Modal Pain Management · Dr. Alex Movshis, MD
After Botox for Chronic Migraine: What to Do, When It Starts Working, and Your Headache Diary
Questions or problems, any hour: (646) 290-6660. Emergency: call 911 or go to the nearest emergency room.
Full guide:modalpain.com/aftercare/
botox-for-chronic-migraine/
At a glance
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Right after the injections
- Small bumps where the needle went in are normal and flatten within an hour or so. A drop of blood can be pressed with gauze.
- Do not rub or massage the injected areas for the rest of the day.
- Botox does not make you drowsy. You can go back to work and drive home unless your vision, eyelids or balance feel off.
- Start a daily headache diary today. The QR code on this sheet opens one you can keep on your phone.
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The rest of the day
- No workouts or strenuous exercise for 24 hours.
- Skip ibuprofen, naproxen, aspirin and other NSAIDs for 24 hours to lower the chance of small bruises. If you need a rescue medicine that day, use one in your plan that is not an NSAID. Do not stop aspirin or a blood thinner prescribed for your heart or blood vessels.
- Try to sleep on your back that night.
- Ice is optional. If a spot on the forehead, scalp or neck feels tender, 10 to 15 minutes of ice is fine.
- Keep taking your usual preventive and rescue migraine medicines unless we changed them.
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The first 2 weeks
- Some people notice fewer headache days in the first week. Many notice nothing yet. Both are normal.
- Neck soreness, stiffness or a heavy-headed feeling, if it comes, usually starts around day 5 to 7 and fades over a few weeks.
- A drooping eyelid, double vision or a hoarse voice needs a call the same day.
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Until your next round
- Fill in the diary every day: headache or not, how bad, how many hours, and every headache pill you took.
- If the effect seems to fade in the last few weeks before your next round, write that down too.
- Your follow-up visit is about 2 weeks after the injections, to check for side effects and early changes. Bring the diary.
- Book your next round for 12 weeks after this one. Most insurers will not pay for a shorter interval.
Call 911 or go to the nearest emergency room for
- Trouble breathing, swallowing or speaking, at any time in the weeks after the injections
- Swelling of the lips, face or throat, wheezing, fainting, or hives spreading over the body
- New weakness all over the body
- A sudden, severe headache unlike your usual ones, or headache with weakness of one side, confusion, fever with a stiff neck, or a seizure
Call us at (646) 290-6660, day or night, for
- A drooping eyelid, double or blurred vision, or a hoarse voice
- Neck weakness that makes it hard to hold your head up
- A migraine flare in the first week that your usual treatment does not control
- Redness, warmth or swelling at an injection site
- Any question about combining Botox with other migraine medicines, or about pregnancy
Your headache diary
Stays on this device. What you enter here is saved only in this browser, so you can come back every day. Nothing is sent to Modal Pain or to anyone else. Print it or bring your phone to your follow-up visit and your next round.
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No headache Mild Moderate Severe Not recorded
No days recorded yet. Add today, including days with no headache.
Twelve weeks is the unit that matters now. The injections took a few minutes, and the real result will be written in a diary over the months ahead, one headache day at a time. Today’s job is simple: go back to your day, leave the injection spots alone, and start counting.
These are the instructions Dr. Alex Movshis gives after Botox (onabotulinumtoxinA) for chronic migraine at Modal Pain Management. If yours was given elsewhere, the diary and the warning signs still apply, but follow your own physician’s instructions where they differ.
The day of the injections
Small bumps where the needle went in are normal and flatten within an hour or so. Leave the injected areas alone for the rest of the day. Do not rub or massage them.
For the first 24 hours, we ask you to:
- skip workouts and strenuous exercise
- skip ibuprofen, naproxen, aspirin and other NSAIDs, which can make small bruises more likely. If you need a rescue medicine that day, use one in your plan that is not an NSAID. Do not stop aspirin or a blood thinner prescribed for your heart or blood vessels.
- try to sleep on your back that night
To be straight about the evidence: these are our precautions, not proven rules. The FDA label gives no instructions about exercise, lying down or posture after the injections (AbbVie 2024), and we know of no controlled study in migraine patients that has tested them. They cost little, so we keep them.
