Botox for Chronic Migraine: Knowledge of Anatomy Is Critical

by Teri Robert Patient Advocate

Botox (onabotulinumtoxinA) can be a very effective treatment for people with chronic migraine. As with other treatments, it doesn’t work for everyone. One way in which Botox differs from oral Migraine preventive treatments is that its efficacy and safety can be impacted by the expertise of the person administering the Botox treatment and their appropriate observation of injection sites and the muscles involved.

Blumenfeld, et. al., explored this in a 2017 article in Headache.

The article:


“To provide clinically relevant insights on the identification of the muscles and techniques involved in the safe and effective use of onabotulinumtoxinA for chronic migraine prophylaxis.”


“Although guidance on the use of onabotulinumtoxinA for chronic migraine is available, based on the Phase III Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) clinical program, clinical experience has shown that insufficient understanding of the anatomy and function of the head and neck muscles may lead to undesirable outcomes and suboptimal efficacy.”

Based on clinical experience, researchers noted that side effects or unwanted outcomes sometimes led practitioners to lower the Botox dosage or omit some of the injection sites in the standard injection protocol. Side effects also led some doctors and patients to repeat Botox treatments less frequently than the recommended 12 weeks. However, they also noted that, “It must be cautioned that lowering doses, avoiding muscles, or delaying repeat treatments may lead to suboptimal efficacy.”

They wrote:

“Thus, there is a need for further guidance in identifying the correct muscle sites for injection and in applying optimal techniques to achieve the efficacy and safety observed in clinical trials;”


The authors advise:

  • The identification of the muscles in the Botox injection protocol as established in the PREEMPT trials of Botox for chronic Migraine should be based on each patient’s unique anatomy.

  • Botox injections should be administered using the advised techniques established in the PREEMPT trials of Botox for chronic Migraine.

  • A thorough examination of the patient and their medical history prior to administration of Botox treatment is critical to determine if any preexisting conditions may increase the risk for unwanted outcomes

  • Appropriate treatment expectations for Botox treatment should be discussed the patient prior to injecting.


“Thorough knowledge of the functional anatomy of the muscles involved in the standardized PREEMPT injection paradigm is critical to achieve the efficacy and safety observed in clinical trials. In addition, it is important to assess a patient’s baseline condition to anticipate the risk for unwanted outcomes that may result from treatment.”

Summary and implications for patients:

This follow-up on the safety and efficacy of Botox can, if it reaches practitioners who are administering Botox, may well result in better treatment results for some patients.

If you’re considering Botox treatment for the chronic Migraine prevention, don’t hesitate to ask about the qualifications of the person who will be administering the treatment. The protocol for chronic Migraine is different from protocols for other medical conditions and cosmetic procedures. It’s vital that anyone administering Botox for chronic Migraine have proper training.

If you’re received Botox treatment for chronic Migraine, and it was ineffective or resulted in negative side effects, you may want to check to see if the treatment was administered correctly. If it wasn’t, you might want to consider trying it again with a properly trained clinician.

The image at the top of this article shows the injection protocol for Botox for chronic Migraine. After a thorough examination of your musculature and review of your medical history, your doctor may vary from this protocol slightly.

David B. Watson, MD, a UCNS certified Migraine and headache specialist, offered his perspective on this topic:

“I agree that proper training and experience are important in the injection of Botox for chronic Migraine. I often see patients who have "failed" Botox in the past, but on further questioning were given limited injection sites (often limited to the forehead) or sometimes injected in a purely "follow the pain" technique. While for some people this can still be effective, it is not evidence based. However, I also will sometimes change sites, increase dose per injection, or eliminate injection sites based on the patient's experience and preference. However, if the change does not add benefit, the fall back is to return to the PREEMPT protocol.”

Blumenfeld A, Silberstein S, Dodick D, et. al. Insights into the functional Anatomy Behind the PREEMPT Injection Paradigm: Guidance on Achieving Optimal Outcomes. Headache. Early view. First published online April 6, 2017.

Email interview with David B. Watson, MD, director of the Headache Center at West Virginia University. August 6, 2017.

Teri Robert
Meet Our Writer
Teri Robert

Teri Robert is a leading patient educator and advocate and the author of Living Well with Migraine Disease and Headaches. A co-founder of the Alliance for Headache Disorders Advocacy and the American Headache and Migraine Association, she received the National Headache Foundation's Patient Partners Award and a Distinguished Service Award from the American Headache Society.