Botox for Migraine

According to the World Health Organization (WHO), headache disorders are among some of the most common nervous system disorders, and around 15% of the world’s population experiences migraine attacks.¹⁹ It’s estimated that up to 5% of people diagnosed with migraine meet the criteria for chronic migraine: having a headache at least 15 days per month, with at least eight of those days featuring migraine symptoms, for over three months.

While there are various preventive medications for chronic migraine on the market, many come with a host of side effects, making them uncomfortable or undesirable. Of these preventives, Botox injections typically come without systemic side effects and do not require a daily or even monthly dose. Botox has been shown to be an effective preventive medication for chronic migraine, with over a million people receiving treatment as of 2023.

If you’ve been wondering about Botox treatment for chronic migraine, read on for a primer on this popular treatment, and get prepared for your next doctor’s appointment.

What is Botox?

Botox comes from the toxin onabotulinumtoxinA, produced by the bacteria Clostridium botulinum. The pharmaceutical company Allergan, owned by AbbVie, treats and purifies this botulinum toxin to create a protein that, when injected, stops muscle contractions. It does this by interfering with the release of neurotransmitters at the neuromuscular junction, where the nerves and muscles meet.⁹ This interrupts the pain pathway. Once the protein is created, the dose is calculated and put into vials containing 100 or 200 units, and it is called Botox.

History of Botox as Treatment for Chronic Migraine

Botox is commonly associated with cosmetic use, which minimizes facial wrinkles and fine lines. While cosmetic use accounts for half of all Botox treatments, it has also been used as a medical treatment for various conditions besides migraine, such as strabismus (crossed eyes), since the 1970s.

Botox Medical Treatments

In 1998, Beverly Hills cosmetic surgeon Dr. William Binder documented that several patients who received Botox on their foreheads and around their eyes reported improved migraine attacks. This led to several scientific studies centered on Botox’s potential for treating migraine.

For example, the PREEMPT study, ending in 2008, resulted in Botox being FDA-approved in the United States for the prevention of chronic migraine in 2010.³ Botox was also approved for migraine prevention by the Medicines and Healthcare Products Regulatory Agency (MHRA) in the United Kingdom that year.⁶ The Therapeutic Goods Administration (TGA) in Australia quickly followed suit with its formal approval of Botox for chronic migraine in 2011.¹

How Botox Helps Prevent Migraine Attacks

Botox is used differently depending on the condition being treated. Receiving treatment for one condition will not necessarily affect another condition. Dr. Andrew Blumenfeld, a primary researcher in the PREEMPT clinical trial, says that Botox is injected shallowly into the muscle at “31 dedicated injection sites, all of which are around pain fibers … since these sites are at sensory nerve-ending sites, they won’t have the effect as if injected into cosmetic sites.”

The PREEMPT clinical trial produced the injection site locations and eventually led to the FDA approval of Botox as a migraine preventive treatment. The purpose of injecting at these sites is to suppress the peripheral pain nerves connecting the brain with painful stimuli involved in migraine. Since the mechanisms of migraine are complex and not fully understood, it is hard to fully understand what makes Botox work. 

Often, a person with migraine will try to control their triggers to minimize the number of episodes. However, many individuals with migraine are easily triggered by everyday things that are often unavoidable, such as a glare, loud environment, or strong smell. Botox decreases this hypersensitization and allows for better control of environmental triggers.

Figuring Out if Botox is a Good Fit

For 30 years, researchers have been searching for biomarkers indicating whether Botox will be successful for individual patients.¹⁵ While more research is needed to say who specifically will benefit from Botox, several factors can indicate that it may not be the correct preventive medication for some. 

1. Episodic migraine is not currently considered a good fit for Botox; this is because the injection sites developed during the PREEMPT study were found while focusing on individuals with chronic migraine with a stable headache history.³
2. Individuals who have had a craniotomy, or skull surgery, should inform their provider. If a person has an implanted stimulator in their scalp, the injector must know where to avoid damaging the leads.¹⁰
3. Botox should be avoided if there is an infection at the proposed injection site or if the individual is hypersensitive to any botulinum toxin preparation.¹²
4. Individuals who have Myasthenia Gravis, Lambert-Eaton Syndrome, Amyotrophic Lateral Sclerosis (ALS), and neuropathies are also not considered candidates for Botox.¹²

Defining Successful Preventive Treatment

Of the PREEMPT study, Dr. Blumenfeld states, “We typically saw a 50% response rate. This means that the study participant felt 50% better.” One in four study participants saw a 75% response rate. Participants also frequently noted dramatic improvement in their neck and shoulder pain. Many of the physicians who spoke with the Migraine World Summit have seen even better results among their patients than those of the PREEMPT Trial.¹³ Their reported results were sometimes as good as 75% of patients expressing a marked decrease in headache days and migraine attacks.