Botox for migraine is given without sedation and does not make you drowsy. Most people go straight back to work. The one activity warning on the FDA label is about driving: do not drive or do anything hazardous if you notice drooping eyelids, blurred vision, dizziness or weakness, which can appear hours to weeks after the injections (AbbVie 2024).
When it starts working
Botox prevents headaches. It does not stop one that is already under way, so keep your rescue medicine plan.
In the pooled PREEMPT trials, headache days were already lower than with placebo injections in the first week, and the gap held from the third week on (Dodick 2019). Over 24 weeks, headache days fell by 8.4 a month with Botox and 6.6 with placebo injections (Dodick 2010). The placebo number is large because counting headaches, seeing a specialist and the natural ups and downs of migraine all lower it. That is why the diary compares you with yourself, over months.
Response often takes more than one round. About half of patients reached a 50% cut in headache days in the first round, and about 1 in 5 more first got there in the second or third, so the PREEMPT authors advise at least two or three rounds before deciding (Silberstein 2015). The American Headache Society counts a 50% cut in headache days, shorter or milder attacks, better response to rescue medicine, or less disability as success, and counts too little response after two quarterly rounds, about six months, as reason enough to try a CGRP medicine (Ailani 2021). The trial numbers in more detail are in the Botox for migraines guide.
The headache diary
The diary on this page keeps a 12-week calendar on your phone and prints it for your visits. Paper works just as well. Either way, write one line a day, including the good days:
- headache or not
- how bad at its worst (mild, moderate or severe) and how many hours it lasted
- whether it had migraine features, such as throbbing, nausea, or sensitivity to light and sound
- every rescue medicine you took, by name
- whether it kept you from work or what you had planned
Start it before the first round if you can, so there is a baseline to compare against. If you have not kept one, estimate your headache days in the 4 weeks before the injections. The diary prints the totals for each 4-week block, which is how the trials and most insurers count.
Count your rescue medicine days. Triptans, opioids or combination pain relievers on 10 or more days a month, or plain ibuprofen or acetaminophen on 15 or more days a month, for more than 3 months, can cause medication-overuse headache and keep the headaches going (Headache Classification Committee 2018). If you are near those numbers, tell us.
Insurers read it too. Each plan’s own policy decides, and our office checks yours. As examples of published policies, Aetna renews Botox for chronic migraine when monthly headache frequency has fallen since treatment started (Aetna 2026). Cigna approves a year at a time and asks for a documented benefit, such as fewer migraine days or fewer severe migraine days (Cigna 2026). Anthem approves the first 6 months, then wants fewer migraine days or severe migraine days plus another meaningful benefit (Anthem 2026). Your diary is the evidence our office sends with the renewal.
Neck soreness, a droopy eyelid, and a bad first week
Most people have no side effects worth mentioning. The common ones come from the toxin weakening the muscles it was injected into. In the trials, neck pain affected 9% of patients given Botox and 3% given placebo injections, eyelid drooping 4% against less than 1%, and muscle weakness 4% against less than 1% (AbbVie 2024). Neck pain began about a week after the injections on average and lasted about three and a half weeks (Diener 2014). These effects wear off, and the next round can be mapped to avoid them. A drooping eyelid, double vision or a hoarse voice needs a call the same day.
A rough first week happens. Severe worsening of migraine that needed hospital care occurred in about 1% of patients given Botox, usually in the first week, against 0.3% given placebo injections (AbbVie 2024). A flare your usual treatment does not control needs a call. The side-effects guide explains why each side effect happens and how technique prevents most of them.
The weeks before your next round
Botox is repeated every 12 weeks. Some people feel it fading before then. In a study of 112 patients who responded to Botox and kept diaries, 25% had headache days creeping back by weeks 10 to 11, and about half by weeks 12 to 13, though the authors note some of it may be a placebo effect or the natural ups and downs of migraine (Ruscheweyh 2020). No study supports giving Botox more often, and most insurers will not pay for an earlier round. Write the fading down. It helps us decide whether to add another preventive.
