FDA-Cleared · Minimally Invasive

If migraines dominate your calendar, Botox might finally give you your days back.

Botox — onabotulinumtoxinA. Delivered on the standardized PREEMPT protocol, it reduces headache days for the right candidates. At Exhale Sinus, TMJ, Headache and Sleep, we evaluate whether you qualify, coordinate insurance, and the injections.

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What is Botox for migraines?

Botox is the brand name for onabotulinumtoxinA, a purified protein that temporarily blocks the release of certain nerve signals when injected into muscle. For migraine, the mechanism isn't primarily muscular— it's thought to work by dampening the release of pain-signaling neurotransmitters (like CGRP and substance P) from nerve endings around the head and neck, effectively lowering the brain's headache threshold.

It is not approved for episodic migraine (fewer than 15 headachedays per month).

Who is a candidate for Botox for chronic migraine?

Botox is indicated for adults with chronic migraine, defined as:

15 or more headache days per month

For at least 3 months

With 8 or more of those days meeting migraine criteria

If your headaches are less frequent than that, you may still have severe migraine — but Botox likely isn't the right tool. Other preventive options (CGRP monoclonal antibodies, oral preventives, trigger management) are usually the better first step. See migraines for the full treatment ladder.

What is the PREEMPT protocol?

PREEMPT — Phase III Research Evaluating Migraine Prophylaxis Therapy — is the standardized injection protocol used for Botox for chronic migraine. It specifies:

31 Injection Sites

Across 7 specific muscle groups (forehead, temples, back of head, upper neck, and shoulders)

155 Units Total

155 units total of onabotulinumtoxinA (with an optional "follow-the-pain" 40-unit adjustment)

Injections Every 12 Weeks

This cadence is critical to sustained benefit

PREEMPT — Phase III Research Evaluating Migraine Prophylaxis Therapy — is the standardized injection protocol used for Botox for chronic migraine. It specifies:

What if I have episodic migraine, not chronic?

You have options. Episodic migraine (fewer than 15 headache days/month) responds to:
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CGRP monoclonal antibody preventives (monthly or quarterly injections)

Oral preventive medications (beta blockers, topiramate, tricyclics, and others)

Gepants (both acute and preventive newer options)

Trigger management, sleep optimization, and treating coexisting sinus, TMJ, and cervical drivers

What is the injection process like?

Injections take roughly 15 to 20 minutes. Most patients tolerate them well. Common experiences:
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Mild pinching or stinging at each site

Small welts that resolve within an hour

Some patients report mild neck ache for 1 to 2 days

Rare temporary eyelid or eyebrow droop

Very rare allergic reaction

You can return to normal activities immediately. We ask you to avoid lying flat, rubbing the injection sites, or heavy exercise for the rest of the day.

How well does Botox for chronic migraine work?

The PREEMPT trials showed that patients receiving Botox averaged roughly 8 to 9 fewer headache daysper month by 6 months compared to baseline, with significant improvements in disability scores and quality of life. Response typically builds over the first two injection cycles — meaning patients often seethe biggest benefit after their second or third round, not the first.

The realistic promise: for the right patient, Botox can turn a life that revolves around migraines into a life that has migraines in it.

Migraine-Specific Quality of Life Questionnaire (MSQ)

Measure what migraines are taking from you.

The MSQ measures how much migraines interfere with your life rather than simply how often they occur. Seven questions cover time lost with family and friends, missed responsibilities at work or home, reduced output, low energy, needing help from others, and plans you've cancelled. Each scores 0 to 4, giving a total from 0 to 28 — higher means greater impact. Because frequency alone understates disability, this score helps your physician judge whether preventive treatment is warranted.

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1 Min Assessment

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Frequently Asked Questions

Is Botox for migraines the same as cosmetic Botox?

Same molecule (onabotulinumtoxinA), different dose, different injection pattern, different purpose. Chronic migraine dosing uses 155 units across 31 sites in a specific protocol. Cosmetic Botox uses much smaller amounts in different locations.

Will it change how my face looks?

The PREEMPT protocol includes forehead sites, so there is a modest cosmetic effect for most patients — often described as fewer forehead lines. It's not designed as a cosmetic treatment, but many patients don't mind the side benefit. Uncommon but possible: temporary asymmetry that resolves within 12 weeks.

How soon will I feel a difference?

Some patients notice reduced headache days in the first few weeks; most feel the strongest effect after their second or third round (i.e., 3 to 6 months in). If you're not responding at all after two full cycles, we reassess the plan.

Does Exhale actually administer Botox for migraines, or refer out?

We evaluate eligibility, coordinate insurance authorization, and deliver injections according to the PREEMPT protocol.

Can I do Botox and CGRP antibodies at the same time?

In some cases, yes — many headache specialists combine them for patients with severe chronic migraine who don't fully respond to either alone. This is a coordination-of-care conversation.

Are there people who shouldn't get Botox for migraine?

Yes. People with certain neuromuscular disorders (myasthenia gravis, Lambert-Eaton, ALS), active infection at injection sites, allergy to any component, or pregnancy should not receive Botox. We screen for all of this.

Can Botox help my TMJ jaw pain too?

The PREEMPT migraine protocol does not include the chewing muscles (masseter, temporalis). Botox for TMJ is a separate, off-label use with different injection sites. We can discuss both if applicable.