Common avoidable problems with Botox injections

One of the most common problems with Botox injections given for chronic migraines is that doctors use the standard protocol without adjusting the dose. One of my patients is an 83 year old woman with chronic migraines who has done exceptionally well with Botox injections with no side effects for the past 16 years. She recently started living in Florida during the winter and had Botox injections given by a local doctor. I provided her with a copy of the injection sites and the total dose, which was 65 units given into 20 sites in the forehead and temples. Her Florida neurologist insisted on giving her the standard 31 injections with 155 units all around the head, neck and shoulders. The result was that she developed drooping of her eyelids and pain and weakness of her neck. It defies common sense to inject a small woman who weighs 90 lbs with the same amount of Botox as a 200-lbs man.

Sticking strictly to the protocol prevents many doctors from addressing clenching and grinding of the teeth (TMJ syndrome), which often worsens migraines. Injecting Botox into the masseter muscles (chewing muscles at the corner of the lower jaw) can have a dramatic effect on TMJ pain and migraines. Other patients may need additional injections into the scalp or upper back, depending on where the pain is felt. Since Botox comes only in 100 and 200 unit vials, if the insurance company approves Botox, it sends us 200 units. Instead of discarding the remaining 45 units, we usually give additional injections into the areas of pain that may not be included in the standard protocol.

Giving injections every 3 months or even every 12 weeks works well for many patients. However, about a quarter of my migraine patients find that the effect of Botox lasts only 10 weeks and in a small number , even less than 10 weeks. Fortunately, some insurance companies allow Botox to be administered every 10 weeks, but many do not. Some even limit injections to every 3 months, and not a day earlier, even though the clinical trials that led to the FDA approval involved giving injections every 12 weeks. Having a week or two of worsening migraines can eliminate the cumulative effect we see with repeated treatments. That is, each subsequent Botox treatment provides better relief than the previous one. This may not the case if headaches worsen before the next treatment is given.

Cosmetic concerns are not trivial since Botox injections can make you look strange – as if you are always surprised or look sinister with the ends of your eyebrows always lifted. This can be easily avoided by injecting a very small amount of Botox into the appropriate muscles above the ends of the eyebrows or a little beyond them. In some patients this can be predicted before the first treatment by looking at the lines seen with lifting of the eyebrows. In others, it becomes apparent only after the first treatment. If the appearance is very unappealing, we ask the patient to return to get two small additional injections for which we do not charge.

To minimize bruising and pain we use very thin needles. A 30-gauge needle is used most often, however an even thinner, 33-gauge needle is also available, but is rarely used (higher number indicates a thinner needle). We recommend using a 33-gauge needles, at least for the forehead, where injections tend to be more painful and where bruising, if it happens, is very visible.

Many dermatologists and plastic surgeons tell their patients not to bend down or do anything strenuous to avoid movement of Botox which may lead to drooping of the eyelids. There is no theoretical or practical evidence for this restriction. Once injected, Botox does not move around freely but stays in the injected area. In my 22 years of injecting Botox, I’ve treated thousands of headache sufferers and fewer than 1% of patients developed drooping eyelids and none were related to bending or any other activities. Drooping is more common in older patients, is always reversible within days or weeks, and sometimes can be relieved by eye drops (aproclonidine).

  1. Sarah says: 08/16/201712:12 pm

    Thank you, Dr. Mauskop! It looks like I will be seeing an anesthesiologist since he is more experienced in administering Botox for migraines than my neurologist. Thanks again for your informative website! I will be asking the dr. to adjust my dose and start with a lesser amount. I wouldn’t have had the confidence to do so without reading your article first.

  2. Dr. Mauskop says: 08/15/201710:12 pm

    You should definitely look for a neurologist or an anesthesiologist who is experienced in treating migraines with Botox. You can find one near you at this website:

  3. Sarah says: 08/15/20172:03 pm

    Thank you for this great information! I have had Botox recommended to me for my chronic migraines and am ready to look for a practitioner. Do you recommend a neurologist, dermatologist, or anesthesiologist specifically or simply whoever has had the most experience injecting Botox for chronic migraine? Also, do you happen to know anyone in Spokane, WA you can recommend? Thanks so much!

  4. Dr. Mauskop says: 02/06/201710:32 am

    Headache and neck pain are two most common side effects after Botox injections and occur in 9% of patients. These usually go away once Botox starts helping a week or two after the injections. If the pain is severe or persistent, the doctor can prescribe a muscle relaxant and a pain medicine, such as naproxen (Aleve) or a different prescription NSAID. For the headache, the first step is sumatriptan or another triptan with or without an NSAID.