The FDA recommends repeating Botox every 12 weeks. However, 44-62.9% of patients who receive Botox to treat their chronic migraine report noticing a wearing off around weeks 9-10.¹⁵ Some patients have benefitted from a shortened time window between injection sessions.

Getting Access to Botox Treatment for Migraine

Insurance Requirements

Access to Botox through insurance companies involves several administrative hurdles before being considered. First, an individual must meet the FDA standards for chronic migraine.⁷  This includes each attack lasting at least four hours per day.

Many insurance companies in the U.S., as well as the U.K.’s National Institute for Health and Care Excellence (N.I.C.E.), require the person with migraine to try two to three different classes of preventive treatment without seeing results.⁸ Frequently, insurance companies will then need prior authorization for the treatment, which must be updated every year.

While Botox may be considered an expensive preventive option, Botox can be cost-saving compared to emergency room visits, urgent care visits, imaging studies, or other medication costs. It does not take many emergency room visits to pay for Botox treatment. Getting approved for migraine preventive treatment with Botox can be challenging and time-consuming, but the option may be a viable one for many.

One thing to note: Many insurance companies will deny Botox if a patient already uses a CGRP medication. This differs across the healthcare industry. It is recommended that you speak to your insurance company to get their criteria. 

There is a Botox savings program in the United States for those with commercial insurance. This program helps cover some of the costs of the medication and procedure. It is designed to help cover the out-of-pocket costs after insurance.

Finding the Right Physician

Finding the right physician to administer Botox is crucial to getting good results from Botox for chronic migraine. Ideally, look for a headache specialist or neurologist who has been specifically trained in the use of Botox for chronic migraine. A dermatologist or cosmetic surgeon focused on cosmetics would not place the injections at the nerve sites needed to treat chronic migraine. A good place to start is Allergan’s search tool for finding a Botox Specialist. It links to physicians who are experienced in treating chronic migraines with Botox. 

Before undergoing preventive treatment with Botox, ask questions such as: 

1. Does the provider inject the full 31 injection sites? 
2. What dose does the provider use? 
3. How many patients has the provider treated for chronic migraine? 
4. Have their patients experienced drooping eyelids or neck pain? 
5. What percentage of patients decides to continue the preventive treatment?

How Botox Treatment Feels

Choosing Botox can be scary, as people fear the pain of repeatedly getting injected in the head and neck. While no injection is entirely comfortable, going into the appointment with informed expectations can help ease the fear.

The needles used for Botox are slightly thicker than an acupuncture needle and about half an inch long. With both the small needles and the injection’s shallowness, some say it feels like a very fast pinch with some sting. The Botox administrator usually uses conversation as a distraction; for most, this is enough for the injection to go unnoticed.

The exception is usually when the patient is in a pain flare, perhaps during an active migraine attack or allodynia. Since the pain structures of the head and neck are already hypersensitive, the injections can cause more discomfort, with some patients describing it as similar to a bee sting. While the discomfort usually passes quickly, here are a few things that can help mitigate some of this discomfort:

1. Take Tylenol before the appointment.
2. Ask for a local anesthetic.
3. Use ice to numb the injection sites before and after the injection.

Potential Side Effects

In a conversation with the Migraine World Summit, Dr. Bronwyn Jenkins discussed the most common side effects of Botox. “The most common is minor skin irritation, such as redness, a small bump at the injection site, and some bruising. Flu-like symptoms, such as fatigue, chills, and muscle stiffness, have also been reported.” These side effects usually fade within a few days of onset. 

Rare side effects include:¹⁵

• Difficulty lifting eyebrows, droopy eyelids (less than 3%) 
• Headache, neck stiffness, and muscle spasms (4%) 
• Discomfort in the neck muscles (9%) 

Many of these side effects are short-lived, and having a well-trained Botox administrator can minimize many of them.

There are some very rare and severe effects of Botox such as: difficulty swallowing, speaking, or breathing. This can be due to weakening of associated muscles, can be severe and result in loss of life. You are at the highest risk if these problems are preexisting before injection. Swallowing problems may last for several months.

There is also the risk of the Botox toxin spreading to surrounding tissues after the treatment. This can lead to: loss of strength and all-over muscle weakness, double vision, blurred vision, drooping eyelids, hoarseness or change or loss of voice, trouble saying words clearly, loss of bladder control, trouble breathing, and trouble swallowing.¹²

Safety Considerations and Misconceptions

Since Botox has become widely known and accepted, there are a few myths and fears that many have when considering Botox for treating migraine. These include:

The Bottom Line

Botox is considered a safe and effective migraine preventive option for many. Due to its high success rates, it has proven popular with both patients and providers. With over a million people with chronic migraine having received Botox, it is safe to say that Botox is a preventive option that deserves more attention.