Botox for Chronic Migraine

Many patients have expressed that they receive differing information on what to do prior to and following their Botox treatments. Furthermore, many patients with chronic migraine also live with central nervous system sensitivity and can experience a “Botox Flare” immediately after their procedure. This presents as a worsening of their migraine symptoms for 5–7 days following their injections. This document is meant to be a Discussion Guide to help mitigate those flares and to improve the overall Botox experience for patients.

This Guide has been vetted by five of the top Headache Specialists across the country: Dr. Rose Giammarco (Hamilton), Dr. Ian Finkelstein (Toronto), Dr. William Kingston (Toronto), Dr. Sameer Chhibber (Calgary), and Dr. Sian Spacey (Vancouver). The doctors’ responses vary but will give you a range of options that you can discuss with your own Botox physician.

Nota bene:

  1. Botox for Chronic Migraine is available across Canada. HCPs trained in this injection protocol can be found at www.mychronicmigraine.ca

  2. Botox can be accessed via three methods:
    — Private Health Insurance Plans
    — Provincial Drug Plans in select provinces (check your own province for criteria) — Abbvie Cares compassionate program for those who cannot access the above methods. This must be initiated by your physician so be sure to ask!

  3. Medical Disclaimer: there are no studies on pre- and post-Botox protocols, so all recommendations are based solely on clinician experience and MUST be discussed with your own physician.

Pre-Botox Protocols:

1. Can the patient take OTC meds prior to treatment? Our specialists are divided on this: you can take OTC meds including NSAIDS but some specialists feel there might be a low risk of some increased bruising or bleeding with NSAIDS.


2. Is there a pre-treatment protocol that can be used to mitigate a Botox flare if the patient has severe central nervous system sensitivity? There are many options that can be used (based on your personal medication contraindications, and of course, which medications and treatments are typically most effective for you). Here are some suggestions:

  • Toradol or Naproxen plus a PPI (proton pump inhibitor to protect your stomach lining) a few hours prior to injections and for 3–4 days following.

  • Frovatriptan BID (two times per day) starting the morning of the treatment, prior to treatment and continuing for 2–3 days following treatment.

  • A short increase in your preventives for two days prior to treatment and two days following (e.g. Gabapentin or Amitriptyline).

  • If the flare involves more flu like symptoms you could be having a histamine response. In these cases, Benadryl can be used one hour before the procedure and 3–4 hours after the procedure.

3. What can be used on the patient’s scalp, in cases of severe allodynia or hyperalgesia? Numbing cream such as Emla can be used 20–25 minutes before the procedure but is not typically effective. What seems to be more effective is icing the front of the face or wearing an IceKap for 10 minutes prior to your Botox treatment.

Post-Botox Protocols:

1. Can the patient take NSAIDs immediately after treatment? Yes, as long as you do not have any contraindications to NSAIDS.

2. How long does the patient need to sit up/not lie down after treatment? Do not lie down or touch the face/forehead for 4–6 hours after treatment. If you need to rest, try to remain at a 45–90 degree angle for 4–6 hours after treatment.

3. Can the patient put ice on their head after treatment? Yes, but do not apply any direct pressure to the face/forehead for 4–6 hours after the procedure.

4. Can the patient apply heat to their head after treatment? Yes, but heat could cause the Botox to diffuse so wait 4–6 hours after the treatment to apply it.

5. Does the patient need to scrunch their forehead to prevent brow freeze? This is up to your Botox physician — some of our specialists feel that scrunching helps the binding capacity of the Botox and prevents diffusion, and others feel it does not make any difference at all.

6. How soon after treatment can the patient get bodywork such as massage, acupuncture or physiotherapy? Wait 24 hours before getting any bodywork.

7. Can the Cefaly device be used after getting Botox treatments? If so, how soon after? Wait 24–72 hours and then use as per normal instructions.

8. Should the patient avoid vigorous aerobic exercise after Botox and if so, for how long? Wait 24–48 hours before resuming vigorous exercise.

9. Should the patient expect to see benefits after the first treatment or wait until the third treatment to assess efficacy? About 50% of patients see results after the first procedure, but many don’t see results until the third. The consensus is that if Botox is going to be tried as a preventive therapy, you should commit to three procedures to give it a proper trial even if the first two are not successful. If there is no improvement after three procedures, it is fair to give it up. If there is even a slight improvement, continue to five procedures.

© 2022 Maya Carvalho | Canadian Migraine Society