Botox isn't only cosmetic. Since 2010 onabotulinumtoxinA has been approved in the US for preventing chronic migraine, and it is now used worldwide, including in Lebanon.
Do you have chronic migraine?
By the International Classification of Headache Disorders (ICHD-3) definition, chronic migraine means:
- headache on 15 or more days per month,
- for more than 3 months,
- with migraine features on at least 8 of those days.
Botox was not effective in trials for episodic migraine (fewer than 15 headache days a month). Those patients have other good options.
The PREEMPT protocol
Treatment follows the injection pattern from the PREEMPT trials: 155 units divided into 31 tiny injections across seven muscle areas of the forehead, temples, back of the head, neck and shoulders. The visit takes about 15 minutes and is repeated every 12 weeks.
Botulinum toxin is thought to work by reducing the release of pain neurotransmitters, including CGRP, from sensory nerve endings. This calms the pain pathways involved in migraine.
Timeline: Some patients notice benefit within 2–3 weeks, but the full effect is judged after at least two treatment cycles (about 6 months). In the PREEMPT program, response continued to improve with repeated cycles.
Side effects
Treatment is generally well tolerated. Possible effects include neck pain or stiffness, temporary injection-site discomfort, a brief worsening of headache, and, less commonly, a mild drooping of the eyelid or brow that resolves as the effect wears off. Botox is avoided in pregnancy and in certain neuromuscular disorders.
Medical Botox vs cosmetic Botox
It is the same molecule, with a very different dose and pattern. Cosmetic treatment of frown lines typically uses around 20 units. The migraine protocol uses 155 units placed in specific muscles. Some migraine patients notice a smoother forehead as a bonus, and Dr. Agha can adjust placement for balance. The two treatments should be planned together, not by separate injectors who don't coordinate doses.
Combining with other treatments
Botox can be used alongside CGRP monoclonal antibodies or gepants when one therapy alone is not enough. Real-world studies suggest additional benefit for some patients. See all current migraine treatments →
Sources
- Aurora SK, et al. OnabotulinumtoxinA for treatment of chronic migraine: pooled analyses of the 56-week PREEMPT program. Headache. 2011;51(9):1358–1373.
- Dodick DW, et al. PREEMPT pooled results. Headache. 2010;50(6):921–936.
- Headache Classification Committee of the IHS. ICHD-3. Cephalalgia. 2018;38(1):1–211.
American board-certified neurologist with subspecialty expertise in clinical neurophysiology. More than 10 years of practice in Chicago and Beirut. Sees patients in Beirut, Beverly Hills and Upland.
This article is educational and is not a substitute for a medical consultation.