Botox for Migraine: What You Need to Know About This Preventive Treatment

Botox may be best known for smoothing wrinkles, but for many living with chronic migraine, it’s also a powerful tool to help prevent attacks. Approved by the U.S. Food and Drug Administration (FDA) in 2010, Botox for migraine has become a widely used and effective preventive treatment.

Whether you’re just beginning your migraine management journey or have tried several preventive medications without success, Botox might be worth considering. In this article, we’ll break down what Botox is, how it works, who it’s for, and what you can expect before, during, and after treatment.

** While Migraine Strong writes about the latest in migraine treatments, this is not medical advice. We are patient educators. All information you read should be discussed with your doctor.

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What Is Botox?

Botox is the brand name for onabotulinumtoxinA, a purified neurotoxin derived from the bacterium Clostridium botulinum. While it’s widely known for cosmetic use—reducing fine lines and wrinkles—it’s also FDA-approved for several medical conditions, including chronic migraine.

The discovery that Botox could help with migraine was somewhat accidental. Patients receiving Botox injections for cosmetic reasons reported fewer headaches, prompting researchers to explore its effects on migraine. Clinical trials confirmed its effectiveness in reducing the number of headache and migraine days for people living with chronic migraine. Botox was officially approved for chronic migraine in 2010 by the FDA.

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How Botox Works for Migraine

While the exact mechanism isn’t fully understood, Botox is believed to work by blocking the release of certain neurotransmitters involved in the pain pathways associated with migraine. These neurotransmitters signal pain, and Botox may help interrupt that communication before an attack begins.

Unlike acute treatments, which are taken once a migraine attack has started, Botox is a preventive treatment. The goal is to reduce the number, frequency, and severity of migraine attacks over time. On average, Botox reduces 8 to 9 headache and migraine days per month [1].

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Who Qualifies for Botox for Migraine?

Botox is approved only for chronic migraine, not for episodic migraine. According to the International Classification of Headache Disorders, chronic migraine is defined as:

• 15 or more headache days per month, and
• At least 8 of those days must include migraine features, such as head pain, sensitivity to light or sound, nausea, or visual aura
• Symptoms must persist for more than 3 months

In most cases, insurance providers require that patients try and fail two or more preventive treatments—either due to lack of effectiveness or intolerable side effects—before approving Botox. This is called Step Therapy.

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The Botox Procedure: What to Expect

Botox for migraine is typically administered by a neurologist or headache specialist trained in the PREEMPT injection protocol, which involves:

• 31 small injections
• Across 7 specific muscle areas in the head, neck, and shoulders
• Every 12 weeks (approximately every 3 months)

The treatment itself usually takes between 5 to 15 minutes. A fine needle is used to inject small amounts of Botox into the targeted areas. Most patients describe the sensation as a series of small pinches or stings, and the procedure is generally well tolerated.

There is no required recovery time—you can typically drive yourself home afterward and return to your regular activities the same day, though some people prefer to rest for a few hours. Most doctors recommend not exercising or lifting for 24 hours after the procedure. The Cleveland Clinic has a good overview of what you should and shouldn’t do after Botox for migraine.

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When Will You See Results?

Botox is not an instant solution. Results typically appear gradually over time. According to studies and patient reports:

• Some people experience improvement within 4 weeks
• Most see significant results after 2 to 3 treatment cycles, spaced 12 weeks apart
• On average, Botox reduces 8 to 9 headache or migraine days per month [1]

Research shows that even if a patient doesn’t respond after the first cycle, they may respond after the second or third. A large study found that:

• ~25% of people who didn’t improve after the first treatment cycle responded after the second
• Another ~25% who didn’t respond after the second round improved after the third

This supports the recommendation to try Botox for at least three full treatment cycles before evaluating its effectiveness [3].

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Predicting Whether Botox Will Work for You

While there’s no guaranteed way to know whether Botox will work for an individual, some studies have looked for possible predictors.

A study by Dr. Rami Burstein suggested that the type of migraine pain a person experiences might help indicate whether they’ll respond to Botox. The research found:

• People who describe their pain as “imploding” (a crushing or inward sensation) were more likely to respond to Botox
• People who describe “exploding” pain (as if pressure is building inside the head) were less likely to respond

In fact, 92% of non-responders reported “exploding” pain, while 74% of responders described “imploding” or “ocular” migraine pain [5].

Overall, about 65% of chronic migraine patients respond to Botox after three cycles [4].

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Botox Side Effects and Safety

Botox is considered a safe and generally well-tolerated treatment. However, as with any medical procedure, side effects can occur. The most commonly reported side effects include:

• Neck pain
• Headache or worsening of migraine symptoms
• Eyelid or eyebrow drooping (ptosis)
• Muscle stiffness or weakness near the injection sites
• Mild bruising or swelling [6], [7]

The good news is that side effects tend to decrease with each subsequent treatment [8].

If side effects persist, your doctor may adjust the dose, recommend a different botulinum toxin like Myobloc, or consider discontinuing the treatment altogether.

