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Botox for Migraine and Tension Headaches

by , last modified on 4/14/21.

Since the 1990s, there have been increasing literature that documents the efficacy of botulinum toxin type A (Botox) for the treatment of a variety of pain states including migraine and tension type headaches. Even though Botox is most well-known for causing a muscle paralysis by preventing the release of acetylcholine from nerve endings resulting in wrinkle reduction and resolution of muscle spasticity (blepharospasm, spasmodic dysphonia, etc), it also reduces the release of a variety of pain neuropeptides as well as blocking the feedback loop transmission of pain sensation.

For tension type headaches where persistently chronic muscle contraction contributes to the headache, a partial paralysis of the muscle in the region of the pain does much to alleviate the headache.

Please note that botox is NOT effective for severe stabbing pain in the cheek region or next to the eye. This type of headache may be a contact point headache. Click here for more information.

Information on "sinus headache" complaints which principally involve the cheek and around/behind the eye can be found here.

Not All Migraine Headaches Respond Equally Well to Botox!


Certain migraine headache types respond better than others. For those whose headaches are described as imploding (vise-like, squeezing, crushing, etc) have a much higher response rate to Botox injections (>80%) than those headaches described as exploding in nature (15%). Headaches due to muscle spasms (especially in the back neck region) respond well to Botox too as well as most types of tension headaches.

However, headaches in certain areas do NOT respond well to botox including top of head, cheeks, between eyes, and immediately behind ear.

Areas (shaded red in picture to the right -->) that generally respond well to botox injections include forehead and back neck regions. The temple areas have mixed results (some patients respond well, whereas others do not). The area noted in blue is also amenable to botox injection due to TMJ pain.

Where and How are the Injections Performed?

Generally speaking, the injections are performed not only in the distribution of one's headaches on one side, but also on the opposite side even if there is no pain (fixed-site strategy). Why? Well, experience has shown that injecting only on the side where the headaches are located will result in the appearance of migraine headaches on the opposite side. Injecting both sides prevents this switch from happening.


There are 4 general regions that are injected: glabellar (right above and between the eyebrows), forehead, temples, and upper neck. Each region requires anywhere from 4 - 5 injections on average to as many as 10 injections with each injection containing 2.5 - 5.0 Units of Botox. Most patients require injections to more than one region.

After injection, there is a SLOW reduction in the severity and frequency of migraine headache attacks resulting in decreased need for medications (if at all) over time. As such, it may be up to 2 months before the benefit of Botox may be realized by the patient. Repeat injections are required every 3-4 months to maintain the benefits as Botox wears off by than. Although the maximum benefits occur when used prophylactically (treatment to prevent future attacks), it can also be used in the acute setting, though not as successfully.

Click here to read the consent you will be asked to sign before every injection session.

contact headache

Botox is NOT effective for severe stabbing
pain in the cheek region or next to the eye
(areas shaded in red). This may be a contact
point headache
. Click here for more

Who Qualifies for Botox Injections?

Contraindications... You are NOT a candidate if you suffer from:

  • Neuromuscular Disorders (ie, Myasthenia Gravis)
  • Myopathic Disorders (ie, amyotrophic lateral sclerosis)
  • Pregnant

If you have none of the contraindications, the next steps to take are:

  • Full neurologic workup by a neurologist required (please have your neurologist fax a summary report to us)
  • Failure or minimal responsiveness or unacceptable side effects with standard migraine headache medications as prescribed by your neurologist OR
  • Financially speaking, cheaper to obtain Botox injections than continue with medications. See next section regarding this.

Does Insurance Cover Botox Injections for Headaches?

Unfortunately, few insurance companies cover Botox for headaches in spite of the extensive literature that supports its use. Even with FDA approval for Botox usage in treating migraine headaches in 2011, insurance companies have still made it very difficult for patients to obtain coverage by putting in place numerous barriers. Often insurance companies will require extensive documentation that treatment with other migraine preventives from at least 2 or 3 other drug classes (anti-hypertensives, anticonvulsants, antidepressants) have been tried and failed. A letter documenting all facts regarding migraine treatment by a neurologist is needed.

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In summary, a letter from your neurologist documenting the following:

  1. Adult individual diagnosed with chronic migraine headache; and
  2. Fifteen (15) or more migraine days per month with headache lasting four (4) hours or longer; and
  3. First episode at least six (6) months ago; and
  4. Symptoms persist despite trials of at least 1 agent in any 2 of the following classes of medications used to prevent migraines or reduce migraine frequency:
    • Antidepressants (e.g., amitriptyline, nortriptyline, doxepin); or
    • Antihypertensives (e.g., propranolol, timolol); or
    • Antiepileptics (e.g., valproate, topiramate, gabapentin).

Continuing treatment with botulinum toxin injection for ongoing prevention of chronic migraine headaches is considered medically necessary per insurance when the migraine headache frequency is reduced by at least 7 days per month (when compared to pre-treatment average) by the end of the initial trial or  migraine headache duration was reduced by at least 100 total hours per month (when compared to the pre-treatment average) by the end of the initial trial. 

Given not uncommonly insurance denies botox treatment, we will require pre-payment before treatment. One can than submit the receipt to your insurance company for reimbursement if possible or refund will be provided in event insurance does cover and pay for the treatment.

HOWEVER, if headaches are triggered by muscle spasms, most insurance companies will cover Botox injections for these spasms. Determination of whether these spasms are present or not is done by your neurologist.

Financial Assistance

Reimbursement assistance for those who are uninsured or otherwise unable to afford BOTOX can be found here ( Or call 1-800-44-BOTOX, option 6. The form you will be required to complete can be downloaded here.


OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 2 trial. Cephalalgia. 2010 Jul;30(7):804-14. Epub 2010 Mar 17.

OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 1 trial. Cephalalgia. 2010 Jul;30(7):793-803. Epub 2010 Mar 17.

Exploding vs imploding headache in migraine prophylaxis with botulinum toxin A. Pain. 2006;125(3):286-295.

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