The most common mistake I see in chronic migraine Botox protocols is a rigid aesthetic map applied to a neurological problem. Migraine responds to patterns of nerve compression, muscle hyperactivity, and trigger point behavior, not just where lines appear on the surface. When you treat the frontalis as if you are chasing wrinkles, you miss the temporalis band that spikes two days before a storm or the occipital knots that light up after a long drive. The difference between a barely helpful session and a life-changing one lies in how you read the patient’s headache diary, palpate the scalp and neck, and adapt your units across zones that behave very differently.
What changes when you treat migraine instead of wrinkles
Cosmetic protocols focus on expression balance, brow shape, and wrinkle softening. Chronic migraine protocols target muscle groups implicated in peripheral sensitization and trigger propagation. The goal is not cosmetic stillness, it is to quiet the input that feeds trigeminal and cervical pathways. That shift changes how we map, how deep we inject, and how we pace touch-ups.
" width="560" height="315" style="border: none;" allowfullscreen="" >
The PREEMPT paradigm remains the backbone: 155 units across 31 standardized sites from the corrugator to the cervical paraspinals, with optional 40-unit follow-the-pain additions in temporalis, occipitalis, and trapezius. It is a framework, not a ceiling. My most consistent long-term responders almost always require some customization within safe boundaries, guided by the patient’s individual pain topography, muscle strength testing, and how they metabolize the product.
The patient workup that predicts success
I ask for a three-part intake. First, a 4 to 6 week headache diary marking pain location, time of day, triggers, and associated neck or scalp tenderness. Second, a brief video set: neutral face, full frown, squeeze eyes, lift brows, wide smile, clench, flare nostrils, purse lips, then gentle head rotations to expose cervical recruitment. Third, a hands-on exam that includes palpation of temporalis bands, occipital insertions, levator scapulae, and trapezius trigger points. I document dominant muscle pulls, asymmetries, tenderness grades, and any sensory changes.
Aesthetic features can help you avoid side effects but should not drive dosing. Heavy brows, thin skin, and a short forehead demand cautious forehead units and specific injection planes to protect function. Masseter hypertrophy, bruxism, or a gummy smile reveal movement patterns that may amplify pain and merit targeted dosing for relief, not just contouring.
Mapping the migraine grid: from brow to neck
The standardized map anchors the plan, then you layer in functional nuance. Below, I outline the zones as I mark them in clinic, with specific comments on dosing strategies for different facial muscles, unit mapping in forehead and glabella, and how injection depth and diffusion control techniques change by location. Dosages reference onabotulinumtoxinA units unless otherwise specified.
Glabellar complex, the tension gate
Corrugator supercilii and procerus work like a vise on the central forehead in many migraineurs. Even those without a deep “11” often report pressure here. I map five points: two corrugator points per side and one procerus center. Typical total is 20 to 25 units, divided 4 to 5 units per corrugator point and 4 to 5 units in the procerus. Strong frowners and those with hyperactive facial expressions may need 30 units across the complex for full relief.
Depth matters. Corrugator origin near the orbital rim demands a deep intramuscular angle before exiting more superficially toward the tail to avoid diffusion into the levator palpebrae. I prefer a 30-gauge, half-inch needle and a bevel-in approach, aspirating lightly when near vascular grooves. The safety margin near the orbital and periorbital area is nonnegotiable. Stay at least a fingerbreadth above the bony rim and inject medially, then track laterally with shallower placement as the muscle thins.
Frontalis, the balance beam
Frontalis dosing is where migraine protocols diverge from wrinkle chasing. Over-relaxation can drop brows and worsen tension headaches by forcing compensatory contraction elsewhere. On the other hand, under-dosing in patients who lift their brows constantly can perpetuate frontal trigger layering.
I map a grid of 4 to 8 points across the upper two-thirds of the forehead, rarely below the mid-forehead line in migraine patients, and I stay at least two centimeters above the brow to reduce ptosis risk. Unit mapping for forehead and glabellar lines must consider muscle dominance. For a strong frontalis with high movement, I use 12 to 20 units in total across the forehead, microdosed in 1.25 to 2 units per point. For a weak frontalis or a short forehead, I drop to 6 to 10 units, spaced widely to preserve lift. The injection plane is intramuscular but shallow, just enough for a gentle wheal if the muscle is thin. If the patient’s brow asymmetry flares when tired, I stagger units to correct dominance and avoid over-flattening the expressive side.
