last resort option. However, since Botox is not detectable in the blood after intramuscular use it is not expected to affect fertility or pregnancy outcomes, and an Allergan safety database report has remained consistent with this conclusion. Botox is designated as a US Food and Drug Administration (FDA) pregnancy category C medicine, meaning that there are no well controlled studies in pregnant women, so it should only be used during pregnancy if the benefits outweigh the potential risks. The good thing is that the majority of women naturally get significant migraine improvement during pregnancy (especially 2nd and 3rd trimester) and it is not uncommon to hear migraines go away during pregnancy. So many times preventive therapy may not even be necessary.

What is the best way to do Botox for chronic migraine?

If you are going to get Botox, you need to make sure you are getting the optimal dose, pattern, and technique. A headache specialist will have the most refined technique and experience doing Botox injections, and should be sought out to ensure you are getting the best technique if one is available near you. If you cannot find a headache specialist near you, make sure whomever you get the Botox injections from does them very frequently with good reviews. Other doctors that may do Botox injections as alternatives if a headache specialist is not available include some neurologists, pain management doctors, and primary care doctors, as well as some physician assistants (PA) and nurse practitioners (NP). With knowledge of the precise pattern and technique as outlined below, and enough practice, anyone should be able to do Botox procedures proficiently in the office. It is an easy procedure and can provide dramatic improvement in chronic migraine pain and disability.

The pattern that should be used and modeled after is the PREEMPT protocol (Phase III REsearch Evaluating Migraine Prophylaxis Therapy), based off the trial that led to FDA approval for Botox in the prevention of chronic migraine. The pattern of injections described and illustrated below are of the PREEMPT protocol. However, sometimes I will tweak some of the injection sites depending on the patient’s pain pattern. For example, if their chronic migraine is 100% one sided, I may give additional on that side in the temporalis muscle and occipital regions, taken from the opposite side where they have no or minimal pain. If they have prominent occipital neuralgia, then I will give additional dosing over the correlating occipital nerves.

The PREEMPT protocol used 155-195 units of Botox. Botox vials come in 200 units (either two 100 unit vials or one 200 unit vial). For almost all patients, I use the full 200 units and spread the additional 5 between the trapezius muscles, or use it somewhere else where the pain is most common such as over an occipital nerve in the back of the head. I may use slightly less in patients that have no pain at all in many areas of the head or shoulders and have a very localized pain (such as just in one side of the forehead), are elderly, or young in late teens or early twenties and have not had it before.

Regardless, many of the spots the patient may receive it in, they may not have much pain. However, there should still be some degree of symmetry for muscle weakness balance and to still hit potential areas of chronic migraine input that aren’t recognized as overly painful areas by the patient. I also prefer to gently and briefly rub in the Botox spots right after injection. This helps to distract the brain from the immediate injection pain, flattens the area so it doesn’t leave the Botox as a small lump, and helps to slightly spread the area of coverage for the Botox to work. I like to hit as many of those sensory nerve fibers (the primary target of Botox for chronic migraine) and neuromuscular junctions as possible with each injection.

The depth of injection isn’t supposed to be deep. So if the needle is hitting the bone, it is too deep and will be less effective. The target of the injections is just below the skin and into the top of the muscle. This is where the sensory nerves travel (carrying migraine/headache/pain signals to the brain) and neuromuscular junctions lie (where the nerves that innervate and control the muscles enter the muscle). The sensory nerves traveling just above the muscular layer is really the main target of the Botox for chronic migraine.

So, I like to be strategic where the Botox goes. If your doctor or health care provider is just rapid firing it in (which is always more painful), hitting the bone, you have Botox running down your face, it is more painful than when you get it done with other providers, or you get eye-lid droopiness (ptosis), you should think about moving on to someone with a more refined technique. I see patients all the time that have been getting Botox with me and then they have to get a round sometimes with a different provider for some reason. They invariably say it doesn’t work as well, is significantly more painful, and afterwards they refuse to get Botox with anyone else besides me following that experience. There is validity in that. I’ve spoken to one of the main doctors/scientists involved with developing the original Botox pattern, technique, and dosing for chronic migraine and he agreed that technique and spreading the Botox around strategically and precisely will certainly lead to a better result as opposed to just quickly and less carefully “throwing the injections in”. In fact, they were originally thinking of adding more spots to further spread the Botox around to hit more nerve endings, but they settled on the current pattern to make it easier and less complex to do.

