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Botulinum toxin type A is an established preventive treatment for chronic migraine. Treatment with onabotulinumtoxinA follows the PREEMPT protocol, with injections into specific muscles of the head and neck and repeat treatment typically every 12 weeks.
Botulinum toxin is used primarily for the prevention of chronic migraine. It is not a treatment for an individual migraine attack and should not be confused with cosmetic botulinum toxin injections. The aim is to reduce the overall burden of headache and migraine and their impact on everyday life.
Chronic migraine is defined by headache occurring on at least 15 days per month for more than three months, with migraine features on at least 8 days per month.
Before starting treatment, it is important to confirm the diagnosis, assess headache frequency and characteristics, review medications used for acute attacks, identify possible medication-overuse headache, and consider the results of previous preventive treatments.
The effect of botulinum toxin in chronic migraine cannot be explained simply by muscle relaxation. It acts on peripheral nerve endings and reduces the release of neurotransmitters involved in pain signalling.
This can reduce peripheral sensitisation and decrease nociceptive input into the trigeminal system, contributing to a reduction in headache frequency and severity.
The realistic goal is a clinically meaningful reduction in headache burden and migraine-related disability.
The evidence-based injection protocol for chronic migraine prevention was established for onabotulinumtoxinA. Injections are given at predefined sites across the head and neck, with additional sites possible according to the “follow-the-pain” approach.
standard total dose using the fixed-site PREEMPT protocol
fixed injection sites in the standard protocol
maximum total dose when additional sites are used
standard interval between treatment cycles
PREEMPT is a standardised treatment protocol involving several muscle groups of the head and neck. Treatment is therefore different from injecting only one or two areas where the patient happens to feel pain.
Specific injection sites include the frontal and glabellar muscle groups.
Bilateral injections into the temporalis muscles form part of the protocol.
Defined injection sites are located in the occipital muscles.
The protocol also includes selected muscles of the posterior neck and upper shoulder region.
The effect of preventive treatment should not be judged by a single good or bad migraine attack. The overall headache pattern before and after each treatment cycle is more informative.
A headache diary is particularly useful. It allows both patient and neurologist to assess changes in headache and migraine days, use of acute medication and the functional impact of migraine.
Headache frequency, migraine symptoms, acute medication and previous preventive treatments are reviewed.
The PREEMPT injection pattern is planned and the need for additional sites is considered.
Small amounts of the medication are injected into standardised sites of the head and neck. Treatment is performed on an outpatient basis.
Response is assessed using the headache diary, and subsequent treatment can be adjusted when appropriate.
Improvement may begin during the first weeks after treatment, although the timing and magnitude of response vary between patients. For some people, the benefit becomes more apparent after repeated treatment cycles.
Botulinum toxin does not permanently cure migraine. Preventive treatment aims to reduce headache frequency and severity, decrease reliance on acute medication and increase the number of days on which migraine does not interfere with normal activities.
Modern migraine prevention includes several treatment options. Depending on the clinical situation, these may include conventional oral preventive medicines, CGRP-targeted therapies and botulinum toxin treatment.
Treatment choice depends on migraine type and frequency, previous treatment response, coexisting medical conditions, tolerability and patient preferences.
In selected patients, botulinum toxin may also form part of a combined preventive strategy. Such decisions are individual and should be based on the overall clinical response and treatment history.
Read more about CGRP-targeted treatment and other options: modern migraine treatment .
Botulinum toxin treatment for chronic migraine is generally well tolerated. Temporary discomfort or a small bruise may occur at an injection site.
Treatment-related adverse effects can include temporary neck pain or muscle weakness, and occasionally temporary drooping of the eyelid or eyebrow.
Dr Lidiia Prakhova, MD, PhD, is a neurologist with clinical experience in migraine management and the use of botulinum toxin for neurological disorders.
For a patient with frequent headaches, the first step is not simply to decide whether to “have Botox”. The headache diagnosis, migraine frequency, previous preventive treatments, acute medication use and factors contributing to migraine chronification should first be assessed.
Treatment is then selected according to the individual clinical situation, including whether botulinum toxin, CGRP-targeted therapy or another preventive strategy is appropriate.
If you have previously received botulinum toxin treatment, it is useful to bring information about the product, total dose, date of the previous treatment and your response. A recent headache diary is also helpful.
The established indication is chronic migraine. Botulinum toxin is not a standard preventive treatment for episodic migraine.
The standard PREEMPT protocol includes 31 fixed injection sites. Additional sites can be used when appropriate, bringing the total number of injection sites to 39.
Under the standard PREEMPT protocol, treatment is usually repeated approximately every 12 weeks.
Not necessarily. Some patients show a clearer response after repeated cycles. Treatment effectiveness is generally reassessed after 2–3 consecutive cycles.
In selected clinical situations, combination treatment may be appropriate. The decision depends on migraine severity, previous treatment response, other medical conditions and tolerability.
Yes, if possible. A headache diary provides an objective way to track headache and migraine days and to assess the response to preventive treatment.
If you have frequent migraine or headache, a neurological consultation can help clarify the diagnosis, review previous preventive treatment and determine whether botulinum toxin therapy is appropriate for you.
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