Temporalis, the silent amplifier
Temporalis trigger points are notorious in weather-sensitive or jaw-clenching migraineurs. Standard PREEMPT calls for 20 units per side in this region. I palpate for tenderness bands and allocate 20 to 30 units per side based on pain maps and muscle strength. In bruxism patients or those with masseter hypertrophy, temporalis fibers often overwork. Spread injections across anterior, middle, and posterior temporalis, keeping to an intramuscular depth and perpendicular angle to avoid superficial scalp spread that accomplishes little. Diffusion control matters: I use smaller aliquots per point, 2.5 to 5 units, with injection spacing at least 1.5 to 2 centimeters to limit pooling.
Occipitalis and suboccipitals, where headaches break
Posterior scalp and upper neck insertions can decide whether a patient gets two good weeks or three good months. Occipitalis points sit along the superior nuchal line. I start with 15 units per botox NC side, then follow the pain along occipital grooves with another 10 to 20 units if there is persistent tenderness. Keep the angle at 45 to 90 degrees into the muscle belly, not superficial dermis. Too shallow and you waste units on scalp numbness rather than muscle relaxation.
Cervical paraspinals and trapezius, the posture problem
Desk work, driving, and heavy training load recruit the paraspinals and trapezius into a state of chronic guarding. The PREEMPT total for cervical paraspinals and trapezius is 10 units per side and 15 units per side, respectively. For athletes with high muscle mass or people with prominent trapezial bands, I titrate to 20 to 25 units per trapezius side, divided across three to four points superiorly and medially. Avoid deep medial plunges to stay clear of vascular structures. A 30-gauge half-inch needle generally suffices; in very thick trapezius, a one-inch needle ensures intramuscular placement.
Periocular crows’ feet, a migraine-adjacent decision
Crows’ feet are not part of the core migraine map, but in patients who squint against light, tiny lateral orbicularis doses can reduce photophobia-related tension. The priority is to avoid cheek flattening and smile asymmetry. I place 2 units per point, two points per side, slightly posterior to the lateral canthus and above the zygomatic arch. Microdosing preserves natural movement and minimizes diffusion risk into the zygomaticus. If the patient has thin skin or strong malar smile lines, I skip this zone in early sessions.
Depth, angle, and diffusion: how technique preserves function
Injection depth and diffusion control techniques are the guardrails. Intramuscular placement works for most migraine-relevant muscles. When muscles are thin, such as superior frontalis or lateral corrugator tails, a shallow intramuscular or deep intradermal approach limits drift. I aim for perpendicular entry except near the orbital rim, where a slight cephalad angle protects eyelid elevators.
Spacing controls diffusion spread. I mark a two-centimeter spacing in temporalis and trapezius, smaller spacing for glabella and forehead. I avoid boluses larger than 5 units in thin forehead zones. If a patient has a history of eyelid ptosis, I raise the forehead grid further superiorly and remove medial frontalis points in the first session, then reintroduce cautiously later.
Units, dilution, and conversion: why small choices change outcomes
Dilution ratios define how the product spreads and how precisely you can microdose. For migraine, I prefer a standard dilution that makes math easy and dispersion predictable. Reconstituting a 100-unit vial of onabotulinumtoxinA with 2.5 mL of preservative-free saline yields 4 units per 0.1 mL. If I anticipate fine periorbital work or forehead microdosing, I sometimes dilute to 3 mL to allow smaller aliquots without sacrificing accuracy. More dilute solutions tend to diffuse slightly wider, which can help in thick muscles like trapezius but punish you in the forehead. If I need pinpoint control around the orbicularis, I use a tighter dilution and smaller volumes.
