📅 19 August 2026🏷 Medical Botox

Botox for Chronic Migraine: The Protocol, the Criteria and the Cost

By Lucas, Founder & Lead Researcher

Reviewed for medical accuracy against our Medical Review Board · Last updated 19 August 2026

Part of Botox Guides: Basics, Dosing and Safety

Botox for chronic migraine is 155 units given across 31 fixed injection sites, every 12 weeks, and it is only approved for people with 15 or more headache days a month. It is a preventive treatment. It does nothing for a migraine you already have.

A clinician injecting the temple of a patient wearing a headband during a treatment — The temples take 40 of the 155 units in the approved protocol, more than twice the forehead, and they are only one of seven muscle groups treated.

This is the one use of Botox on this site that is a medical treatment rather than a cosmetic one. It has been FDA approved since 2010, it has a fixed published protocol, and it is usually paid for by insurance. Almost everything that follows is different from the cosmetic treatments, including who should be holding the needle.

1. The 15-day gate, and why most people are turned down

The approved indication is narrow and precise. Botox is indicated for the prevention of headaches in adults with chronic migraine, and chronic migraine has a definition: 15 or more headache days a month, with headaches lasting four hours a day or longer.

That threshold is the whole ballgame, and it is where most enquiries end.

14 days is not 15. Fewer than 15 headache days a month is episodic migraine. Botox is not approved for it, the trials were not run on it, and an insurer will decline it. This is not your doctor being obstructive. It is the line the approval draws.

The practical consequence: keep a headache diary before your appointment, not after. Dates, duration, and whether it was a headache day at all. A neurologist cannot certify 15 days a month from memory, and a vague history is the most common reason a request fails at the insurance stage rather than the clinical one. Three months of records is the usual expectation.

2. The full protocol: 155 units, 31 sites

Unlike cosmetic treatment, where dosing is a judgement call, this protocol is fixed. It comes from the PREEMPT trials, two Phase III studies of 1,384 adults that supported the 2010 approval, and it is the reason your treatment should look the same in Denver as in Chicago.

The PREEMPT protocol: 155 units in total, 5 units at each of 31 fixed sites, spread across seven muscle groups on the head, neck and shoulders. Injections are repeated every 12 weeks.
Muscle group	Units	Sites	Where that is
Frontalis	20	4	The forehead
Corrugator	10	2	Between the brows, one each side
Procerus	5	1	The bridge of the nose
Temporalis	40	8	The temples, the largest share
Occipitalis	30	6	The back of the head
Cervical paraspinal	20	4	The back of the neck
Trapezius	30	6	The tops of the shoulders
Total	155	31	Every 12 weeks

Two things worth noticing. The temples take the largest share at 40 units, more than twice the forehead. And more than half the total, 80 of the 155 units, goes into the back of the head, the neck and the shoulders rather than the face.

Some prescribers add further injections beyond the 155 units, following where a particular patient's pain actually sits. That is a recognised approach and the labeling allows for it, but the fixed 155 is the starting point rather than a menu.

For comparison, a whole forehead treated cosmetically takes about 20 units. This is nearly eight times that dose. Our units guide and calculator sets out the cosmetic figures for every area.

3. It is prevention, not rescue

This is the most expensive misunderstanding in the subject, so it is worth being blunt.

Botox does not treat a migraine you currently have. It will not shorten an attack, it is not a painkiller, and being injected during an attack is not how it works. It is prophylaxis: a treatment given on a schedule to make future attacks less frequent. Your rescue medication stays exactly as it is.

The measure of success is also not what most people expect. It is not "no more migraines". It is fewer headache days per month than you were having before. The PREEMPT trials showed a significantly greater reduction in headache days than placebo, which is what the approval rests on. A treatment that takes you from 20 headache days to 12 is working, even though you still get migraines.

Going in expecting elimination is the fastest route to concluding a treatment failed when it did not.

4. Why it goes into your neck and shoulders

Patients are routinely surprised to be asked to sit forward so their shoulders can be injected. It is worth understanding why, because it is not padding.

Chronic migraine pain does not respect the boundary between head and neck. The nerves carrying sensation from the upper neck and the back of the head converge with those carrying sensation from the face and front of the head, and pain in one region is commonly felt in the other. Treating the occipital, cervical and trapezius groups addresses that whole territory rather than just the part of your head that hurts most.

So a protocol that treats only your forehead is not the approved protocol, whatever it is being called. If a provider offers "Botox for migraines" and injects only the face, ask which protocol they are following.

