Botox is one of the most effective and safest treatments for frequent and chronic migraines. One of the potential side effects of Botox is droopy eyelids. When injections are done correctly this happens in a very small percentage of patients. This is more common in older people partly because with age eyelids tend to sag naturally and partly because relaxing wrinkles makes the skin of the forehead relax down. Sometimes, what droops are not the eyelids (ptosis) but the eyebrows (brow ptosis). In either case, it can cause not only a cosmetic problem but can also interfere with vision.
If this happens, two types of eye drops can help lift the eyelids. Apraclonidine (Iopidine) is an old medicine for the treatment of glaucoma. It tightens the eyelid muscle and makes the eylid move up. Oxymetazoline (Upneeq) was approved by the FDA in 2020 to lift droopy eyelids that occur with age (acquired blepharoptosis). Although oxymetazoline is specifically approved for droopy eyelids, I mostly prescribe apraclonidine because of a large cost differential. Oxymetazoline is a branded product protected by a patent, while apraclonidine is an inexpensive generic drug.
Another way to provide temporary relief is to use double-sided eyelid tape.
For one of my patients, none of these methods worked. She developed droopy eyelids every time she had Botox injections even when injections were given high up in the forehead. And she needed those areas injected because her migraine pain was localized to the forhead. She solved this problem by having a plastic surgeon perform a surgical eye lift. This allowed her to continue Botox injections without any side effects.
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