Comparing onabotulinumtoxinA and abobotulinumtoxinA (Dysport) requires attention. The practical clinical conversion sits in the 2.5 to 3 to 1 range, Dysport units to Botox units, though preparations differ. I pick one brand for a patient and stick with it across sessions to help interpret response and modify dosing with fewer confounders. Storage temperature and potency preservation are straightforward: maintain 2 to 8 degrees Celsius, avoid freezing, and use Homepage within the product’s recommended window after reconstitution. I label vials with time and dilution so there is no guesswork.
Metabolism, muscle strength, and how long results last
Longevity differences depend on muscle strength, metabolism, and behavior. Stronger muscles burn through effect sooner, and high-intensity exercise can shorten duration by several weeks in some patients. Bruxism and masseter dominance amplify temporalis strain, which can consume units faster. Most chronic migraine patients sit between 10 and 12 weeks of strong benefit, with a tail to 14 weeks. First-timers often peak later, around week 4, as the nervous system adapts. Repeat patients with stable maps can feel relief in 7 to 10 days.
For fast metabolizers, I use two strategies: slightly higher dosing in dominant muscles, and a shorter treatment interval, often 10 weeks instead of 12. Adaptation in these patients works better than chasing units across the entire map. If they also train intensely, I align sessions just before a planned deload in their schedule.
When to touch up and when to hold
Touch-up timing and optimization protocols matter for both efficacy and safety. I avoid early touch-ups before day 14 unless there is an error to correct, like asymmetrical brow lift that compromises function. Between weeks 3 and 6, a 10 to 20 unit follow-the-pain addition can extend relief without overshooting. If the patient reports 70 percent improvement but persistent unilateral temporal pain, I spend those units in the temporalis and occipitalis on that side, not in the glabella where function is already good.
For long-term maintenance, consistent intervals win. Patients who oscillate between 8 and 16 weeks often experience rebound flares that make mapping harder. I prefer 12 weeks as a default, shift to 10 for fast metabolizers or heavy lifters, and allow 14 for those whose pain calendar stays quiet through month three.
Resistance and why “it stopped working” has layers
True immunogenic resistance to onabotulinumtoxinA appears to be rare in migraine treatment, but reduced response happens for practical reasons. The three most common causes in my practice are under-dosing in dominant muscles after strength increases, changes in trigger behavior due to posture or bruxism, and inconsistent intervals that allow sensitization to rebuild. I also consider neutralizing antibodies after many high-dose sessions or frequent boosters; if suspected, I switch brands or use a different serotype under specialist guidance.
Treatment adjustment options include rebalancing units toward temporalis and occipitalis if frontal zones are already quiet, adding masseter dosing for bruxism, or including trapezius where shoulder tension seeds posterior headaches. If immunogenicity remains likely, I space treatments, minimize unnecessary touch-ups, and consider abobotulinumtoxinA with a careful conversion and new baseline mapping.
Masseter dosing, bruxism, and jaw-driven headaches
Jaw clenching drives a substantial subset of migraine flares. Dosing for masseter muscle reduction overlaps with bruxism relief but must protect chewing strength. I start with 20 to 25 units per side, divided across two or three deep intramuscular points, aiming for the lower half of the muscle belly to avoid zygomaticus diffusion. In large masseters or night-guard dependent patients, totals can reach 30 units per side. If the patient’s facial slimming is not a goal, I monitor volume changes and reduce units once headaches stabilize. Jaw slimming and facial contouring can be a secondary benefit, but the priority is pain reduction and functional chew.
When brow asymmetry and expression habits affect migraine
Hyperactive facial expressions and muscle dominance can propagate triggers. An asymmetrical brow that overcompensates after frontal dosing can recruit forehead strain on the opposite side. I correct with microdosing, 0.5 to 1.5 units, in the dominant frontalis or a slightly higher corrugator dose on the hyperactive side, watching carefully to preserve the patient’s baseline expression. Eyebrow lift mechanics and placement accuracy matter. A subtle lateral lift can relieve pressure for patients who habitually raise their brows to keep eyelids open, but pushing lift too hard creates a Spock-like arch and new muscle tension. If I see eyelid ptosis risk, I remove medial frontalis points and keep corrugator injections more central, then reassess at three weeks.