Other migraine medicines
Keep your rescue medicines and any daily preventive unless we change them. Botox is often combined with CGRP medicines, the monthly or quarterly migraine shots and the daily preventive pill atogepant. In a chart review of 257 patients who added a CGRP antibody to Botox, monthly headache days fell further with no new safety signals (Blumenfeld 2021), and an open-label trial of atogepant added to Botox found no new safety problems either (Rothrock 2026). Neither was a randomized trial. The American Headache Society now counts CGRP medicines as a first-line option for migraine prevention (Charles 2024).
Pregnancy. There are no adequate studies of Botox in pregnancy or breastfeeding (AbbVie 2024). If you are pregnant, planning a pregnancy or breastfeeding, tell us before your next round.
When to go to the emergency room
Botulinum toxin products carry an FDA boxed warning: the effect can spread beyond the injected muscles and cause trouble swallowing, speaking or breathing, generalized weakness, or double vision, hours to weeks after the injections (AbbVie 2024). The Medication Guide notes that no confirmed serious case of spread has been reported at the recommended dose for chronic migraine. If you have trouble breathing, swallowing or speaking, or swelling of the lips, face or throat, call 911 or go to the nearest emergency room, and tell the team you had Botox and on what date. A sudden, severe headache unlike your usual ones, or a headache with weakness of one side, confusion, fever with a stiff neck or a seizure, is also an emergency.
After the result
Dr. Movshis reviews your diary with you at the 2-week follow-up and at each round. A clear drop in headache days means we keep going, and the next round can be adjusted for any side effects. Little change after two or three rounds means we look again at the diagnosis and the plan. That can mean adding or switching to a CGRP medicine with your neurologist, treating medication overuse, or a nerve block for a headache that starts in the back of the head or neck. The routes below are where we usually look. The headache and migraine injections page explains who qualifies for Botox and how it is given.
Frequently asked questions
Rubbing or massaging the injected areas that day, and driving if you notice drooping eyelids, blurred or double vision, dizziness or weakness, which is the one activity warning on the FDA label (AbbVie 2024). Our own precautions for the first 24 hours are no workouts, no over-the-counter NSAIDs such as ibuprofen or naproxen, which can make small bruises more likely, and sleeping on your back that night. Keep taking any aspirin or blood thinner your doctor prescribed. They cost little, though no study has tested them. Keep taking your usual migraine medicines unless we changed them, and if you need a rescue medicine in the first 24 hours, use one in your plan that is not an NSAID.
Usually yes, the same day. Botox for migraine is given without sedation and does not make you drowsy. The FDA label says not to drive if you develop drooping eyelids, blurred vision, dizziness or weakness, which can appear hours to weeks after the injections (AbbVie 2024). If that happens, stop driving until it clears and call us.
Give it at least two rounds, about six months. In the trials, the difference from placebo injections showed up as early as the first week (Dodick 2019), but some people respond only in the second or third round. About half of patients reached a 50% cut in headache days in the first round, and about 1 in 5 more first got there in the second or third, which is why the PREEMPT authors advise at least two or three rounds before deciding (Silberstein 2015). The American Headache Society counts too little response after two quarterly rounds as reason enough to try a CGRP medicine (Ailani 2021). Your diary is how we tell.
Because the result is measured in headache days, and memory is a poor judge of them. Insurers also ask for it. Aetna renews Botox for chronic migraine when monthly headache frequency has fallen since treatment started (Aetna 2026). Cigna asks for a documented benefit such as fewer migraine days or fewer severe migraine days (Cigna 2026). Anthem approves the first 6 months and then wants fewer migraine days or severe migraine days plus another meaningful benefit (Anthem 2026). The diary is that documentation.
It is common. In a study of 112 patients who responded to Botox and kept diaries, 25% had headache days creeping back by weeks 10 to 11, and about half by weeks 12 to 13, though the authors note some of it may be a placebo effect or the natural ups and downs of migraine (Ruscheweyh 2020). No study supports giving Botox more often than every 12 weeks, and most insurers will not pay for it. Record the fading in your diary and tell us, because it helps us decide what else to add.
Yes. Keep your rescue medicines and any daily preventive unless we change them. Botox is often combined with CGRP medicines, the monthly or quarterly migraine shots and the daily preventive pill atogepant. Studies of people on both have not found new safety problems, though none were randomized trials (Blumenfeld 2021, Rothrock 2026). Count the days you take rescue medicine, because frequent use can keep headaches going (Headache Classification Committee 2018).
