Botox ® for Migraine

Botox® (onabotulinumtoxinA) is a medication that works by reducing abnormal nerve signaling involved in headache disorders.

For headache treatment, Botox ® is not cosmetic. It is injected into specific muscles of the head and neck using a standardized medical protocol.

Botox ® has an established role in treating chronic migraine.

There is growing evidence supporting the use of Botox ® for other specific headache disorders (e.g., refractory trigeminal neuralgia).

Botox ® has not been shown to be effective for episodic migraine, or tension-type headache.

Botox ® works by:

• Reducing release of pain-related neurochemicals (including CGRP)

• Decreasing sensitivity of pain pathways in the head and neck

• Lowering the likelihood that migraine circuits are activated

Although injected into muscles, Botox’s ® primary effect in headache is neurologic, not muscular.

Botox ®:

• Does not suppress the immune system

• Does not cause sedation or brain fog

• Does not circulate systemically in meaningful amounts

Chronic migraine

Botox ® is an evidence-based, guideline-supported treatment for chronic migraine.

Clinical studies show Botox ® can:

• Reduce the number of headache days per month

• Decrease migraine severity

• Improve quality of life

• Reduce reliance on acute medications

Benefit often increases over repeated treatment cycles.

Off-label use 

Botox ® may be considered off-label for other headache disorders when supported by evidence, such as:

• Refractory trigeminal neuralgia

• Certain refractory headache syndromes

• Headache with prominent muscle-related pain components

Off-label use is:

• Carefully discussed

• Individualized

• Based on symptom pattern, prior treatments, and available data

Not all headache types are appropriate for Botox ®.

Botox ® for headache is delivered using a standardized injection protocol. For chronic migraine, the only proven protocol is the PREEMPT protocol.

• Small injections are placed across the:

  • Forehead

  • Temples

  • Back of the head

  • Upper neck

  • Shoulders

• Typically 31 injection sites

• Injections use a very small needle

Most people describe the sensation as brief pinpricks.

When does Botox ® start working?

• Botox ® does not work immediately

• Improvement often begins within 1–2 weeks

• Full benefit is usually assessed after 2 treatment cycles (about 6 months)

Common, temporary side effects

• Mild neck or shoulder soreness

• Injection-site discomfort

• Head tightness or pressure

• Fatigue for a day or two

Less common side effects

• Temporary eyelid or eyebrow droop

• Neck weakness

These effects are usually mild and reversible.

Botox ® is typically given every 12 weeks (3 months).

Botox ® can be used:

• Alone

• Alongside oral preventive medications

• Alongside CGRP-targeted therapies (from a medical perspective although limited by insurer's policies)

Insurance plans may limit coverage of simultaneous advanced therapies, which we help navigate.

Yes.

Botox ® use during pregnancy or breastfeeding is an area of growing evidence.

Our clinic:

• Does offer Botox ® during pregnancy in selected cases

• Uses an individualized, evidence-informed approach

• Reviews available safety data and uncertainties

• Coordinates with obstetric care when appropriate

Botox® does not affect the immune system and does not cross the blood–brain barrier.

In Ontario, insurance coverage for Botox ® often requires:

• A diagnosis of chronic migraine

• Prior trials of at least two oral preventive medications

• Documentation of headache frequency and disability

We assist with:

• Insurance forms

• Prior authorizations

• Treatment sequencing