Perioral, nasal, and DAO: small zones, outsized consequences
Migraines are not created in the lips, but perioral strains can magnify facial pain. For fine perioral lines, I use 0.5 to 1 unit per point in the upper lip to avoid affecting speech or smile. Bunny lines merit a cautious 2 to 3 units per side in the nasalis, avoiding over-relaxation that flares nasal flare control. Downturned mouth corners respond to 2 to 4 units per side in the depressor anguli oris, placed low and medial to protect the smile. A gummy smile correction, if relevant, typically uses 2 units per side in the levator labii superioris alaeque nasi or combined sites. These are advanced add-ons in migraine patients and should wait until the core map is stable.
Neck bands, contour, and the migraine connection
Platysmal bands often accompany cervical strain. For neck contour refinement in a migraineur with band-mediated tension, I treat conservatively, 5 to 10 units per prominent band across two to three sites, keeping superficial to avoid deeper structures. I avoid aggressive diffuse neck dosing during the same session as heavy cervical paraspinal work to minimize swallowing concerns. Vertical neck lines and banding can be addressed in later sessions once headache frequency has dropped.
Safety margins, thin skin, and vascular awareness
Safe migraine mapping requires respect for anatomy. Near the orbit, keep a clear buffer from the rim, particularly medially. In patients with thin skin, reduce per-point volume, use smaller units, and consider more points to distribute effect. Be mindful of vascular structures in the temple and neck; superficial fans in the temple risk intravascular adverse events if you are careless with angle and aspiration. Needle selection best practices matter. I use 30-gauge halves for face and scalp, one-inch for thick trapezius or heavy masseters, and I change needles frequently to keep the tip sharp and reduce pain and bruising.
Skin texture, oil, and the side benefits patients notice
Patients often report smoother skin and less oiliness where we treat. Botox effects on skin texture versus wrinkle depth likely stem from decreased muscle pull on the dermis and reduced sebum output in some zones. The improvement is a bonus in migraine care but not a target. If a patient values these changes, microdosing along the forehead or chin can be shaped to preserve function while offering subtle texture benefits. Avoid chasing pores near the brows in migraine patients until you know their ptosis risk.
Sequencing multi-area treatments without losing the plot
When combining aesthetic and migraine targets in one session, sequence from core migraine zones to optional aesthetic refinements. I start with glabella, temporalis, occipitalis, and cervical groups. If the patient also wants lateral canthus or perioral tweaks, I add them after, adjusting totals to stay within safe cumulative dosing. Combination therapy with dermal fillers belongs on a different day in most cases, especially if significant forehead or temple mapping was done. Edema from fillers can distort your interpretation of muscle response and complicate follow-up.
The preventive mindset: when early intervention helps
Patients with high-movement facial zones, expressive personalities, or strong occupational demands on the brow often build trigger layers over years. Preventative use in these zones, especially considered microdosing in the frontalis and corrugator complex, can reduce the frequency of migraines even before chronic criteria are met. I anchor this strategy in a trial of two to three sessions spaced at 12 weeks, adjusting based on how often headaches cut into function. The key is to preserve natural facial movement while removing the repeated over-recruitment that feeds the pain cycle.
How I adjust over time: muscle retraining and atrophy
Across repeat sessions, muscles adapt. Long-term muscle atrophy benefits and risks should be weighed. Reduced thickness in the temporalis or trapezius can lower headache propagation, but excessive atrophy in masseter or frontalis may alter facial harmony and function. I track changes with simple muscle strength testing before and after animation, and with photos that show symmetry during speech and smiling. Dosing differences for first-time versus repeat patients usually trend down by 10 to 20 percent in zones that remain quiet for two sessions, while stubborn hotspots keep their totals. The goal is muscle retraining, not blanket paralysis.
Complications management: if something goes wrong
The big three issues are eyelid ptosis, neck heaviness, and smile asymmetry. For eyelid ptosis, apraclonidine or oxymetazoline drops can lift the lid a millimeter or two while you wait for recovery. Future sessions should adjust frontalis grids upward and keep corrugator injections more medial with cautious units. Neck heaviness responds to activity modification, gentle physiotherapy, and spacing future trapezius points higher and more lateral with smaller aliquots. Smile asymmetry after perioral or zygomatic spread calls for time, tiny compensatory doses on the contralateral side if needed, and stricter injection plane control next visit.
