Botox against migraine

Prevent migraine with Botox

When Botox helps against migraine

Preventing migraines with Botox: at least for chronic migraines, this is possible. This may surprise you at first, because most people associate Botox with the treatment of wrinkles. But the toxin is not only used for cosmetic purposes; it also alleviates neurological conditions. These include spasms and dystonia, which have long been treated with Botox. And since 2011, Botox for migraines has also been officially approved. In this post, I’d like to explain Botox for migraines in more detail. These are the topics:

  • Preventing migraine with Botox
  • How well does Botox work against migraine?
  • How does the treatment work?
  • Side effects and contraindications
  • Cost of Botox against migraine

Prevent migraine with Botox

For Botox to work against migraines and effectively reduce headaches, preventive treatment is needed. In the case of an acute attack, it is too late. This is because the toxin needs a few days to take effect. If successful, the attacks occur less often or the headaches are not as severe. Ideally, both are achieved and Botox noticeably alleviates migraines in terms of both frequency and intensity.

Migraines less frequent and pain less severe

Botox has been officially approved for chronic migraine since 2011. Before that, no drug was available for the specific prophylaxis of chronic migraine. Only the drug topiramate was considered for this purpose. However, its effect is limited in chronic migraine. In addition, severe side effects are possible, including central nervous disorders.

Since the end of 2018, “Erenumab“is another drug that is designed to reduce the frequency of attacks. Unlike Botox, the active ingredient specifically targets the CGRP receptor which is centrally involved in migraine. CGRP is a neurotransmitter that is released more frequently in migraine. In studies, erenumab had a comparable effect to Botox in migraine. However, since erenumab is the first drug to directly block the CGRP receptor, the long-term effects of such a blockade are still uncertain. In this respect, this is an advantage of Botox, which is considered to be thoroughly researched.

Botox only effective for chronic migraine

Chronic migraine means massive losses in quality of life. Botox against migraine gives sufferers new hope.

However, Botox only works for chronic migraine. And only in chronic cases there is a chance that the costs for Botox against migraine will be reimbursed by the health insurance. Chronic migraine is when headaches occur for more than 3 months on at least 15 days a month. Chronic migraine affects about 1-2% of the population. It is associated with a much greater impairment of quality of life compared to episodic migraine. In my practice, several patients have Botox injections for their migraines, even though they are not reimbursed by the insurance companies. But the gain in quality of life is worth it to them.

And for episodic migraine?

The official approval only provides for the use of Botox in chronic migraine. The physician can, of course, try to treat with Botox Treat migraines even in episodic cases. This is possible in the so-called “Off Label Use“. This refers to the use of a drug that is approved for a specific therapeutic objective to achieve another for which it is not approved. In such a case, the physician must provide the patient with particularly comprehensive information. However, studies suggest that Botox does not work better than placebo for episodic migraine. Therefore, one should ask oneself whether one really wants to accept the considerable costs for Botox for migraine if the therapy has no great prospect of success. In any case, health insurance does not usually cover the cost of Botox for episodic migraine.

How well does Botox work against migraine?

Unclear how Botox attenuates migraines.

In most of the cases I see in my practice. Botox Improve migraines both by frequency of occurrence and severity of attacks. Exactly how Botox reduces migraines, however, is unclear in detail. A direct, pain-relieving Effect of Botox could so far namely neither for animals still in humans detected can be.

However, the lack of knowledge also stems from the fact that it is not yet known exactly how migraines actually develop. In the past, it was believed that the attacks originated from a malfunction of the blood vessels in the brain. The vessels would constrict and the brain would be undersupplied as a result. And that would cause the headaches. According to this theory, Botox relieves migraines by relaxing the muscles, as in wrinkle therapy. This would relieve the pressure on the vessels and migraine attacks would become less frequent. That was the theory. But this theory is now disproved.

Does Botox relieve migraines by inhibiting neurotransmitters?

Today, it is more commonly believed that migraines are triggered by overactivity of nerve cells in the brainstem. This overactivity causes important nerves in the face to send pain impulses to the brain. In this process, messenger substances play an important role, transmitting signals between the cells. And this could be precisely the lever that Botox uses to reduce migraines. Botox has long been known to inhibit the release of neurotransmitters. The best-known such messenger is Acetylcholine. Botox prevents the release of acetylcholine, thereby interrupting the transmission of stimuli between nerves and muscles. Studies indicate that Botox inhibits other neurotransmitters besides acetylcholine. Some of these are involved in pain stimulation, including. Glutamate, Substance P, CGRP and Neurokinin A. Inhibition of these neurotransmitters is thought to reduce pain sensitivity. And this could be the mechanism by which Botox is able to relieve migraines. But this has not been proven. So it is still not clear how exactly Botox works against migraine.

Relief already after the first treatment

When migraine responds to Botox, the effect occurs after the first treatment. And then increases with further treatments. Studies on the effectiveness of Botox in migraine show a steady reduction of headaches with repeated therapy. Half of the patients showed a 50% reduction in the number of days with attacks after the first treatment. After a second and third treatment, the proportion of patients increased from 50% to 60%. Another study also showed a reduction in headaches in patients treated every 3 months for 2 years. Botox was injected against migraine, a steady improvement. From the 2nd year onwards, there is usually a flattening out and the effect does not improve any further.