  5. My daughter had a botox for 24/7 migrane of 3 months she has increase in headache and neck pain how long it will take untillit will at least come to the base line says: 02/06/20178:03 am
  6. Dr. Mauskop says: 01/17/20172:27 pm

    This rarely happens and usually goes away quickly. This kind of a reaction is not likely to happen again, especially with Botox injections since the needles used are much thinner than those for IV infusions.

  7. Kelley says: 01/17/20171:33 pm

    I was in the ER yesterday for a 3 week long migraine. When they inserted the IV into my arm I had extreme pain, burning and sensitivity. They tried my other arm but the same thing. Finally, they gave me a pediatric needle in my wrist. I have never experienced such pain with an IV in the past. I’m assuming it was skin sensitivity due to the acute migraine.

    I plan to do Botox but am currently a bit squeamish about having it done based on my recent experience with needles. Have you heard of this type of sensitivity? Thank you very much.

  8. Dr. Mauskop says: 01/13/20173:36 pm

    There is a list of recommended injection sites for Botox, but as I mentioned in the post, these have to individualized.

  9. Kelley says: 01/12/20178:19 pm

    Thank you for the referral info. I assume the doctors on that list know how to use Botox specifically on patients with migraines. Is there a certain protocol or list of recommended injection sites you follow that I could show my doctor who probably will do his own version anyway but it would be good to know. The way you explained how you gauge the amount/location of Botox depending on the size/age, etc. of the patient was very good.

  10. Dr. Mauskop says: 01/12/201710:55 am

    I don’t know anyone personally, but Allergan, Botox manufacturer lists doctors who inject Botox for migraines. Here is the link –

  11. Kelley says: 01/12/20171:12 am

    Hello Dr. Mauskop,
    Could you recommend a neurologist/headache doctor in the Charlotte, NC area? And/or South Carolina? Thank you for all of the wonderful information that you provide.

  12. Dr. Mauskop says: 11/24/201611:13 pm

    I don’t know any headache specialists in Richmond, but Dr. Stuart Stark in McLean is a good headache specialist who injects Botox.

  13. Tracey says: 11/24/20165:28 pm

    Hello, I recently saw a neurologist who suggested Botox but without giving me many details. I chose to try the medications he prescribed first (which had almost zero effect on my daily headache). I did not feel confident that this practitioner was the person to see about my chronic headache, with occasional aura and photophobia. Do you have any recommendations for headache specialists in the Richmond, VA area?

  14. Dr. Mauskop says: 10/29/20162:31 pm

    Yes, it is worth trying Botox again, but without injections into the neck and shoulders.

  15. Suki Graves says: 10/29/20169:48 am

    I have Pseudotumor Cerebri (or IIH) that triggers chronic migraine- pretty much a continuous headache of one kind or another. When I tried 2 rounds of botox (prior to IIH diagnosis) the result was muscle spasms in my neck and shoulder so I stopped. Today I have the same pain (occurs occasionally with the IIH and/or migraine) but haven’t received Botox for years. Wondering whether I should try again or whether Neurologist every try adjusting the sites where it’s delivered to avoid this sort of thing. (Preparing for a neuro appointment- looking at options).

  16. Dr. Mauskop says: 10/26/201610:56 am

    Yes, we usually recommend trying at least two rounds of Botox, but you may want to ask the doctor not to inject the areas that have become painful.

  17. Maria says: 10/25/20169:39 pm

    I had my first round of Botox injections. I suffer from barometric pressure migraines. I found no relief from this round. I suffered from very sore shoulders and very sore occipital area for weeks after. My question to you is would you recommend another round of Botox or should I just forget about it.

  18. Dr. Mauskop says: 10/06/20168:13 pm

    I don’t, but the manufacturer of Botox, Allergan maintains a list of injectors across the country and you can find one in Phoenix on this site –

  19. Amy says: 10/06/20165:21 pm

    Do you have a referrals for the Phoenix metro area? I have been receiving botox injections for years and my neurologist is not this particular nor does not factor in all these individual differences when injecting. I would love to find someone who does. I have been considering a second opinion for the past 6 mos and your article has really made steered me more in that direction. Thank you.

  20. Jack Wehr says: 10/04/20162:23 am

    Thank you, doctor. I will give them a call.
    Much appreciated.

  21. Dr. Mauskop says: 10/03/20164:33 pm

    I would recommend the UC Headache and Facial Pain Center

  22. Jack Wehr says: 10/03/201612:57 pm

    Greetings Dr. Mauskop.
    Would you happen to know any headache specialist in Cincinnati, Ohio who you would recommend for a botox trial? I read that you trained quite a few doctors, and I have not had any luck finding someone with the expertise for headache/migraine relief. Thank you in advance for any assistance you can provide.
    Jack Wehr

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