Botox for migraine is now a common treatment. Botox is indicated for chronic migraine and can potentially be claimed on insurance for migraine prevention.
You might be wondering how does an injection of Botox into wrinkles around my face help with migraine?
As with many other drugs used for migraine, Botox wasn’t invented to treat migraine. People using Botox for other purposes started reporting benefits in their migraine condition. After enough case reports, eventually a clinical trial was established to see if there was any merit to these patient examples.
Find out what it is, how effective Botox could be and what risks or side effects you should be aware of before trying Botox for migraine.
What is Botox?
According to a recent article 84% of people don’t know what’s in the injections that are given for Botox.
Botox is a type of Botulinum toxin medically known as OnabotulinumtoxinA. It’s a purified protein produced by a bacteria.
Once this purified protein enters the nerve it breaks the protein strand. Once this protein strand is broken, chemical signals from the nerve to the muscle or to other nerves are blocked.
This block is temporary, it is not permanent. Botox can effectively weaken a muscle for a period of 3 to 4 months. (1)
The chemical signals blocked are blocked are mostly those responsible for muscle contraction. (2)
Just about everyone has heard of Botox for cosmetic purposes. As we get older a few unwelcomed wrinkles tempt a growing number of people to get Botox to help them look younger.
But there are actually many legitimate medical uses for Botox than the general public is aware of.
Isn’t Botox just a beauty treatment?
Cosmetically Botox works by blocking the nerve signal to the muscle. This leads to muscle relaxation which is why a wrinkle may be smoothed out. But this is not actually how it works in migraine.
Since the 1970s Botox has been used to treat a variety of medical conditions. Today there are at least 20 conditions where Botox may be used, some of which have not been approved by medical authorities or the FDA (i.e. used off-label).
Common uses for Botox include:
- Cervical dystonia – severe neck muscle spasms
- Blepharospasm – an uncontrollable eye twitch or muscle spasm
- Severe and excessive underarm sweating
- Eye alignment or fixing ‘cross-eyes’
- Bruxism or teeth grinding (used off-label)
- Overactive bladder
- Chronic migraine – note: this has been approved for use by the FDA.
Botox for migraine
Like many other migraine treatments it’s discovery was accidental. Botox was originally discovered when patients reported an improvement in their migraine condition whilst taking Botox for cosmetic reasons.
Botox was approved for migraine in 2010 when Allergen, a supplier of Botox, presented evidence to the FDA from two studies showing a decrease in the number of headache days in patients with chronic migraine whilst undergoing Botox treatment. (3,4)
Why Botox helps with migraine is not fully understood.
Sensory nerves carry pain impulses. They also secrete chemicals such as CGRP. CGRP has been shown to be a strongly implicated in the cascade of migraine symptoms. When Botox enters the muscle, the muscle acts as a container to keep Botox around the sensory nerve, allowing it absorbed into the nerve. Once in the nerve, it decreases the release of CGRP and other chemicals involved in migraine. (9)
When Botox is used cosmetically, it works specifically on the muscle. For a muscle to contract, the nerve releases a chemical messenger called acetylcholine. Acetylcholine is a neurotransmitter which sends signals from one neuron to another. In this case, acetylcholine attaches to cells in the muscle which causes them to contract. When Botox is injected the release of acetylcholine is blocked which prevents the contraction of the muscle.
Abnormal muscle contraction is reduced by Botox which allows the muscle(s) to become less stiff. This aspect of Botox might help with neck muscle stiffness which is commonly seen in patients with chronic pain.
What to expect
Over 500,000 patients in the USA have now been treated with Botox for chronic migraine.
If you’re getting Botox, you’re getting lots of quick short-needle injections.
There needs to be a minimum of 31 injection sites over your head and neck for migraine. A specific migraine protocol strictly instructs the administering doctor exactly where to insert each needle. These injection sites target the sensory nerves involved in the cascade of a migraine attack. This migraine protocol was established in clinical trials that involved thousands of patients.
It’s a good idea to understand the areas of these injection sites not only so you know what to expect but so that you can ensure your doctor follows them. If the migraine protocol isn’t followed it can compromise the effectiveness of your treatment.
The injections may take around 15 mins with most injections feeling like a small pinch. A short needle is used and all the injections are superficial, they are not deep injections. Expect the injections around the forehead and eyebrows to be a little more uncomfortable than the rest.
5% of patients can develop a headache after the treatment is delivered. The most common symptom is neck pain which is experienced by 9% of patients. (3)
You will typically require 2-3 rounds of injections to confirm whether Botox will work for you or not. That’s up to 9 months before you may experience any meaningful improvement.
Some migraine patients can respond within the first month, while others may require 3 treatments before they can confirm one way or the other. If, after the third treatment you don’t have an improvement, then it is unlikely to help in any further attempts.
Botox doesn’t interact with the usual preventative headache medications so those may be continued during Botox therapy with the approval of your doctor.