The Botox trials were done by mixing Botox in 0.9% normal saline (basically, sterile water). However, I will sometimes mix the Botox instead with a numbing medicine such as bupivacaine or ropivacaine. The Botox typically takes about 1-2 weeks to start kicking in. So the addition of a numbing medicine can provide some temporary relief as the Botox is slowly kicking in. Many times chronic migraine patients are significantly tender throughout their head to the point the hair can “hurt” and feel sore. This is called allodynia, or central sensitization, and is a common finding in chronic migraine. The additional numbing medicine can also provide some temporary relief throughout some of these sore areas. In most patients, they have tenderness over their occipital nerves in the back of the head (occipital neuralgia), and this can also provide some additional temporary relief over these nerves. Many chronic migraine patients also have tenderness throughout their shoulders, and many have associated fibromyalgia. This can also be helpful with some temporary relief through these muscles, and in a way is like getting trigger point injections at the same time.

What is the difference between Botox and Botox for migraines

Receiving Botox injections is a common treatment for medical conditions, such as excessive sweating, eyelid spasms, cervical dystonia, and chronic migraine. Injections of these toxins have been an effective preventative measure to control headaches, allowing the patient to have a more improved quality of life. Since it’s also a popular wrinkle treatment, some wonder if a Botox procedure for chronic migraine can also reduce the appearance of frown lines.

So can Botox for chronic migraine remove frown lines? It may somehow reduce its appearance because it also targets the muscles causing the lines. But you may not receive the results you want because it’s not dedicated to that purpose, and it also contains more doses than the medications plastic surgeons use for frown lines, called Botox Cosmetic injections. Consult your doctor if you want to resolve both your chronic migraine and facial lines in one treatment session.

Could Botox for Chronic Migraine Reduce the Appearance of Your Frown Lines?

Your injections for chronic migraine may somehow reduce the appearance of the lines between your brows or glabellar lines – these shots also target the muscles responsible for the lines, such as the corrugator and procerus muscles. Besides, experts first discovered Botox as a preventative measure for migraine when women noticed relief from headaches after receiving injections for their deep wrinkles and forehead lines.

But since Botox for chronic migraine isn’t really done for removing your facial wrinkles at once, you may not receive the results you want for your 11s. The muscles for your wrinkles won’t receive the injections at the right angle, technique, and dose because the treatment is dedicated to chronic migraine only.

Botox for chronic migraine and Botox Cosmetic only have the same active ingredient, botulinum toxin type A. The only difference is that they don’t have the same dose because Botox Cosmetic has lesser units. Another thing you need to note is that Botox for chronic migraine does not have the same dose for your vertical lines, giving you the risks like having droopy eyelids or droopy eyebrows, having an almost expressionless face, and more. 

You can still have your frown lines removed during your botulinum toxin injections if you’ve carefully discussed it with your doctor – they’ll also know how to proceed with both procedures with fewer risks. Patients can receive Botox for chronic migraine and Botox Cosmetic simultaneously, as long as the doses they’ve received are just below 400 units in 3 months. You might have a risk of experiencing serious side effects if you’ve received too many doses of Botox.

How Botox for Chronic Migraine Smoothens Lines and Wrinkles

The botulinum toxin type A from Botox and Botox Cosmetic is derived from bacteria called clostridium botulinum. These are the same poisonous toxins you might find in spoiled food, but if purified and injected into the muscle in small doses, it proves to be safe and helpful. These toxins work well for cosmetic treatments and treating several medical conditions.