Reduction of attacks and pain by one third.

These studies were also able to prove that even patients in whom migraines continued to occur frequently despite Botox nevertheless experienced relief. This is because the headaches were no longer as severe as before due to the Botox. In practice, the aim is to use Botox against migraine therefore achieve that either the frequency of attacks or the intensity of headaches decreases. And best of all, of course, both. The measure of therapeutic success in both cases is usually a reduction by one third.

Discontinuation if no success after third treatment

If none of these goals can be achieved in a patient after the third treatment at the latest, then Botox will foreseeably fail to relieve migraine and the therapy should be terminated. At this point, the treatment has usually already cost more than 2,000 euros, and further injections of Botox seem pointless. Simply because of the high cost of Botox for migraine, I then advise patients against further attempts. In addition, of course, there are the many injections and the associated risks, which should not be accepted if success is unlikely.

How does the treatment work?

Risks and side effects

Every successful treatment begins with a detailed consultation. Also and especially in the case of Botox for migraine. This is because there are a number of contraindications that must be ruled out. Possible side effects must also be addressed. This is because Botox is injected in relatively high doses for migraine, which can be unpleasant in individual cases. Short-term nausea and headaches are possible, as well as dizziness. From an aesthetic point of view, Botox injections into the forehead, as intended for migraine, can cause drooping eyebrows. I try to prevent this in my patients. But it cannot be completely ruled out.

Cost of Botox for migraine

The cost of treatment must also be discussed. Even the minimal protocol for migraine, in which 155 units of Botox are injected, incurs costs of around 600 euros (guideline value) per session. With a frequency of initially one treatment per quarter, costs quickly add up to 2,000 euros. And since costs for Botox against migraine are only reimbursed by health insurance if conventional therapies were demonstrably unsuccessful, patients often have to bear them themselves. This must be made clear in advance.

Migraine medication and Botox

Furthermore, it must be clarified whether another medication for migraine is being taken in addition to Botox. If this helps at least partially, then it can be retained initially. After successful first or second treatment with Botox, discontinuation should then be considered. In such cases, it is recommended to continue the medication with the same dose during the treatment in order to be able to assess the effect of Botox against migraine in isolation.

Dosage and injection regimen of Botox for migraine.

The dosage of the toxin per treatment is between 155 and 195 so-called “Allergan units“(AE). The first treatment is carried out regularly with 155 AE, distributed over the following 4 zones and a total of 31 injection points:

20 units (5 per point) in the left temporalis muscle.

20 units (5 per point) in the temporalis muscle on the right

5 units each into the frontalis muscle (top), the procerus muscle (bottom center), and the corrugator muscle (bottom lateral).

20 units cervical paraspinal (top) and a total of 30 units (15 per side) into the trapezius muscle.

If there is no success after the initial treatment with this dose, the dose is increased to 195 AU in a second session. The additional units of Botox are then injected into the zones where the patient is most violently plagued by migraine.

Treatment Intervals

In the first year of treatment, an interval of 3 months is strictly observed. In the 2nd year, if the effect persists, an attempt can be made to extend the interval to 4 months. Alternatively, the 3-month interval is maintained but the dose is decreased. If this does not lead to a worsening of the migraine, then an attempt can also be made to suspend the treatment altogether and only resume it when symptoms return.

Side effects and contraindications

Side effects

Common side effects of Botox for migraines include neck pain, headache, nausea, and dizziness. All symptoms are short-lived and usually go away after 1-2 days. There is short-term redness at the injection sites that passes within a few minutes. Small hematomas are possible if the needle punctures a blood vessel. They usually disappear after 2-3 days.

Due to the rather high dose injected into the forehead, there may be drooping eyebrows (Ptosis) can occur. I try to avoid this in my patients by specifically selecting the injection sites depending on the musculature and, in a first step, possibly also setting the dose lower than intended.


There are some contraindications to Botox that generally need to be considered. These include:

  • Neuromuscular transmission disorders, such as. Myasthenia gravis and Lambert-Eaton syndrome
  • The presence of dysphagia or chronic respiratory distress.
  • Acute infections and inflammations
  • The use of drugs that affect muscular transmission and certain antibiotics (Amynoglycoside-Antibiotics, Spectinomycin)
  • Hypersensitivity to any of the components of the Botox preparation used.
  • Pregnancy and lactation

Treatment costs

The cost of a treatment with Botox against migraine according to the standard scheme (155 AE) in my practice in Munich is about 620 euros as a guideline. The large regimen with 195 units, according to which Botox against migraine is injected when the standard regimen does not bring the desired effect, causes costs of about 820 euros (guideline value). Please note that individual billing is always done according to the German Medical Fee Schedule (GOÄ) and may deviate from the above guideline values.

In order for the health insurance to cover the costs of Botox for migraine, there must in any case be a chronic migraine according to the criteria outlined earlier in the text. Furthermore, the therapy with conventional drugs, such as Metoprolol, Flunarizine or Topiramate must have been previously tried unsuccessfully. Unsuccessful means that either the desired effect was not achieved or the drug was not tolerated. I recommend that my patients check with their health insurer in advance to see whether the costs will be covered.