Are You Receiving Botox Injections in the Right Places?

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I am currently receiving Botox injections for Chronic Migraine from a nurse practitioner in my neurologist’s office. She is ordering my prescription for 344 units. When I come in she has three small syringes half full and the liquid is a pink color. She injects into most of the areas on the charts I have seen except the neck and shoulder. (I have bulging discs, so this is odd to me.)

I am concerned that I am not receiving the amount prescribed, that it might not be Botox at all, that it is not being supervised by the neurologist, and that it is not being injected in all the correct areas for migraine treatment. Should I find someone that is strictly a pain or migraine specialist? Thanks, Claire.


Dear Claire,

Many things about your experience seem outside of the norm. That does not, however, necessarily mean that anything is wrong.

Botox is provided by the manufacturer (Allergan) in 100- or 200-unit vials. The actual Botox is a dried substance at the bottom of the vial that looks like a white residue. It is recommended that Botox be mixed with preservative-free normal saline, which is clear, and that the mixture appears clear as well.

The recommended dosing of Botox, based on the FDA approval for chronic migraine, is a “fixed-site, fixed-dose” protocol of 155 units spread out over 31 injection sites, including the forehead, temples, neck muscles, and even upper trapezius muscles. However, many providers, myself included, will deviate from this protocol when it seems warranted. We may increase the total dose, shift some of the dose to other locations, or even skip certain injections due to past side effects. 344 units is a very strange amount at any time, as it is hard to be more accurate than five-unit increments.

Honestly, bulging disks should have nothing to do with the decisions related to chronic migraine and Botox.

A nurse practitioner or physician’s assistant is often the person who does the injections in many offices. This is not a problem as long as they were trained appropriately.

Before you go in search of a different provider, I recommend you ask your current provider a few questions:

  1. Is this actually Botox (onabotulinumtoxinA)? Are there are other forms of botulinum toxin that are not approved for chronic migraine, but may be appropriate in certain circumstances?
  2. Why is it that color?
  3. Why are you not injecting my neck and shoulders as is recommended?
  4. How and when were you trained to give Botox?

If you don’t get satisfactory answers, or they seem reluctant to answer you, then you should seek out alternatives.

Thank you for your question,

Dave Watson

See more helpful articles:

Botox for Chronic Migraine: Knowledge of Anatomy Is Critical

Botox for Migraine – A Suggestion for Easing Injection Site Pain

How many Botox injections for chronic migraine?

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