5. What to expect, and why you need two cycles

The appointment takes roughly 15 to 20 minutes. Thirty-one injections sounds worse than it is, because each one is a very small volume through a fine needle.
Onset is gradual. Expect two to four weeks before you can judge anything, not days.
Every 12 weeks. Not "when it wears off". The schedule is part of the protocol.
Two cycles before deciding. This is the part most worth knowing: benefit typically builds across treatments, and the second cycle often does more than the first. Abandoning after one round is the most common way people conclude it does not work for them.

Keep the diary going. You will be asked whether it helped, and "I think so" is a weak answer both clinically and to an insurer deciding whether to keep paying. Counted headache days before and after is the evidence that keeps your treatment approved.

6. Insurance: the one that usually is covered

Every other use of Botox on this site is either cosmetic and never covered, or off-label and usually declined. This one is different: it is an approved indication for a recognised medical condition, and coverage is normal rather than exceptional.

What insurers generally want to see:

A chronic migraine diagnosis from a physician, typically a neurologist or headache specialist.
Documented 15 or more headache days a month. Your diary.
Failed preventive medications. Usually at least two different classes tried and either ineffective or not tolerated. This is the step people skip, and it is the one that generates denials.
Prior authorisation before the first treatment.
Documented benefit to keep it approved after the first cycles.

Contrast this with masseter Botox for clenching and grinding, where the same drug in a lower dose is off-label and insurers decline it almost as a matter of routine. The difference is not the medicine. It is whether an approved indication exists.

7. Who should be injecting this

This is not a med spa treatment, and that is the clearest line on the whole site.

Chronic migraine needs diagnosing before it needs treating, which requires a physician who can rule out the other causes of frequent headache. The injections themselves cover the back of the head, the neck and the shoulders, which is anatomy most aesthetic injectors never work in. And the paperwork that gets it paid for is neurology paperwork.

In practice this means a neurologist or headache specialist, or a clinician working directly in that setting. If an aesthetic clinic offers migraine Botox, the questions are who made the diagnosis, which protocol they use, and whether they inject the neck and trapezius at all. Whoever treats you, you can confirm they hold a current license for free, and we list the lookup for every state in how to verify a Botox injector's license.

8. What it costs if you pay cash

Most people will not pay this, because insurance covers it. But the number is worth seeing, both because some people are declined and because it shows what the insurer is actually funding.

The PREEMPT dose of 155 units, priced against the per-unit rates published by clinics in the twelve cities we verify. Rates checked August 2026. These are cosmetic cash rates and a neurology practice will often price migraine treatment differently, so treat this as the order of magnitude rather than a quote.
City	Published rate per unit	155 to 155 units
Atlanta, GA	$9 to $15	$1,395 to $2,325
Austin, TX	$11 to $13.5	$1,705 to $2,092
Charlotte, NC	$9 to $15	$1,395 to $2,325
Chicago, IL	$9 to $15	$1,395 to $2,325
Denver, CO	$10 to $16	$1,550 to $2,480
Las Vegas, NV	$10 to $16	$1,550 to $2,480
Nashville, TN	$10 to $14	$1,550 to $2,170
Phoenix, AZ	$9.99 to $13	$1,548 to $2,015
Raleigh, NC	$13 to $14	$2,015 to $2,170
San Antonio, TX	$10.5 to $12.5	$1,628 to $1,938
Scottsdale, AZ	$10.5 to $13.5	$1,628 to $2,092
Tampa, FL	$10 to $18	$1,550 to $2,790

That is per treatment, four times a year. It is the most expensive Botox treatment there is by a wide margin, which is exactly why the insurance route in section 6 matters more here than anywhere else. Our Botox price guide covers how per-unit pricing works.

9. Side effects at 155 units

A larger dose in more places brings its own pattern, and it is not the cosmetic pattern:

Neck pain and stiffness, the most commonly reported complaint with this protocol. It reflects where the injections go.
Neck weakness. Some people notice their head feels heavier, particularly leaning forward. It comes from treating the cervical and trapezius groups and it eases as the effect wears off.
Injection-site soreness across the scalp and shoulders for a day or two.
Eyelid drooping, from the forehead and glabellar part of the pattern, exactly as in cosmetic treatment.
Headache after treatment, which is a genuinely unwelcome irony and usually short-lived.

There is no reversal agent, so anything that does occur resolves on its own over weeks to months. Report new or worsening symptoms to the prescribing physician rather than waiting for the next cycle.

