What it is for
Chronic migraine — headache on fifteen or more days a month, with migraine features on at least eight of them — is a specific diagnosis, and Botox is approved specifically for it. It is a preventive treatment: it does nothing for a migraine already in progress, and the measure of whether it is working is how many headache days you have in a month compared with before.
For people who reach that threshold, that measure is the one that matters. The difference between eighteen headache days and ten is the difference between a life organised around headaches and a life with headaches in it.
How it is given
A defined protocol, not an improvised one: a set number of small injections at specified sites across the forehead, temples, back of the head, the neck and the tops of the shoulders. Each injection is a brief sting with a very fine needle. The appointment takes about fifteen minutes and there is no recovery — you leave and carry on with your day.
It is repeated every twelve weeks.
What to expect, honestly
- It builds. The response to the second cycle is typically better than to the first, which is why two cycles is the standard trial before deciding.
- It reduces, rather than eliminates. Fewer headache days, and often less severe ones, is the realistic target.
- It is assessed against a diary. You will be asked to keep one, because “I think it’s a bit better” is not a basis on which to continue a three-monthly injection regimen for years.
- If it is not working after a fair trial, it stops.
The insurance part
Most plans that cover this require documentation that you meet the chronic migraine criteria, and many require that other preventive medications have been tried first. Prior authorisation is usually necessary. None of that is unusual, but it takes time, and it is better done before you are sitting in the chair.
We check your benefits and tell you what your plan requires up front. If your headaches are frequent but do not meet the chronic migraine threshold, you will be told that and the conversation will be about what else is appropriate, rather than about getting you approved for something you do not qualify for.
The other thing that gets checked
Whether your headaches are coming from your neck. Cervicogenic headache is common, frequently mistaken for migraine, and treated in an entirely different way. Dr. D’Alessio is board-certified in Physical Medicine & Rehabilitation, so examining the cervical spine as part of a headache assessment is routine here rather than an afterthought. Some people who arrive asking about Botox leave with a treatment plan for their neck instead — and get better.