Botox may be most commonly known as a way to smooth out fine lines and wrinkles, but many within our community recognize it as a potentially life-altering migraine treatment. Since it was FDA approved for the treatment of chronic migraine in 2010, over 2 million Botox treatments have been given across the country. Still, some people living with chronic migraine are hesitant to make their appointment because of uncertainties surrounding its cost and how it works. To provide an in-depth explanation of the treatment, Nurse Practitioners Jennifer Slonaker and Natasha Mendez of the Mayo Clinic Headache Division sat down for a Facebook Live event hosted by the American Migraine Foundation. They answered questions about the injection process and other need-to-knows for people considering Botox.

Can you explain how Botox works? – Danielle G.

JS: Botox is made from a highly purified protein of the botulinum toxin that is reconstituted with saline and mixed with saline prior to the injections. We think that the treatment works by blocking the pain signals before they can travel to the head and neck after they are produced by the central nervous system.

What are common side effects? – Stephanie M.

JS: A study found that 9% of patients had an increase in neck pain, making it the most common side effect. About 4-5% of patients had an increase in migraine and headache days, but it was transient so it did go away. About 4% experienced ptosis, a droopy eyelid or a droopy brow, which is completely reversible and will go away when the Botox wears off.

Are there any people you wouldn’t recommend for Botox treatment? – Pat S.

JS: There are a few reasons we might not recommend patients for the Botox treatments. First of all, there is some eligibility criteria that has to be met in order to qualify. You must have at least 15 headache days per month, meaning you get a migraine-type headache lasting at least 4 hours in duration. Outside of that, some insurance companies require you to try at least two preventive medications before you can receive approval for these treatments. Other reasons someone might be unable to receive the Botox injections is if they have an infection at the sites we would be injecting or if they have pre-existing conditions like difficulty breathing, muscular disorders like ALS or if they have an allergic reaction to Botox or Botox-like products. At this time, Botox has also not been approved for women who are pregnant or nursing mothers.

Can Botox be used to treat hemiplegic migraine? – Janet T.

JS: Yes, Botox is approved to treat any form of migraine, as long as it’s a chronic migraine.

NM: And just so you know, the procedure is done in an office setting, and it takes about 15 minutes to complete.

Do we see any changes coming as to the cost of Botox? – Monica P.

JS: At this time, we cannot comment on the cost because that varies by insurance. What we do know is that the majority of insurance companies do cover Botox as a migraine treatment. Allergan, the company that produces Botox, also offers a savings plan which allows patients to put money toward their deductible.

NM: If you have commercial insurance, they’re currently offering $400 toward the out-of-pocket costs if you choose to enroll in that plan.

Can they stop working? I have been getting them for 18 months and I feel like they are not working as well. – Cindy J.

JS: It’s possible, and it happens sometimes. It all depends on how many units of Botox you are receiving over a unit of time, and what the interval is. You can reduce the interval of treatments from 12 weeks, the recommended length between treatments, to maybe 10 weeks. There’s also a possibility of increasing the dosage from the standard 155 units all the way up to 195 units.

NM: It’s also important to make sure you’re getting your treatment cycles at exact intervals. A lot of times, we’ll see patients fall behind on their treatment. They might forget to make an appointment and find out they have to wait 13 or 14 weeks until their next treatment, rather than 12. Once you prolong your treatments, the Botox can become less effective. Always make your next appointment right after you receive treatment.

It began working after 8 weeks, which is strange because it’s supposed to start helping after 2 weeks. Have you heard of this before? – Stacy H.

NM: Actually, studies show that Botox can start working as early as 4 weeks into the treatments, but according to the clinical trials that were done, the results can take as long as 24 weeks. If you’re starting off with Botox initially, you’re going to want to do at least two full rounds, but we do recommend that you do three. The evidence has shown that after three full rounds of Botox, you have a better chance at being a responder. After having completed the three rounds of Botox, patients can expect to have a reduction in their headache days by 8 to 9 headache days per month.

Knowledge is a powerful tool for migraine management, so it’s important to stay up to date on the latest news and research. The American Migraine Foundation maintains a comprehensive resource library full of fact sheets, toolkits, and advice sourced directly from the nation’s leading migraine specialists. Visit AMF’s website to learn more and to find a headache doctor near you.