Neck pain is the most common side effect. In the trials it affected 9% of patients given Botox and 3% given placebo injections, and eyelid drooping 4% against less than 1% (AbbVie 2024). Neck pain began about a week after the injections on average and lasted about three and a half weeks (Diener 2014). Both wear off as the effect does, and the next round can be mapped to avoid them. A drooping eyelid needs a call. The Botox for migraines side-effects guide explains why each one happens.
References
Every figure on this page comes from the sources below. Where no study exists, the page says so and explains the reasoning instead.
- AbbVie. BOTOX (onabotulinumtoxinA) for injection: full prescribing information and Medication Guide. DailyMed, U.S. National Library of Medicine. 2024. Source
- Dodick DW, Silberstein SD, Lipton RB, et al. Early onset of effect of onabotulinumtoxinA for chronic migraine treatment: analysis of PREEMPT data. Cephalalgia. 2019. doi:10.1177/0333102418825382 · PubMed
- Dodick DW, Turkel CC, DeGryse RE, et al. OnabotulinumtoxinA for treatment of chronic migraine: pooled results from the double-blind, randomized, placebo-controlled phases of the PREEMPT clinical program. Headache. 2010. doi:10.1111/j.1526-4610.2010.01678.x · PubMed
- Silberstein SD, Dodick DW, Aurora SK, et al. Per cent of patients with chronic migraine who responded per onabotulinumtoxinA treatment cycle: PREEMPT. J Neurol Neurosurg Psychiatry. 2015. doi:10.1136/jnnp-2013-307149 · PubMed
- Ailani J, Burch RC, Robbins MS. The American Headache Society Consensus Statement: update on integrating new migraine treatments into clinical practice. Headache. 2021. doi:10.1111/head.14153 · PubMed
- Diener HC, Dodick DW, Turkel CC, et al. Pooled analysis of the safety and tolerability of onabotulinumtoxinA in the treatment of chronic migraine. Eur J Neurol. 2014. doi:10.1111/ene.12393 · PubMed
- Ruscheweyh R, Athwal B, Gryglas-Dworak A, et al. Wear-off of onabotulinumtoxinA effect over the treatment interval in chronic migraine: a retrospective chart review with analysis of headache diaries. Headache. 2020. doi:10.1111/head.13925 · PubMed
- Headache Classification Committee, International Headache Society. The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018. doi:10.1177/0333102417738202 · PubMed
- Blumenfeld AM, Frishberg BM, Schim JD, et al. Real-world evidence for control of chronic migraine patients receiving CGRP monoclonal antibody therapy added to onabotulinumtoxinA: a retrospective chart review. Pain Ther. 2021. doi:10.1007/s40122-021-00264-x · PubMed
- Rothrock J, Najib U, Ailani J, et al. Safety, tolerability, and efficacy of atogepant added to onabotulinumtoxinA for the preventive treatment of chronic migraine: a phase 3, multicenter, 24-week, open-label study. Cephalalgia. 2026. doi:10.1177/03331024261429118 · PubMed
- Charles AC, Digre KB, Goadsby PJ, et al. Calcitonin gene-related peptide-targeting therapies are a first-line option for the prevention of migraine: an American Headache Society position statement update. Headache. 2024. doi:10.1111/head.14692 · PubMed
- Aetna. Clinical Policy Bulletin 0113: Botulinum Toxin. Aetna clinical policy bulletins. 2026. Source
- Cigna. Drug Coverage Policy IP0637: Botulinum Toxins, Botox. Cigna coverage policies. 2026. Source
- Anthem. Medical Drug Clinical Criteria CC-0032: Botulinum Toxin. Anthem (Elevance Health) clinical criteria. 2026. Source
These are general instructions after a botox (onabotulinumtoxina) for chronic migraine. If the instructions you were given at discharge differ, follow the ones you were given, because they account for your medications and your procedure. For anything you are unsure about, call (646) 290-6660. See the botox (onabotulinumtoxina) for chronic migraine page for how the procedure works and who it helps, or the aftercare instructions for other procedures.