Migraine Therapy with Botulinum Toxin – Enhanced Quality of Life Through Modern Medicine

Dr. med. Thomas Ackermann · Specialist in Anaesthesiology · approx. 6 min read

Migraine is not simply a headache. It can wipe out entire days: throbbing pain, light sensitivity, nausea, the constant fear of the next attack. Clinically, there is often more behind it than a single, isolated problem.

A note on terminology: Many patients search for "Botox" — a brand name of one single product that has become a colloquial umbrella term. The active substance is botulinum toxin type A, contained in several licensed medicinal products. All of them are prescription-only and are injected exclusively by the physician after a medical examination. This page uses the substance name throughout — it refers to the same treatment commonly known as a Botox treatment.

In consultations, I frequently see a pattern that tends to get lost in the strict textbook separation of headache types: migraine, nocturnal teeth grinding (bruxism) and tension-type headache often occur together in the same patient and reinforce one another.

Illustration of migraine therapy with botulinum toxin, head and jaw area
Migraine, bruxism and tension-type headache overlap clinically more often than the strict textbook separation would suggest.

The clinical view: a pain triangle, not three separate diagnoses

A heavily tensed jaw muscle (masseter) can trigger tension-type headaches, which in turn can set off a migraine attack. Rather than treating each diagnosis in isolation, we assess this interplay as a whole — with a medical work-up that locates the individual trigger points before anything is injected.

Where useful, we combine the injection therapy with manual medicine / chiropractic techniques: while botulinum toxin type A reduces sustained muscular tension and affects the transmission of pain-related messengers (including CGRP), manual-medicine techniques release accompanying mechanical restrictions of the cervical spine or jaw joint.

What is actually proven for chronic migraine

Fact

Approval of botulinum toxin type A applies specifically to chronic migraine (at least 15 headache days per month, at least 8 of them migraine-like, over at least 3 months) — not to episodic migraine with less frequent attacks. The pooled PREEMPT study programme (two randomised, placebo-controlled phase III trials, n = 1,384) showed, after 24 weeks, a reduction in headache days of 8.4 days on average versus 6.6 days under placebo (statistically significant). The subsequent long-term COMPEL study (n = 716, over 108 weeks / nine treatment cycles) confirmed the effect over the long term: a reduction of 10.7 headache days and a significant improvement in quality of life (HIT-6 score).

Bruxism: what the muscle tells us

Fact

For treatment of the masseter muscle in bruxism, data exist on the direct muscular effect: an ultrasound study (Erdil et al., 2022) shows a measurable decrease in masseter thickness and a reduction in teeth-grinding symptoms (Fonseca index) after 6 months; another study (Yu et al., 2007) found an average volume reduction of the masseter of around 30%, alongside normalised bite force. This explains the muscular relief — direct proof that this relief also reduces headache frequency has not, by itself, been established.

Tension-type headache: honestly, no established evidence as a stand-alone therapy

In Context

A recent systematic review and meta-analysis (16 randomised, placebo-controlled trials on chronic tension-type headache and cervicogenic headache combined) reaches a sober conclusion: for botulinum toxin type A as the sole, isolated therapy for tension-type headache, there is no clear evidence from controlled trials. That does not mean treatment must be ineffective in this context — but it does mean we do not communicate a reliable guarantee of success here, unlike with chronic migraine.

Our clinical consequence: we do not treat tension-type headache as a stand-alone indication with a promise of success, but as part of the pain triangle described above — in combination with the well-established migraine treatment and the muscular masseter therapy, and with realistic, measured expectations.

Not a Promise of a Cure

Opportunities and limits, honestly stated

  • No miracle cure: medicine is not mathematics — a guaranteed result does not exist for any chronic pain condition.
  • Well established: for chronic migraine, under the criteria named above.
  • Clinically plausible but not established by controlled trials: for isolated tension-type headache.
  • Possible side effects: rarely, temporary mild asymmetries of facial expression, small bruises at the injection site; with masseter treatment, rarely a temporary weakness when chewing very hard foods.

How treatment works in our practice

As a specialist in anaesthesiology, pain medicine is my core expertise. Every treatment is preceded by a thorough medical work-up to locate the individual trigger points.

  • Detailed history and examination, including differentiation of the headache types involved
  • Precise, virtually painless injection with the finest needles at individually determined points
  • Treatment every 12 weeks, as specified in the licensed treatment schedule
  • Follow-up monitoring using a headache diary

Costs depend on findings and the scope of treatment and vary individually — you will find an overview on our costs page.

Medicine is not mathematics. Our clinical experience and the available evidence show, however, that the symptom burden can be significantly and durably reduced in many patients — when the diagnosis is right and expectations stay realistic.

— Dr. med. Thomas Ackermann · Specialist in Anaesthesiology

Frequently asked questions

Does botulinum toxin type A help with every form of migraine?

The established approval relates to chronic migraine (at least 15 headache days a month, at least 8 of them migraine-like, over at least 3 months). For episodic migraine with less frequent attacks, other, better-established therapies take priority — we discuss this in a personal consultation.

Why is the jaw muscle (masseter) also treated when I come in for migraine?

Because migraine, bruxism and tension-type headache are clinically often linked. A tense jaw muscle can trigger headache. Whether co-treating the masseter makes sense depends on the individual findings.

How quickly does the treatment work?

An onset of effect is usually noticeable after a few days to two weeks; the full effect often only appears after several treatment cycles on the 12-week schedule.

Is the treatment the same as for wrinkle treatment?

The active substance is the same (botulinum toxin type A), but dosage, injection scheme and target muscles differ fundamentally from the aesthetic application.

What if the tension-type headache component is the main issue?

Then we discuss openly that the evidence, viewed in isolation, does not show clear efficacy here, and we place the treatment realistically as part of an overall concept — not as a stand-alone therapy with a guarantee of success.

Further reading

What the studies show

Selected sources:
  • Dodick DW, Turkel CC, DeGryse RE, et al., 2010. OnabotulinumtoxinA for treatment of chronic migraine: pooled results from the double-blind, randomized, placebo-controlled phases of the PREEMPT clinical program. Headache. PMID 20487038.
  • Blumenfeld AM, Stark RJ, Freeman MC, et al., 2018. Long-term study of the efficacy and safety of OnabotulinumtoxinA for the prevention of chronic migraine: COMPEL study. The Journal of Headache and Pain. PMID 29404713.
  • Roland SB, Pripp AH, Msomphora MR, Kvarstein G, 2021. The efficacy of botulinum toxin A treatment for tension-type or cervicogenic headache: a systematic review and meta-analysis of randomized, placebo-controlled trials. Scandinavian Journal of Pain. PMID 34090319.
  • Erdil D, Bagis N, Eren H, et al., 2022. The Evaluation of the Relationship between Changes in Masseter Muscle Thickness and Tooth Clenching Habits of Bruxism Patients Treated with Botulinum Toxin A. Journal of Medical Ultrasound. PMID 37180633.
  • Yu CC, Chen PK, Chen YR, 2007. Botulinum toxin A for lower facial contouring: a prospective study. Aesthetic Plastic Surgery. PMID 17674088.
Dr. med. Thomas Ackermann

Dr. med. Thomas Ackermann

Specialist in Anaesthesiology · Evidence instead of promises

This page offers an initial overview. What a treatment specifically means for you — which method, which dosage, which expectations are realistic — belongs in a personal consultation at the practice. Unhurried, with examination, with time.