The first time I tried Botox, I felt like my attack frequency increased, and I ended up giving up on it too soon. I tried it again a few years later and had no noticeable effect until round 3, when I felt there was a slight improvement. The reduction in migraine attacks came after I received my 4th round. While eyebrow drooping (the Spock effect) happened after one round, my headache specialist adjusted the placement of injections and that hasn’t happened since.

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What If Botox Wears Off Early?

Botox is designed to last about 12 weeks, but for some patients, its effectiveness may begin to fade sooner. Unfortunately, insurance companies rarely approve more frequent treatment. However, some patients are successful in getting Botox every 10 weeks with a prior authorization. Read our complete article about Botox for migraine wear-off.

If migraine symptoms return before your next scheduled round, some doctors offer nerve blocks or trigger point injections as a bridge. Another bridge therapy utilizes Nurtec (rimegepant) every other day as a two-week preventive. These can help manage pain while you wait for your next Botox session. Talk to your doctor about what options they think will work best for you.

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What If Botox Stops Working?

In rare cases, Botox may become less effective over time. This could happen for two main reasons:

1. The body develops antibodies that neutralize the effects of Botox (occurs in fewer than 1% of patients) [12]
2. Migraine disease evolves, and Botox is no longer effective

If Botox stops working, your doctor may explore alternatives like Myobloc (rimabotulinumtoxinB), another type of botulinum toxin. While not FDA-approved for migraine, it has been shown to help in some patients [9].

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Is Botox Covered by Insurance?

In the U.S., most insurance providers—including Medicare and Medicaid—cover Botox for chronic migraine, provided specific criteria are met. These typically include:

• A chronic migraine diagnosis (15+ headache days/month)
• Documented trial and failure of other preventive treatments

You may also be eligible for the Botox Savings Program, which helps cover out-of-pocket costs.

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Can Botox Help with Vestibular Migraine?

Although Botox is not officially approved for vestibular migraine (which includes dizziness and vertigo as primary symptoms), there is limited but promising evidence that it may help—especially in people who also experience frequent head pain.

One 2017 case report from Korea described a 58-year-old woman whose chronic migraine and recurrent dizziness disappeared within a day of receiving Botox injections [10]. While this is just one case, it suggests potential benefit in select patients. More research is needed.

A 2021 study found that adding Botox to an oral medication (amitriptyline, propanolol, flunarizine) reduced the frequency of vestibular migraine attacks, but did not decrease the severity of vertigo when the attacks did occur. [15]

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Botox for Migraine and Medication Overuse Headache (Rebound Headache)

Medication overuse headache, also known as rebound headache, occurs when acute migraine medications are used too frequently. These headaches are difficult to treat and often don’t respond well to preventive medications—including Botox—until medication overuse is addressed [13].

Some research recommends detoxing from acute medications before beginning Botox, as this can increase the chances of success [14].

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Is Botox a Standalone Solution?

Botox can be incredibly helpful, but for most people, it’s one part of a comprehensive migraine treatment plan. Managing chronic migraine often requires a combination of:

• Lifestyle changes (hydration, sleep, stress management)
• Supplements
• Preventive medications
• Physical therapy or chiropractic care
• Cognitive behavioral therapy (CBT) or biofeedback

This multi-pronged approach is often referred to as the Migraine Strong ‘Treatment Pie‘—and Botox is just one slice.

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Final Thoughts

Botox for migraine is a powerful option for people living with chronic migraine, especially those who haven’t found relief from other preventive treatments. It doesn’t work for everyone, but studies show it can significantly reduce headache days, improve quality of life, and decrease the need for acute medications.

If you think Botox might be right for you, start the conversation with your neurologist or headache specialist. Together, you can decide whether this treatment fits your overall migraine management strategy.

Feel free to join our Migraine Strong Facebook group to chat with other members who get Botox to manage their migraine disease.

This article is not sponsored by Botox or Allergan.

The information in this article is to help you educate yourself and is not medical advice. Please consult your healthcare provider before changing your migraine treatment.

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References:

[1] OnabotulinumtoxinA: A Review in the Prevention of Chronic Migraine. 2018 
[2] https://www.botoxchronicmigraine.com/chronic-migraine-treatment
[3] OnabotulinumtoxinA: A Review in the Prevention of Chronic Migraine. 2018
[4] The Journal of Headache and Pain. 2018.
[5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1831831/
[6] https://www.botoxchronicmigraine.com/pdf/You_Got_This_Online_DDG_Headache_Specialist.pdf
[7] OnabotulinumtoxinA: A Review in the Prevention of Chronic Migraine. 2018
[8] OnabotulinumtoxinA: A Review in the Prevention of Chronic Migraine. 2018
[9] Onabotulinumtoxina therapy is also effective for dizziness in vestibular migraine
[10] https://www.sciencedirect.com/science/article/abs/pii/S0041010108002705?via%3Dihub
[11] Vestibular migraine
[12] What to do when Botox stops working
[13] OnabotulinumtoxinA: A Review in the Prevention of Chronic Migraine. 2018
[14] https://academic.oup.com/brain/article/142/5/1203/5457721
[15} https://pmc.ncbi.nlm.nih.gov/articles/PMC9615515/