10. The cosmetic side effect nobody mentions

Look at the protocol table again. It includes 20 units in the frontalis, 10 in the corrugators and 5 in the procerus, which is 35 units across exactly the muscles treated cosmetically for forehead lines and frown lines.

So migraine treatment will soften your forehead and frown lines whether or not that is why you came. Most patients are pleased. Some are not, particularly if the brow feels heavy, which is the same mechanism described in the forehead guide: the frontalis is the only muscle that lifts the brow.

Two honest notes. It is not a reason to seek migraine treatment, and it is not a reason to describe cosmetic treatment as migraine treatment to an insurer. It is simply a consequence of the protocol that you should know about in advance rather than discover in a mirror.

11. What to ask before you agree

Do my records show 15 or more headache days a month? Settle this before anything else.
Do you use the full 155-unit protocol, including the neck and trapezius?
Which preventive medications do I need to have tried first for my insurer?
Who submits the prior authorisation, and what happens if it is declined?
When should I judge whether this is working, and what counts as working? A good answer involves two cycles and a count of headache days.
What should I do if my neck feels weak afterwards?

And keep the diary. It is the cheapest, most useful thing you can bring to every appointment in this treatment.

Frequently asked questions

How many units of Botox for migraines?

155 units, given as 5 units at each of 31 fixed injection sites across seven muscle groups: 20 in the frontalis, 10 in the corrugators, 5 in the procerus, 40 in the temples, 30 in the occipitalis, 20 in the cervical paraspinal muscles and 30 in the trapezius. Treatment repeats every 12 weeks. That is nearly eight times the roughly 20 units used to treat a whole forehead cosmetically. Some prescribers add further injections beyond 155 units following a patient's own pain pattern.

Do I qualify for Botox for migraine?

Only if you have chronic migraine, defined as 15 or more headache days a month with headaches lasting four hours a day or longer. Fewer than 15 days is episodic migraine, which this is not approved for and which insurers decline. Keep a headache diary for about three months before your appointment: dates and duration. A vague history is the most common reason a request fails.

Does Botox stop a migraine once it has started?

No. It is a preventive treatment given on a 12-week schedule to reduce how often attacks happen. It is not a painkiller, it will not shorten an attack in progress, and your rescue medication does not change. Expecting it to work like a painkiller is the most expensive misunderstanding in this treatment.

Why does Botox for migraine go into the neck and shoulders?

Because more than half the dose, 80 of the 155 units, is meant to be there. The nerves carrying sensation from the upper neck and the back of the head converge with those from the face, so pain in one region is often felt in the other. A provider who injects only your forehead is not following the approved protocol, whatever they call it.

Is Botox for migraine covered by insurance?

Usually yes, and this is the one Botox treatment where that is normal rather than exceptional, because chronic migraine is an approved indication. Insurers generally want a diagnosis from a neurologist, a documented 15 or more headache days a month, evidence that at least two preventive medications were tried and failed or were not tolerated, and prior authorisation. Compare masseter Botox for grinding, where the same drug is off-label and usually declined.

How long before Botox helps my migraines?

Two to four weeks for the first signs, and you should not judge it until you have had two full cycles, so roughly six months. Benefit typically builds across treatments and the second cycle often does more than the first. Stopping after one round is the most common way people conclude it does not work for them.

How much does Botox for migraine cost without insurance?

At the per-unit rates published by clinics in the twelve cities we verify, 155 units works out at roughly $1,395 at the lowest published rate to $2,790 at the highest, per treatment, four times a year. It is by far the most expensive Botox treatment there is, which is why the insurance route matters more here than anywhere else. Note those are cosmetic cash rates; a neurology practice may price it differently.

Will migraine Botox change how my face looks?

Yes, to some degree, and you should know that in advance. The protocol includes 35 units across the frontalis, corrugators and procerus, which are exactly the muscles treated cosmetically for forehead and frown lines. So those lines will soften whether or not that is why you came. Most patients are pleased; some find the brow feels heavy, for the same reason described in our forehead guide.

Written by

Lucas Pradella

Founder & Lead Researcher, BestBotoxClinics.com

Lucas founded BestBotoxClinics.com to bring clarity to the aesthetics industry, bringing 13+ years of experience in digital research and analysing online data for signals of quality and trust. He is not a physician, his work is research, data analysis and verifying provider credentials.

More about Lucas · How we work

Medical accuracy: BestBotoxClinics.com maintains a Medical Review Board of licensed clinicians. This article is educational and is not medical advice.