Botox for migraine: What to expect

By: Ria Bhola, Headache Nurse Specialist, The Migraine Trust

23rd November 2021

The Migraine Trust information page describes Botox as a migraine treatment, looking at who it might be suitable for, when to consider it and how to access the treatment if you have chronic migraine.

In this blog we look at what to expect at the treatment session, how to prepare for the treatment and the immediate after care.

What is Botox?

Botox is useful to treat and prevent migraine. The full name is Botulinum toxin A.

It is also used to treat a range of conditions such as dystonia, excessive sweating, an overactive bladder, and is used cosmetically.

It is given by injection into specific areas where it causes those muscles to relax but also connects with the nerves in those muscles to help reduce pain.

Any benefit and side effects of Botox are temporary and will wear off completely by 12 weeks. If it is effective, you can usually have it again at 12 weeks.

Who is it for?

Botox is licensed and approved in the UK for people with chronic migraine (at least 15 days of headache a month, eight of which are migraine). Your neurologist or headache specialist will offer this treatment if you have already tried three migraine preventive treatments without them helping to improve your migraine. They will also want to check that you are not using painkillers and triptans too frequently.

What to expect at the clinic

You should bring along your headache diary to the clinic appointment. You should record how many days you have migraine and headache, as well as the number of days (not doses) you use a pain relief treatment.

Many people are understandably anxious about having the 31 injections on their head, neck and shoulders. However, most are surprised at how well they tolerate these very small, superficial injections. The injections are placed with a very fine needle in the forehead, temple area, back of the head, upper neck and shoulders.

The actual injections can be done in 10-15 minutes. However, before the procedure is done, your nurse or doctor will take some time to look at your headache diary, discuss your headache pattern, explain the procedure (including potential benefits and side effects) and allow you time to ask questions.

For most people the injections are done while you are sitting (but you can lie down if preferred or if you feel faint). The injections might be uncomfortable and sting for a few seconds, but this settles quickly.

It is best to come without make-up but the skin will be cleaned prior to the injections, to reduce the chances of infection.

After care

You will be able to return home on your own, but some people prefer to have someone accompany them, especially on the first occasion. It is best to have the rest of the day off, but it is not a requirement to have additional time off following the procedure.

To avoid infection and allow the complete absorption of the drug into the areas injected, it is best to avoid the following during the first 24 hours:

  • Vigorous exercise (e.g. gym, jogging)
  • Hair washing – you may want to wash your hair the day before the appointment
  • Skin cleansing in areas injected
  • Massages and extreme heat such as spas

The areas injected might feel bruised or tender for a few days and you may also notice your migraine symptoms are temporarily more severe or you may have a migraine attack in the days following the treatment. You can use your usual acute treatment (e.g. painkillers, triptans) as needed during this period. The benefit will usually develop a week or two after the injections.

Since Botox is given as two separate treatments, three months apart, the full effect might only be felt after the second set of injections. So a lack of effect after the first treatment does not mean that the treatment is not working. Remember to keep a daily headache diary and take this back to the clinic for your next appointment.

Summary of possible side effects:

  • A temporary worsening of your migraine for some days or a migraine attack on the day of treatment. These should be treated with your usual medication.
  • The skin is cleaned before the injections are done but as with all injections, infection, bleeding, tenderness, and bruising are possible where the injections are placed. This will usually be minor and last no more than a few days.
  • Drooping of the eyelid or brow. It is important not to rub the areas where the injections were done for the first 24 hours. Cleaning the forehead, washing the hair, applying make-up is best avoided until the drug is fully absorbed during that first day.
  • Minor changes to expression lines in the forehead are possible.
  • Weakness and pain in the neck and shoulders which can last a few weeks. If this happens you should let your clinic know and they may avoid injecting those areas in future treatment sessions.
  • If you have found no benefit after the second treatment, a third treatment may be given, or an alternative will be considered.