I also watch for swelling patterns that hint at lymphatic congestion, especially in patients prone to facial puffiness. Botox impact on lymphatic drainage is usually minimal, but large volumes in one area can create transient edema. Smaller volumes, wider spacing, and avoiding same-day fillers help.
Two tight checklists I use in clinic
- Pre-injection map: confirm migraine zones, mark safety margins around orbit, palpate tender bands, document muscle dominance, decide dilution and needle length. Post-injection review: verify symmetry in animation, give onset timeline by area, schedule interval, set touch-up rules, and note any exercise or bruxism adjustments.
A sample protocol for a right-dominant temporal migraineur
Consider a 38-year-old with 18 headache days per month, right-sided temporal throbbing, weather sensitivity, and jaw clenching at night. On exam, right temporalis and occipital tenderness are clear, with mild frontalis dominance on the left and strong corrugators bilaterally. Masseters are thick, more on the right.
I would map the standard 155 units, then add 20 units to the right temporalis, 10 to the right occipitalis, and 10 to the right trapezius, for a total near 195 units. Glabella gets 25 units due to strong frown, frontalis 14 units with a slightly higher density on the left to correct dominance, temporalis 20 left and 40 right, occipitalis 15 left and 25 right, trapezius 15 left and 25 right, cervical paraspinals 10 per side. Masseters receive 20 units left and 25 right. Dilution is 2.5 mL per 100-unit vial for precision in the face and an extra vial at 3 mL for trapezius and occipitalis. I space injections carefully in the right temporalis to cover all tender bands, and I keep per-point volumes small around the forehead.
We schedule at 12 weeks with an option to return at week 4 for a follow-up check, not an automatic touch-up. If day counts drop below 8 by week 6 but right temporal flares persist around storms, I allocate a 10 to 15 unit follow-the-pain booster to the right temporalis and occipitalis.
Subtleties that determine patient satisfaction
- Emotional expression and facial feedback matter. Many patients fear losing their natural look. Microdosing in expressive zones protects identity while still reducing triggers. Exercise intensity can shorten effect; plan intervals and adjust units for athletes. Age and skin elasticity influence plane selection. Thinner, lax skin near the brow wants smaller aliquots and higher placement to avoid droop. Patients with neuromuscular disorders require tighter risk assessment. Contraindications or cautions include myasthenia gravis and certain peripheral neuropathies; coordinate with their neurologist. Storage and preparation discipline prevent variability. Label vials with time, dilution, and patient to avoid potency drift and mix-ups.
What success looks like over a year
By session three, the map sharpens. The glabella may shrink from 25 to 20 units if frown pressure fades. Temporalis on the dominant side may hold its higher total. Masseter dosing often stabilizes or even reduces if the patient commits to a night guard. Treatment intervals settle at 12 weeks with fewer bad days in month three. The patient’s facial harmony and proportion remain intact because you used microdosing where expression matters and heavy dosing where pain originates. The effect duration comparison across regions becomes predictable: glabella and temporalis last longest, frontalis is the first to fade, trapezius varies with workload. The patient learns to recognize early relapse signs and book before the cycle rebuilds.
Final takeaways for clinicians who want reliable outcomes
Chronic migraine mapping with Botox succeeds when you think like a neurologist and inject like an anatomist. Start with the standardized grid so you do not miss foundational sites, then let palpation, animation analysis, and the diary guide unit shifts. Control diffusion with plane, angle, spacing, and dilution. Respect safety margins, especially near the orbital and periorbital area and vascular structures. Use touch-ups sparingly and with purpose. Reassess for resistance only after you have accounted for dosing, intervals, and trigger changes. Above all, treat the patient’s pattern, not the wrinkle map.
Botox remains one of the most flexible tools we have for chronic migraine. With precise mapping, measured dosing strategies across different muscles, and a steady follow-up cadence, you can take a patient from counting sick days to counting good weeks, then good months, without sacrificing their expression or function.