How many Botox injections for chronic migraine?

by Dr. David Watson & Teri Robert Health Professional & Patient Advocate

Full Question:

I've now had botox twice for my migraines without much improvement. My doctor gives me 12 or 13 injections. I've read online that there are usually 31. How important is it that the standard 31 injections be used? My doctor won't discuss why he uses so many less. Should I go to a different doctor? Thanks for any advice you can offer. Laurel.

Full Answer:

Dear Laurel:

The only protocol with FDA approval and the best evidence is for the 31-injection protocol from the preempt clinical trials. In fairness, many of us who use Botox have slight modifications to this protocol, or modify it based on a patient's response. So not everyone getting Botox for chronic migraine needs the exact same thing. Prior to the preempt trials, just about everyone had their own way of giving it. Different doses, different locations, etc. We all thought we were doing the right thing. Once the trials were completed, many of us altered to fit closely to the protocol. Not everyone did. There may be good reasons for this, so just the fact that your doctor does it differently isn't the problem. The problem is the unwillingness to talk with you about your concerns and why what you're getting is different than the approved protocol.

So if you change doctors, do it because of the poor communication, not the style of botox injections. But remember this: if you aren't getting the standard approach to botox, you aren't a non-responder. You need to at least get the 31 injection, 155 unit protocol on two occasions three months apart to decide if botox will work for you. Below is a diagram of the 31 injection sites. You may find it helpful when you talk with your doctor.

Thanks for your excellent question,
David Watson, MD, and Teri Robert

About Ask the Clinician:

Dr. David Watson is a UCNS certified migraine and headache specialists and director of the Headache Center at West Virginia University. He and Lead Health Guide Teri Robert, team up to answer your questions about headaches and Migraines. You can read more about Dr. Watson or more about Teri Robert .

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Dr. David Watson & Teri Robert

Do you have questions about Migraine? Reader questions are answered by UCNS certified Migraine and headache specialist Dr. David Watson, and award-winning patient educator and advocate Teri Robert.