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).
Yes, after injections of Botox about 10% of patients may have worsening of their headaches or neck pain. It usually resolves within a week or so, when Botox starts working. For that worsening, the usual migraine medications, muscle relaxants and NSAIDs can help.
Hi Dr. Mauskop,
This is a great article. Thank you so much for posting. I have had TMJD headaches/migraines for years now. I happened upon a neurologist that started using botox on me – which has had good effects but did not truly give me relief.
I’ve finally opted to get botox in my masseter muscles and we’ve used 60 unites total – after coming back for a second time. I’ve found, all of a sudden, that I’m having a bad headache (what I call a relapse).
I’m wondering if some how the botox shot made it worse? Or is this just part of the process? I know this isn’t truly medical advise and that you may not have enough information.
Have you ever heard of the headache getting worse before getting better when injecting the masseter muscles?
Thanks!
I don’t have enough information to give you an answer.
Hello Dr. Mauskop
I just switched neurologists and was convinced to try Botox injections again as I get more than 15 days a month sometimes combined with cluster headaches. My previous neurologist gave me one that in the middle of my eyes, along my hairline in the front, a few in the side and up the back of my neck on both sides. This is completely different placement from the chart I have seen online and the new doctor showed me. Do I have less of a chance for increased headaches with this approach? You seem to really know what you are talking about.
Thank you
Katie
The loss of muscle strength is the intended effect. Some people need very high doses and repeated quarterly injections to achieve meaningful relief.
Dr. M.,
My neurologist said she only wants to inject my masseter muscle every other treatment now due to risk of loss of muscle strength. 3 weeks post injection I really notice a difference . I am getting alot more frequent headaches that start in the massiter muscle. I don’t feel any loss of strength. Is this a real issue? Anyway I can convince her to do the massiter muscle as well? Thank you!! Lucy
I would wait and see what happens. Chances are the results will be the same. Minor variations in the location of Botox shots is not a problem.
Hi Dr. Mauskop,
I had a second set of Botox injections yesterday. The first set of injections included the temporalis and the protocol of injection sites for migraine were followed. However, for some reason the second time the physician injected 3 injections into the temple area just slightly into the start of the hairline and not into the protocol sites, which are more on the side of the head. It happened quickly, and when I asked why this happened, he said he approached the muscle a different way. At this point my concern is that the injections will at best not be effective, and at worst cause side-effects. I would really appreciate your opinion. Thank you so much
No, that should not be a problem
Hi Dr. Mauskop, Thank you for your response. I wanted to clarify I didn’t have an exaggerated cosmetic appearance from the Botox injections and fortunately have a wonderful, skilled plastic surgeon. My concern was that the next set of injections could possibly do this from a cumulative effect of Botox, given that I’m still seeing a nice cosmetic effect from the last injections. Is this a valid concern, and is it better to wait until either the headaches worsen or cosmetic effect lessens or can a reduced amount of Botox be used in the forehead/eye area? Thank you
You can wait longer than 3 months, but not if headaches start to get worse. The cosmetic effect can last longer than the effect on migraines. I am surprised about the “exaggerated cosmetic appearance” especially because it was done by a plastic surgeon. It should not happen with a good injection technique.
Hi Dr. Mauskop, I had my first Botox injections 3 months ago by a trusted facial plastic surgeon who modified the dose and injection sites to my migraine pattern. It’s difficult to tell yet if the migraines actually reduced and will complete a second set of injections for confirmation.
If the cosmetic effects of Botox are still apparent, can you wait past the 3 months to receive the next injections? I’m concerned about an exaggerated cosmetic appearance. Also, is it normal to have pain when the temporalis muscle on one side was injected? This is one of the sites of my migraine pain. As always, thank you for your help.
Nice article about Botox treatment. Thanks for sharing.
I got my first Botox injections six weeks ago. It was a bad decision. The two first weeks were terrible with nausea and pain in my head, neck, shoulders, arms, and fingers. Then it became slightly better, but I still have to take more tablets (including triptans) a day, than I did before Botox.
Today I woke up feeling a bit strange, like numb in my head, a little dizzy. After I took a shower I realized I have double vision! I have noticed problems with my vision during this time, but today it’s worse. I do hope that I will get my normal vision back when the Botox has left my body.
This is not common, but can happen after Botox or any other injections. We usually prescribe muscle relaxants and anti-inflammatory pain medications and this usually resolves quickly.
i had botox shots two weeks ago in my neck and shoulders for muscle pain, and im in severe pain and can barely move my arm and neck at all. is this usual at all
Talk to your doctor who gave you Botox and ask about getting physical therapy.
Should I do anything about it? Contact the neurologist office? Should I expect the migraines to return? Thank you!
Yes, it sounds like you did not get the standard Botox injection protocol.
I had my botox injections for migraine last week. My normal neurologist is on leave, so the office brought in another neurologist to do all the botox on the necessary patients. I usually get around 30 injections, but this MD gave me less than 10-15, He injected more botox in each site rather than dividing it into different sites. I’m experiencing neck weakness that I’ve not experienced before. Did the MD do it incorrectly?
Yes, an experienced Botox injector should be able to avoid these side effects when treating migraine headaches, even though the dose used for migraines is higher than when trying to achieve only cosmetic effects.
I think precautions are necessary to prevent possible botox cosmetic side effects such as droopy eyelids, double vision, blurred vision, decreased eyesight, eyelid swelling and dry eyes.
The weakness of your neck muscles may not last as long, especially if you do neck exercise to strengthen your muscles. Here is a youtube video with isometric neck exercise.
Thanks for the helpful info ! I almost at one month post-injection for headaches and muscle tension (
(200 units)…..and have had disturbing side effects, the most disabling being droopy head and sore trap muscles, throat muscles, and lower back strain. I am in a cervical collar and miserable.
How long does this last ? My neurologist says another few weeks !!!! I wish he had given me more information prior to this and I blame myself for not exercising due diligence !
Teaching is hard now as I can’t lean over without supporting my head with the left hand. OMG>
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.
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: https://www.botoxchronicmigraine.com/find-botox-specialist/
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!
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.
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.
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.
There is a list of recommended injection sites for Botox, but as I mentioned in the post, these have to individualized.
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.
I don’t know anyone personally, but Allergan, Botox manufacturer lists doctors who inject Botox for migraines. Here is the link – https://www.botoxchronicmigraine.com/find-botox-specialist
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.
I don’t know any headache specialists in Richmond, but Dr. Stuart Stark in McLean is a good headache specialist who injects Botox.
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?
Yes, it is worth trying Botox again, but without injections into the neck and shoulders.
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).
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.
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.
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 – https://www.botoxchronicmigraine.com/find-botox-specialist
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.
Thank you, doctor. I will give them a call.
Much appreciated.
Jack
I would recommend the UC Headache and Facial Pain Center
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