(Adapted from Dr. Mauskop’s book, The End of Migraines: 150 Ways to Stop Your Pain)
Botox Injections
In the early 1990s, I was one of the first neurologists to start injecting onabotulinumtoxinA (Botox) for the treatment of migraine headaches. Many of my colleagues were incredulous. They could not believe that a treatment directed at the superficial nerves and muscles would help a brain disorder such as migraine. At first, we thought relaxing the tight muscles around the scalp was responsible for the relief many patients reported. Since then, scientists have discovered that Botox blocks the release of pain-signaling neuropeptides from nerve endings in the scalp and reduces transmission of pain messages to the brain, interrupting a vicious cycle that begins centrally but depends on input from peripheral nociceptors, or pain sensors.
The mechanism by which onabotulinumtoxinA works in chronic migraine is now well understood. Following injection into tissues, onabotulinumtoxinA inhibits SNARE-mediated vesicle trafficking by cleaving one of its essential proteins, SNAP-25, which occurs in both motor and sensory nerves. By inhibiting sensory nerve endings in the head and neck, onabotulinumtoxinA reduces the number of pain signals reaching the brain and prevents activation and sensitization of central neurons involved in migraine chronification.
My most dramatic result from Botox injections occurred in a 76-year-old woman. She had been suffering from migraines for 60 years, and, for the previous 20 years, they were occurring daily. She was referred by an experienced neurologist who had run out of options. My first thought was that after 60 years of relentless migraines, her brain circuits were burned in, and nothing could break the vicious cycle of pain. Three months after her first Botox treatment, she called to report that this was the first time in her life that she had three months without a single migraine.
More than 300 doctors from around the world have visited our clinic for training in Botox injections. We've participated in one of the pivotal trials that led to the approval of Botox for the treatment of chronic migraines. I have written extensively on my blog, in articles, and in book chapters. One of the chapters appeared in the volume on headaches in the authoritative 174-volume Handbook of Clinical Neurology. Despite these efforts and guidelines from our professional societies, Botox remains underutilized.
Nerve Blocks
Nerve blocks consist of injecting a drug such as lidocaine or bupivacaine to numb the nerves around the scalp. The most commonly blocked nerves are the occipital nerves, located at the back of the head. We also block the supraorbital (forehead) and temporal (temples) nerves. Your head will feel numb for a few hours after these shots. For many people, this stops migraines.
The evidence supporting occipital nerve blocks for migraine is substantial. A 2025 meta-analysis of randomized controlled trials involving 930 patients found that local anesthetic occipital nerve blocks significantly reduce headache severity in acute migraine attacks within 30 minutes. The 2025 American Headache Society guideline gives occipital nerve blocks a "must offer" recommendation for acute migraine in the emergency department, based on three positive randomized controlled trials. Adding supraorbital nerve blocks to occipital nerve blocks can provide additional benefit, and the same guideline gives the combination a "should offer" recommendation.
Nerve blocks are useful for people who do not respond to medications or have contraindications to taking drugs such as triptans, and for pregnant women who prefer to avoid taking medications. Weekly nerve blocks can also help patients who respond well to Botox (onabotulinumtoxinA) injections but whose effects last less than 12 weeks and who cannot receive more frequent injections because the insurer does not allow them.
Sphenopalatine Ganglion Blocks
The sphenopalatine ganglion (SPG) is a collection of nerve cells underneath the skull and behind the nasal cavity. These cells have a wide network of connections, and numbing them with a local anesthetic such as bupivacaine seems to help migraine headaches.
