Migraines Treatment
How the Injections Prevent Migraine
The injections use botulinum toxin type A, placed in small amounts into specific muscles of the head and neck. It works by blocking the release of the chemicals that nerve endings use to send pain signals. Over time this quietens the pain pathways that have become over-sensitised in chronic migraine, so attacks are triggered less easily and, when they do happen, they tend to be less severe.
This is a preventive treatment. It is designed to reduce how often migraines happen over the coming weeks and months, not to stop a migraine that has already started. Your usual acute treatment still has a role on the days you need it.
The effect builds gradually and lasts around 12 weeks, which is why treatment is repeated on that cycle. Each cycle adds to the last, and most people find the benefit becomes clearer over the first two or three cycles.
Your Consultation
Every course of treatment starts with a consultation with Dr Karwal. Its purpose is to confirm that what you are experiencing is chronic migraine, to rule out other causes of frequent headache, and to decide together whether this treatment is the right next step for you. Suitability is determined at your consultation.
Keeping a headache diary before you come in makes this assessment far more useful. For at least four weeks, note each day you have a headache, whether it had migraine features such as nausea, light sensitivity or one-sided throbbing pain, and any medication you took. A simple note on your phone is enough. It gives us a clear picture of your baseline and something to measure your response against later.
It helps to bring a list of your current medications with doses, any preventive treatments you have tried in the past and why they were stopped, and any letters from a neurologist or headache specialist. The more we know about what has and has not worked, the better we can advise you.
The PREEMPT protocol
The injection technique used for chronic migraine is based on the PREEMPT programme, short for Phase III Research Evaluating Migraine Prophylaxis Therapy. These were the large clinical trials that established which muscles to inject, how much to use, and how to administer it, and they form the evidence base on which this treatment was approved.
The standard paradigm delivers a total of 155 units of botulinum toxin type A across 31 fixed injection sites, spread over seven muscle areas of the head and neck. Injections are given symmetrically on both sides, with the single exception of the procerus at the midline, and each site receives a small, precise, shallow intramuscular dose.
Where a patient's pain is concentrated in particular areas, up to 40 additional units may be added using a "follow the pain" approach, allowing the treatment to be tailored to the individual rather than applied identically to everyone. This flexibility is part of the original protocol, not an add-on.
The seven injection areas
Frontalis (forehead): 20 units across 4 sites
Corrugator (between the eyebrows): 10 units across 2 sites
Procerus (bridge of the nose): 5 units at 1 midline site
Occipitalis (back of the head): 30 units across 6 sites
Temporalis (temples): 40 units across 8 sites
Cervical paraspinal (upper neck): 20 units across 4 sites
Trapezius (upper shoulders): 30 units across 6 sites
Following a standardised paradigm like this is not about rigidity. It is about delivering the treatment in the same way it was delivered in the trials that proved it worked, so that your treatment is grounded in real evidence rather than guesswork.
What to Expect
You will not feel a change straight away. Some people notice fewer or milder attacks within the first two to three weeks, but the real measure of this treatment is how your months look, not your days. Keep your headache diary going between cycles so that we can compare like with like.
A good result means fewer migraine days each month, attacks that are milder and shorter when they do happen, and less reliance on painkillers and triptans. It does not mean no migraines at all. Some people do become almost attack-free, but that is not the promise, and we would rather you came in with realistic expectations than feel let down by a result that is, by any clinical standard, a success.
Treatment is repeated every 12 weeks. Consistency matters, because each cycle builds on the last and a long gap lets the benefit fade. We judge your response after two or three cycles. If by then there has been no meaningful change in your diary, we will say so and talk through other options rather than continue treating.
Prices
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£800
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£300
FAQs
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It reduces the release of the pain-signalling chemicals involved in migraine and calms the sensitisation of the pain pathways in the head and neck. The aim is to prevent attacks, so you have fewer migraine days, rather than to treat a headache once it has started.
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Across seven muscle areas of the head and neck: the forehead, the area between the eyebrows, the bridge of the nose, the temples, the back of the head, the upper neck and the upper shoulders. This multi-site approach targets the muscles and nerves most commonly involved in migraine.
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The full appointment is around 15 to 20 minutes, with the injecting itself taking only a few minutes.
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The needle used is very fine, so most people find it very tolerable and no anaesthetic is usually needed. Any discomfort is brief.
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Some people notice an early change within the first couple of weeks, but the meaningful benefit builds over the first two to three cycles, so it is best judged over months rather than after a single session.
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Botulinum toxin type A has been an approved preventive treatment for chronic migraine for over a decade, first receiving regulatory approval for this use in 2010, with NICE guidance following in the UK in 2012. This is a well-established, evidence-based treatment rather than an off-label experiment.
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Most are mild and temporary: neck stiffness or discomfort, a short-lived headache before improvement, mild neck or shoulder muscle weakness, and tenderness, bruising or swelling at the injection sites. Temporary eyelid drooping is uncommon. Serious effects, such as difficulty swallowing or breathing, marked muscle weakness or an allergic reaction, are rare, and you would be advised to contact us immediately if you experienced anything concerning.
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No. This is a treatment that helps many people with chronic migraine but not all, which is exactly why the assessment before treatment matters.
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Every 12 weeks. Consistency is part of what makes the treatment work.