Is botulinum toxin (Botox) useful for migraine?

Botox or “botulinum toxin” is a liquid that relaxes muscles. It is injected into multiple muscles in the back of the neck, and sometimes over the face. The procedure takes only a few minutes, is not very painful and is extremely safe. The effect of Botox starts about 1 week after injection, and lasts for around 3 months.

There is a huge controversy regarding the use of Botox in migraine. Some researchers think it is useful; other researchers think it is useless.

I think the biological reasoning behind its use (prevention of inflammatory mediator release, prevention of central sensitization) is certainly sound.

But in my opinion, most patients do not need it, and neither is it useful in all patients. It is most useful in a small, select group of patients. I think it is most useful in patients with neck arthritis who have compressed nerves in the neck, resulting in worsening of their migraine.

Most migraine patients do not need Botox.

Most doctors will agree that, since it can be expensive, it should only be tried when oral medications have failed or cannot be given.