If you respond successfully, Botox can help you experience a significant reduction in migraine frequency per month provided treatment is ongoing. It may also assist in reducing the severity and duration of your migraine. (7)
Will it make you migraine free? According to Dr. Andrew Blumenfeld, Director of the Headache Center of Southern California suggests “that this result occurs only in a small percentage of patients, it should not be expected”.
GET A LIST OF PROVEN MIGRAINE PREVENTATIVE TREATMENTS. FREE FOR A LIMITED TIME
Botox Evidence & Results
Studies began originally in the mid 1990s to see if Botox could improve headaches. Several large, quality trials were conducted for Botox with several types of headache and tested several different types of injection. It took 10 years to establish the current injection protocol and to identify the ideal patient which is someone who has chronic migraine. (8)
Two Phase 3 clinical trials recruited 1,384 patients to test Botox against placebo. These trials were called the PREEMPT trials for Phase 3 Research Evaluating Migraine Prophylaxis Therapy.
The results showed the Botox significantly outperformed placebo.
The placebo showed a reduction of 6.4-6.9 headache days per month versus the Botox treatment which showed a 7.8-9.2 fewer headache days per month. Both results were measured after 24 weeks. (7)
Like other migraine studies, the placebo factor was significant. Still, based on the results, a migraine doctor might expect an average of 7 to 9 less headache days per month with their patient after 24 weeks on Botox (or 2 treatments).
Botox has not been proven to work for the treatment of migraine headaches that occur 14 days or less per month or for other forms of headache.
Challenges to Botox for Migraine
Several criticisms have been voiced about Botox for chronic migraine. (6)
- Critics of Botox for chronic migraine have argued that the actual reduction of headache days in terms of reduced headache days greater than placebo is small from the studies. This criticism looks at the total population of patients in the clinical trials which includes both the responders and the non-responders to the treatment. In patients who do respond, there is a significant benefit that is comparable to the most effective migraine preventive treatments.
- Some have criticized the PREEMPT trial design as focusing on medication overuse headache (MOH). Although patients with medication overuse (MO) were allowed in the trial, patients whose headaches were escalating and had MOH not MO were excluded. MOH is not the same as MO. The PREEMPT trials did not contain patients with MOH and escalating headaches.
- Botox is expensive.
- Side effects included headache, droopy eyelids, neck stiffness & muscle spasm.
Other migraine specialists have observed that results from Botox vary. Some patients experience no change at all whilst others experience a very significant reduction in headache days. (6)
Interestingly, the UK’s drug regulatory agency mentioned in its approval that Botox helps avoid the systemic side effects of pills and its safety profile was better overall.
Costs for Botox varies by country and practice. Another factor which affects how much the treatment gets back is how much you can claim from your health insurer.
Health insurance rarely covers the full cost, but you may be able to get a co-contribution from your health insurer if you qualify for the treatment as a chronic migraine patient.
If you have commercial insurance, the manufacturer co-pays up to $500 per treatment for the co-pay. This means that there is no out of pocket cost for these patients.
If you have government insurance, the cost is fully reimbursed resulting in no out-of-pocket expenses.
US based Allergen offer funding program you can find out more about if your insurer does not cover Botox for migraine or if you don’t have insurance. You can find out more about that here.
For a single Botox visit you can expect the cost to be around $700 before any rebates. Depending on your health insurer, you may be able to your out of pocket expense down to $300-500.
Similarly, one 3-4 month treatment may cost up to £500-600 pounds. Botox treatment on the NHS will cost around £350.
Should I try Botox?
Botox sales are over a billion dollars a year. Half of that comes from medical conditions such as chronic migraine.
Botox may be worth considering if you:
- have frequent disabling headaches consistent with a chronic migraine diagnosis
- have trouble remembering to take your medication
- have severe side effects from your current medication
- don’t have current effective treatment(s)
In cases of migraine, prevention is important and there are also effective non medicinal preventative therapies or strategies available. Botox is not the only choice, there are many other choices such as biofeedback, devices, and medications which have all been shown to help prevent migraine attacks.
Botox does help some people.
You’ll love it if you get results. According to Dr. Peter Goadsby, the results for an individual can be “quite spectacular” for some.
Given the cost of the treatments, don’t expect a freebie to smooth out your crows feet as well as a migraine treatment. For the most part, the injections sites are in different locations besides the forehead.
In the rare case where someone gets worse it will typically resolve within 12 weeks. Severe side effects are not common and can be minimized by ensuring you consult an experienced practitioner for migraine injections.
At the end of the day, Botox is a welcomed addition into the migraine treatment toolbox.
Have you tried Botox or are thinking about it? Let me know your experience so far?
MORE TREATMENT OPTIONS TO PREVENT MIGRAINE
Get a list of the top proven preventative migraine treatments according to guideline recommendations from the US and Europe.
(1) American Society of Health-System Pharmacists (October 27, 2011). “Botulinum Toxin Type A”. drugs.com. Retrieved 4 Jul 2015.
