Botox Migraine Injection Sites

Botox, or botulinum toxin, is a common remedy for migraines that you can’t get rid of by other means. Perhaps you're scared of needles or curious about where your doctor will insert the needle for this treatment.

This article will explain how Botox alleviates migraine symptoms. We’ll also detail the procedure the doctor will use when providing the injection, including the locations they may use. 

Botox for migraine

Most people have heard of Botox, but we often associate it with celebrities and others looking to reverse the effects of aging. While the substance is most famous for its cosmetic use, it has several medicinal uses. Let's take a closer look at Botox and how it works.

What is Botox?

Botox is a specific type of botulinum toxin, and it's the same toxin found in food that causes botulism. Botulinum toxin has several subtypes, which we'll discuss later. The term toxin might sound scary, and without the aid of a medical practitioner, it can be. 

However, the injections doctors give you are a small enough dose that they won't harm you. Instead, these injections target neurotransmitters that are causing unwanted effects in the body. These toxic effects are temporary, making the treatment safer than it would be otherwise, but it also means you'll need repeated doses to continue feeling the benefits.

How does Botox prevent migraine?

The exact method of interaction between Botox and migraine pain isn't fully understood. Scientists know that the substance is a potent neurotoxin. Researchers believe that Botox works by preventing the release of certain peptides responsible for migraine pain and blocking neurotransmitters responsible for pain sensation.

Types of botulinum toxin for migraine

There are seven primary types of botulinum toxin. These are labeled A through G. Doctors only use A and B in a medicinal capacity. The different types are related but distinct from one another. 

Other than type C, all types are neurotoxins. They have different strengths and preparations that prevent them from being used interchangeably. 

The A group has four subtypes, and there is one B-type in clinical practice: 

Onabotulinumtoxin/A

This is the botulinum toxin under the brand name Botox. Doctors commonly use onabotulinumtoxin/A for treatments, perhaps because it has the highest safety profile of all botulinum toxins. This type of botulinum toxin uses crystallization to form a powder, which healthcare providers mix with a liquid to make an injection.

Abobotulinumtoxin/A

Most commonly known under the brand name Dysport, abobotulinumtoxin/A has the second-best safety profile of the major botulinum toxins used in clinical settings. While Botox relies on crystallization to separate it, Dysport uses a process known as chromatography. The procedure dissolves a substance into a solvent and carries it through various materials.

Because of the way different chemicals react to various materials, separation occurs. 

Incobotulinumtoxin/A

The final common A-type of botulinum toxin is incobotulinumtoxin/A under the brand name Xeomin. Like Dysport, Xeomin uses chromatography. This type has fewer side effects than Dysport but has lower efficacy than both Dysport and Botox. 

Prosigne

Prosigne is a Chinese formulation of A-type botulinum toxin. It uses¹ bovine gelatin, which can result in allergic reactions or immunological responses. Prosigne isn't FDA-approved, so doctors cannot use it in the United States.

Rimabotulinumtoxin/B

The only B-type botulinum toxin commonly used in clinical settings is rimabotulinumtoxin/B under the brand names Myobloc and Neurobloc. This type fell just after abobotulinumtoxin/A in the safety profile test. While the other types mentioned come in powder form, this type comes in a liquid form.

Researchers believe its acidic pH is responsible for the increased discomfort of this type versus the others. 

Injection sites

Typical Botox treatment for migraine pain involves several injections across seven sites. The most common treatment involves 31 injections. Some treatment options call for additional injections to better target the areas where the pain occurs. This could result in up to 39 injections for full treatment. 

Here are the sites doctors typically choose:

The lower part of your forehead, right above your nose

The procerus is a small muscle between your eyebrows and above your nose. This is the muscle you use when you’re angry and pull your eyebrows downward. Your doctor will make a shallow into this thin muscle right between the eyebrows. Often, this is the first injection that a doctor will make during the treatment.

The lower part of your forehead, near the inside edge of each eyebrow

The corrugators are muscles above each of your eyebrows. Like many other muscles in your face, these are very shallow muscles, so the injection will not be very deep. Your doctor will use one injection on each side of the face, close to the inside of your eyebrow. For safety, your doctor will inject upward, away from the eyelid. 

