Botox for Chronic Migraines: How Botox Can Help You Have More Pain-Free Days

Migraines are a complex neurological condition. People with migraines often have intense headaches and other symptoms that make it hard to do everyday activities, like going to work or school. About 15% of adults get occasional migraines. But each year, about 3% of them develop chronic migraines.

In 2010, the FDA approved a surprising treatment for preventing chronic migraines: Botox (onabotulinumtoxinA). That’s right — Botox can do a lot more than give you wrinkle-free skin. It can also prevent chronic migraines and provide long-lasting migraine relief. 

What are chronic migraines?

People with chronic migraines have headaches at least 15 days out of every month, with symptoms that last at least 4 hours. Imagine spending nearly half your time in pain. It’s easy to see why people with chronic migraines are always looking for treatments that can deliver more pain-free days. 

Treatment for chronic migraines focuses on three key areas:

• Identifying and avoiding migraine triggers

• Preventing migraines before they start

• Relieving pain once a migraine starts

Botox treatment for chronic migraines helps with the second goal: preventing migraines before they start. The main goal of treating chronic migraines is to give people more days without pain. That’s why treatments that stop migraines before they happen are key to keeping migraine attacks as low as possible. 

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What is Botox?

Botox (onabotulinumtoxinA) is an injectable medication. It’s made from a toxin found in the bacteria Clostridium botulism. The toxin is known for causing a serious, often life-threatening, condition called botulism. 

But Botox uses a very small, purified amount of this toxin, so it doesn’t cause botulism. Instead, it works by temporarily paralyzing (freezing) the muscles where it’s injected. The effects of Botox can last several months before they fade away.

How does Botox work for chronic migraines?

Botox (onabotulinumtoxinA) works by preventing migraines before they start. 

It’s not exactly clear how Botox prevents migraines. Scientists believe it may stop the body from making chemicals that trigger migraines. It might also stop nerves from releasing chemicals that transmit the sensation of pain.

Botox is considered a second-line treatment for chronic migraine prevention. That means it’s usually saved for when people don’t do well with first-line prevention treatments like:

• Propranolol (Inderal)

• Amitriptyline (Elavil)

• Topiramate (Topamax)

• Valproic acid (Depakene)

About half of the people who start a first-line prevention treatment have 50% fewer headaches after 3 months. But for the other half, these treatments don’t help enough. For them, adding Botox can lead to more pain-free days and shorter headaches during migraine attacks.

Is Botox effective for migraine treatment?

Yes, Botox is an effective treatment for chronic migraines. 

In clinical trials, people who got Botox for chronic migraine prevention had fewer headache days and fewer migraine symptoms after 24 weeks of treatment. People who continued getting Botox still reported fewer headache days in follow-up studies.

It’s important to know that the effects were modest. On average, groups that received Botox reported 2 fewer headache days each month than the group who got a placebo. Still, researchers and officials at the FDA saw this as a significant difference. 

So, while Botox won’t stop chronic migraines completely, it can give people more pain-free days. 

What to expect from Botox therapy for chronic migraines

Botox therapy for chronic migraines involves shots, which can be intimidating or even frightening for some people. But knowing what to expect can help you prepare. Here’s what to expect if you’re getting Botox therapy for chronic migraines.

Where do they inject Botox for migraine treatment?

During Botox therapy, a trained healthcare professional injects the Botox solution into seven different muscle groups on your:

• Forehead

• Temples

• Back of your head

• Upper back

In total, this adds up to about 30 to 40 injections during each visit.

Some people also feel pain in other parts of their body during migraines. If that happens to you, your healthcare professional might also give you extra injections in these spots.

Are Botox injections painful?

Shots can be uncomfortable. But the good news is that Botox injections tend to be less painful than other types of injections.

Healthcare professionals only use a very small needle (30 gauge) for Botox injections. It’s much thinner than needles used for blood draws or vaccines. The needle doesn’t go very deep, and the amount of fluid injected into each site is also very small. All this helps make the injection less painful. So, Botox may not hurt as much as you’d imagine. 

How often do you need Botox injections for migraines?

Botox injections need to be repeated every 3 months, which can be time-consuming. But in the long run, Botox treatments may save you time and energy — especially if you can take fewer medications to prevent and treat migraines. 

Dr. Olivia Begasse de Dhaem, a neurologist and headache specialist at Hartford Healthcare, says Botox works well for her patients. 

“About 50% of people respond after the first set of injections, but the effect tends to build up over time with repeated injections,” Begasse de Dhaem said.

Side effects of Botox injections

Like all medications, Botox injections can cause side effects. In clinical trials for chronic migraines, the most commonly reported side effects included:

• Pain at injection site

• Neck pain

• Muscle pain

• Muscle stiffness

• Muscle weakness

• Worsening headaches

• Eyelid drooping (ptosis)

In rare cases, Botox can spread to nearby areas of your body and affect those muscles too. This can cause:

• Generalized muscle weakness

• Double vision

• Trouble swallowing

• Difficulty speaking

• Voice changes

• Trouble breathing

These complications haven’t been reported in people getting Botox for chronic migraine prevention when used at the recommended doses. But you should seek medical care right away if you develop any of these symptoms. 

Does insurance cover Botox for chronic migraine prevention?

Yes, insurance plans and Medicare will cover Botox for chronic migraine prevention. In fact, Botox is considered a “low-cost option” for chronic migraine treatment. That’s because it lowers costs overall by cutting down on the number of visits and medications people need to control their migraines.

But keep in mind that Botox is a second-line treatment for chronic migraine prevention. This means you’ll have to try one or more first-line treatments before your insurance will pay for Botox. 

Also, Botox is only FDA-approved for adults 18 years and older. Children and teens can still get Botox for migraines, but this is called “off-label” use — and insurance may not cover it in these situations.

The FDA recommends 155 units of Botox per treatment. This can cost between $300 and $600. If your insurance doesn’t cover it, there’s a Botox Savings Card that can help lower costs.

It’s also important to keep in mind that only Botox is FDA-approved for chronic migraine prevention. Other forms of botulism toxin, like Dysport (abobotulinumtoxinA), haven’t been studied for chronic migraine prevention and aren’t covered by insurance.

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Written by:

Ronald W. Dworkin, MD, PhD

Ronald W. Dworkin, MD, is a board-certified anesthesiologist who has been practicing anesthesiology in a community hospital for 30 years. He has taught in the honors program at George Washington University for over 10 years and works as a senior fellow at the Hudson Institute.

Edited by:

Patricia Pinto-Garcia, MD, MPH

Patricia Pinto-Garcia, MD, MPH, is a medical editor at GoodRx. She is a licensed, board-certified pediatrician with more than a decade of experience in academic medicine.

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