How Botox Works

Generally, Botox relaxes the muscles to stop muscle contractions. This action of botulinum neurotoxin is used as a treatment for wrinkles and as prophylaxis to chronic migraine.

For Migraine

Botox has shown positive results in clinical trials for several medical conditions, like cerebral palsy, muscle spasms, dystonia, and more. Its success in critical trials has earned its FDA approval also as a prophylaxis for chronic migraine in 2010.

Chronic migraine is a condition involving headaches for 15 days – 8 days of which are migraine headaches. Patients with chronic migraine also experience neck pain, nausea, severe migraine headache, vomiting, and sensitivity to light and sound.

Botox serves as a prophylaxis for chronic migraine because the toxins interrupt the nerve impulses from the brain that send pain and trigger headaches. The botulinum toxin does this by relaxing the muscles between the brain and the nerve endings at the spinal cord.

Chronic migraine triggers headaches when the brain releases signals that transmit pain to the nerve endings. Botox blocks these signals when injected into the muscles around the face, head, and neck.

Experts are still studying why patients experience chronic migraine, but it’s usually caused by the following:

Chronic migraine may also be just a symptom of a pre-existing medical condition. Botox only serves as a preventative measure and does not treat the root causes of your throbbing headache. But it already provides the patients immense relief because of the reduced frequency of headaches, enabling them to move forward with other treatments for their condition.

For Lines and Wrinkles

Botox Cosmetic is one of the popular treatments for reducing the appearance of different types of wrinkles and lines, such as horizontal forehead lines, eye wrinkles, and other dynamic wrinkles and deeper lines. This solution to wrinkles gives patients a more youthful appearance because Botox relaxes the muscle movement that causes wrinkles.

Where to Receive Injections  

Some Botox injections sites for chronic migraine also target some of the muscles causing forehead wrinkles. Because of this, your treatment may also affect your vertical lines, but it might not give you desired results.

For your chronic migraine, the proper injection placement is the following:

When receiving Botox injections for chronic migraine, it’s important to go to a licensed and experienced injector to ensure accurate administration.

For removing the vertical lines between your eyebrows, your plastic surgeon might inject Botox Cosmetic in the following areas:

Botox for chronic migraine treatment may also target the muscles causing vertical lines. Because of this, you may notice a few changes in your frown lines, but you might not experience perfect results – it needs the right dose and the right angle. 

How Much Units of Botox You’ll Receive

Botox for migraine has higher doses or units than Botox Cosmetic. A vial of Botox comes in single-use vials containing 100 to 200 units, while Botox Cosmetic comes in 50 to 100-unit vials.

For chronic migraine, patients will receive the following units:

All in all, patients will receive 155 units of Botox to ease their chronic migraine. 

The units of Botox Cosmetic you’ll receive for the vertical lines between your eyebrows may vary depending on their severity and your aesthetic goals, but plastic surgeons will usually recommend 20 units.

How to Receive Botox for Migraine and Wrinkles at the Same Time with Fewer Risks

Botox for chronic migraine also targets the muscles for your frown lines, reducing their appearance. But it’s important to note that Botox for frown lines would need an accurate injection site or angle for it to have the results you want. You’ll also have risks of serious side effects due to the units of Botox you’ll receive.

The good thing is that you can receive injections of the toxin for chronic migraine and worry lines in one procedure. You just need to inform your doctor and take the necessary steps, like having them assess you to ensure the proper units and injections sites. It’s important to seek a highly trained injector.

1) Consult Your Doctor

If you want to get Botox Cosmetic for your frown lines on top of your chronic migraine procedure, make sure you consult with your doctor. This allows them to come up with a treatment plan that takes into consideration both your aesthetic goals and your medical condition. 

2) Assess Medical History

Your doctor will assess your medical history and confirm if you’re qualified to receive the needed dose of Botox for chronic migraine and frown lines. They will also screen you if you can handle that number of Botox units because you’ll receive many doses for chronic migraine.

Leave a Comment

Your email address will not be published. Required fields are marked *