Between your shoulder and neck on your right and left

Your trapezius muscle is the big muscle that sits between your shoulders and your neck. The doctor injects three of the shots into your trapezius. They will visually divide the muscle into three parts and inject each one. Your doctor will repeat this process on the other side of your body, resulting in six total shots in this location. 

Between the back of your head, behind each ear

The occipitalis muscle is on the back of each side of the head. It’s between the bony prominence (occipital protuberance) and the back of each ear. Your doctor will give three injections on each side into this muscle: The first will be in the middle of the muscle, and the next two are above and to either side of the first injection, forming an imaginary V shape on each side. 

Cervical paraspinal muscle group

The cervical paraspinal muscle group is in the neck region. Your doctor will give you four more injections in this area, two on each side. The first injection is just off the midline of the cervical spine below the bony prominence of the occipital bone. The second is diagonally above that, toward the ear.

Although the muscle in this area is thicker than the facial muscles, your doctor will likely use a shallow injection to avoid weakness or pain in the neck.

The middle of your forehead, above each eye

Most of your forehead contains the frontalis muscle. This is the site for the next set of injections. There are two shots on each side, for four shots total. Each injection is near the top of the forehead.

Your doctor will place the first injection in the upper third of the forehead, above the corrugator injection sites. The second injection will be to the side of it, in line with the outer edge of the cornea (the transparent front part of the eye).

Behind each temple, above the ear

Covering your temples is a muscle known as the temporalis. At this location, above the ear, your doctor will give you four injections on each side of the head for eight total injections.

The first injection will be above your ear, with a second slightly above that. The third injection will be between those two positions vertically but closer toward your temple in the front. The final injection will be behind the second one. The doctor repeats the process on the other side.

Botox side effects

Although the word toxin in the name may be intimidating, studies² show that Botox injections for migraines are well-tolerated. Compared to similar treatments, Botox has a low discontinuation rate due to side effects. However, like all drugs, the potential for side effects exists. 

Common side effects include: 

• Injection site pain or discomfort

• Headache

• Dry mouth

These symptoms usually go away shortly after the treatment. Contact your doctor if you feel that something isn't right after receiving your Botox injections.

Some people experience allergic reactions to Botox. More severe side effects can occur in rare cases when the toxin spreads beyond the desired location and causes symptoms similar to botulism. The most common sign of toxin spread is difficulty swallowing and muscle weakness. 

If you experience swelling of your tongue or throat, blurry vision or difficulty speaking or swallowing, get immediate medical help.

Receiving Botox injections

Typically, because of the inconvenience and expense of receiving dozens of shots, Botox injections are a choice you and your doctor will make after trying easier and more affordable methods, such as over-the-counter or prescription painkillers. 

If you and your doctor decide that Botox injections are the right treatment for your migraines, you'll be able to get all of the injections in one sitting. However, it may take 2-3 treatments before you notice a reduction in migraine severity. You’ll typically have treatments every 12 weeks.

Dosage

Dosages depend on the specific type of botulism toxin used. For Botox, your doctor will evenly distribute the initial 31 injections from 155 units. If your doctor uses extra injections for added pain targeting, they will give you those from an additional 40 units. 

Higher dosages or more frequent treatments than every three months may result in resistance to the drug and reduce its effectiveness. 

How doctors give Botox

An experienced physician can administer all of the shots within ten minutes. They will give you some of the injections while you are sitting down. For other injections, the doctor may ask you to lie down.

After providing all the shots, they will observe you for a few minutes to ensure there are no adverse reactions to the injections. 

Immediately following the injections, there will likely be swelling in your forehead. This is an expected reaction and will go away within a few hours. The Botox effects should be noticeable within ten days, and your doctor can repeat them in 12 weeks.

Do you need Botox injections for migraine treatment?

While up to 39 injections in one setting may sound like a lot, many people experience frequent and painful migraines that other treatments do not help. If your migraines are persistent in the face of other treatment options, Botox injections might be a valid option for you.

Although the migraine easing effects of the injections aren't permanent, the treatment typically works for months, which is significantly longer than other treatment options. Your doctor will be able to advise you about the use of Botox for migraine relief and let you know whether it's right for your case.

The lowdown

Botox is an effective migraine treatment that has helped many people with chronic migraines. Doctors deliver the treatment via injection. Unlike many other injections, migraine treatment with Botox requires several injections at various locations around the head and face. You’ll typically have these treatments every 12 weeks and feel the effects within a few days.