(2) Botulinum toxin A inhibits acetylcholine release from cultured neurons in vitro, Ray P, PubMed, In Vitro Cell Dev Biol Anim. 1993 Jun;29A(6):456-60.
3) Walsh, S. “FDA approves Botox to treat chronic migraine”. FDA Press Releases. Retrieved Jun 15, 2015.
4) Watkins, T. “FDA approves Botox as migraine preventative”. CNN (US). Retrieved Jun 15, 2015.
5)Aurora, S. K., et al. “OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 1 trial.” Cephalalgia 30.7 (2010): 793-803.
6) ‘Effectiveness of Botox Questioned.’ National Headache Foundation. Mar 15, 2011.
7) Diener, H. C., et al. “OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 2 trial.” Cephalalgia 30.7 (2010): 804-814.
8) Migraine Fact Sheet “Botox For Migraine”. Migraine Trust. Accessed 7 July 2015.
9) Jenkins, Bronwyn. Migraine World Summit 2018 Interview. April, 2018.
Good article, I appreciate the info. I had botox injected today for the first time. Fingers crossed..
Good luck Sunny! Let us know how it works out for you after you’ve had your second injection. I think others would be very interested to hear as well 🙂
Botox is actually available free of charge in England (not sure re. Scotland) on the NHS. That said, it requires a good bit of determined hoop-jumping to access it. It took me about 18 months & 3 ineffective drug treatments before I landed my first session.
That was 3 months ago & after a slow start with little change, the reduction in the frequency of my headaches is now really marked. Certainly worth trying it.
Thank you so much for sharing Catherine. Great to hear about that NHS support and finding great results. Hopefully some people from England are able to benefit from this.
I’ve been getting Botox for a couple of years now, and I don’t know what I would do without it! It has reduced my migraine frequency by at least 80%, probably more. When I do get migraines, they’re easier to manage and very rarely put me out for an entire day like they did before the Botox. It works better every time I get it. I switched insurance earlier this year and went over a month past my due date and my migraines got pretty bad again. I’m so grateful that I found something that gave me my life back!
That’s a fantastic result Annadell! Congratulations. I hope your improvements continue!
Thank you for sharing your experience with us!
I have been getting Botox shots for about 3 years or so now and it is wonderful. I will admit that the first time I got the shots, it caused me to have a bad migraine all day long, that day. I used to miss so much work and life in general, as I had them so bad and would get so sick.I used to get approximately 25 to 30 a month. My migraines started when I was 13 and I was hoping that they would go away when I hit menopause as my mother’s did. However, I was not that lucky. The Botox shots have saved my life. I get 155 units every three months and I do not get bad migraines after the shots until about 2 to 3 weeks before time for the next shots. Today, my neurologist increased the dosage so that hopefully it will take me through the full three months without having a bad one. He has some patients that started taking the shots 15 years ago and now they only have to come in about once a year for shots.
Hey Carl, I am doing a research paper and I am wondering when this article was posted for citing purposes?
Hey Kristen, the original date is in the URL at the time of writing. If the article is updated since it will be mentioned in the first paragraph.
I had a nerve block and my POTS symptoms increased severely even though the nerve block made the pain better. Has anyone who tried Botox for migraines had their POTS symptoms improve or worsen? I’d love to hear if it helps with the nausea, auras, etc. and not just the pain.
I can’t comment on this sorry, perhaps another reader can share their experience.
So far not much benefit following one treatment. Actually may be worse.
And I don’t know where you got your cost info, but it’s way off. The Mayo Clinic charges $1642 for the injections and $1950 for 150 units of Botox. Highway robbery!!
Not sure if I’ll try the second injection series or not. So far, not a huge fan.
Hi Bill, thank you for sharing. I’ll revisit the costs for the US.
Note: generally speaking doctors only expect to start seeing results in their patients until after the 2-3 injection i.e. you need to give it 6-9 months to see if it will work for you.
I am in Vancouver, Canada and have a teenage son who suffers debilitating migraines each time he is exposed to perfume/scented sprays. Imagine navigating high school with this challenge. So discouraging for him. I am wondering if there is success specifically with teens utilizing botox for migraine reduction….anyone?
Hi Heather, I know several doctors who have voiced frustration at not being able to provide Botox for migraine in teens that may be 16-17 years old. The clinical trials only tested Botox in those 18 years and older. Which is why it is only indicated this way.
Studies suggest teens are particularly responsive top Cognitive Behavioral Therapy (CBT), biofeedback and can benefit from many behavioral and lifestyle changes that facilitate consistent sleep, regular exercise, a diet with minimal processed foods, relaxation and if appropriate, supplements. These are not easy to implement but if successful children and teens can “grow out” of migraine or at least, control it more effectively. These are all nonmedicinal options which provide healthy habits and skills that they can apply elsewhere in their life. I hope that helps.
Hi, thanks for sharing article.
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