Minor Surgery / Procedures

Botox for headaches and migraines

Headaches that start in the neck and the base of the skull are common, exhausting and often mistaken for migraine. This page explains how they form, what actually helps, and where doctor delivered Botox fits in.

From £360

per treatment, after an £80 suitability appointment

20 minutes

in clinic, no downtime beyond the day

3 to 4 months

typical duration of effect

Norwich

in person, doctor delivered

How these headaches form

A headache that starts in the neck

Two of the most common headaches we see do not begin in the head at all.

The plumbing, in one sentence

Pain signals from the top three neck segments and from the head arrive at the same relay station in the brainstem, so the brain cannot always tell which one is complaining.

Tension type headache

The most common headache in the world. In the occasional form it is largely a muscle problem: the muscles of the scalp, jaw, neck and shoulders are held tight for hours, often without you noticing, and the tissue becomes tender. The pain is felt as a tight band or pressure on both sides of the head.

When it happens on more days than not, the pain pathways in the spinal cord and brain become sensitised. They fire more easily and turn the volume down less well, so ordinary muscle tension is now felt as a headache. This is why frequent tension type headache usually needs more than painkillers.

Cervicogenic headache

Here the source is the upper neck itself: the small joints between the top three vertebrae and the deep muscles at the base of the skull. Poor posture, desk work, an old whiplash injury or simple wear irritate these structures, and because their nerves join the head's nerve supply in the brainstem, the pain is referred upwards. It is felt over the back of the head, the temple or behind the eye, usually on one side.

There is also a mechanical part. The greater occipital nerve leaves the spine just below the skull and threads through the semispinalis and trapezius muscles on its way to the scalp. When those muscles are chronically tight they squeeze the nerve, producing a sharp or burning pain up the back of the head. This is the part that Botox targets.

Cervicogenic headache infographic showing the neck muscles and upper cervical joints, common causes, where pain is referred in the head, and how this differs from tension type headache and migraine

Telling them apart

Is it tension, neck or migraine?

Many people are told they have migraine when the pattern fits a neck driven headache, and the reverse also happens. The label matters because the treatments differ.

Tension type headache

Treated here

Feels. Both sides. A pressing band, mild to moderate. Scalp and neck muscles tender.

Clues. Not worsened by activity. No vomiting. Builds through the day and lasts hours to days.

Cervicogenic (neck) headache

Treated here

Feels. One side, and stays on that side. Starts at the base of the skull and spreads forward, sometimes to behind the eye.

Clues. Worse with neck movement or long periods at a desk. Pressing the upper neck reproduces the head pain.

Migraine

Feels. Often one side. Throbbing, moderate to severe. Nausea and sensitivity to light and sound.

Clues. Attacks of 4 to 72 hours, worse with activity. Chronic migraine is 15 or more headache days a month, and Botox has good evidence here.

Cluster headache

Feels. Strictly one side around the eye. Excruciating. Red watery eye and drooping lid on that side.

Clues. Short attacks at the same time each day for weeks. Needs specialist care.

Medication overuse headache

Feels. Dull, daily or near daily, never quite gone.

Clues. Painkillers on 10 to 15 or more days a month for over 3 months. Improves once they are withdrawn with support.

Many people have more than one type at once. Chronic migraine is often accompanied by neck pain and muscle tenderness, which is one reason Botox in the neck muscles helps migraine too.

Clinical features

What we look for

The diagnosis is made from the story and the examination. There is no scan or blood test for these headaches, and imaging is only needed when something does not fit.

Risk factors

Long hours at a desk or screen with the head held forward
Stress, anxiety and low mood
Poor or short sleep
Previous neck injury or whiplash
Jaw clenching or teeth grinding
Family history of headache
Regular painkiller use

Points towards the neck

One sided pain that does not swap sides
Starts at the base of the skull and spreads forwards
Worse after long periods at a desk or on waking
Neck stiffness or reduced turning to one side
Pressing the upper neck reproduces the head pain

Points towards migraine

Throbbing pain that is worse with activity
Nausea or vomiting
Needing darkness and quiet
Visual aura before the pain
Strong family history

When a headache needs urgent attention

Botox and physiotherapy are for benign headaches. Call 999 for the first two below. See a doctor promptly for the rest.

Sudden severe headache peaking within minutes
Headache with fever, neck stiffness, rash or confusion
New weakness, numbness, slurred speech or double vision
New headache over 50, or with cancer or a weak immune system
After a head injury, or worse lying down or coughing
Jaw pain on chewing, scalp tenderness or visual loss

Management

What helps, and how good the evidence is

We work up this ladder, not down it. Botox is one option among several and for many people the earlier steps are enough.

Our position

If we do not think an injection will help you, we will not offer it. The suitability appointment exists so we can say that honestly.

Self care and habits

Screen breaks, monitor at eye level, heat on the neck, hydration, regular sleep, less caffeine and a headache diary.

The foundation in every headache guideline. Low cost, low risk, limited trial data for individual habits.

Stretching and exercise

Daily stretches for the upper trapezius, levator scapulae and suboccipital muscles, deep neck flexor strengthening and regular aerobic exercise.

A six week neck exercise and manual therapy programme cut cervicogenic headache frequency with benefit still present at 12 months (Jull, Spine 2002). Aerobic exercise reduced migraine frequency as well as topiramate did in a Swedish trial.

Physiotherapy

Assessment of posture and neck movement, hands on treatment of the upper neck and a tailored exercise plan.

Moderate quality evidence for manual therapy plus exercise in cervicogenic headache. More modest but positive for tension type headache. Very low risk.

Medication

Ibuprofen, aspirin or paracetamol for occasional episodes. Low dose amitriptyline at night for frequent headache. Migraine has its own preventives.

Simple painkillers help episodic tension type headache modestly (Cochrane). Amitriptyline reduces frequency in chronic tension type headache and migraine (BMJ 2010). Using painkillers on more than 10 to 15 days a month causes medication overuse headache.

Nerve block

Local anaesthetic, sometimes with steroid, injected around the greater occipital nerve at the base of the skull or into tender muscle knots.

Reduces headache days in chronic migraine and gives good short term relief in cervicogenic headache. Relief lasts weeks rather than months.

Botox

Small injections of botulinum toxin into the upper trapezius, splenius and suboccipital muscles, with or without steroid, relaxing them for around three months.

Strong for chronic migraine. Mixed for tension type and neck driven headache. Detail below.

How Botox works

Three things happen when the muscle relaxes

The evidence, in short

Strong for chronic migraine. Mixed for neck driven headache. Weak for occasional tension headache. We recommend it selectively.

It switches off the overactive muscle

Botulinum toxin blocks acetylcholine, the chemical nerves use to tell a muscle to contract. The muscle relaxes over 5 to 14 days and stays relaxed for 3 to 4 months while the nerve endings regrow.

The relaxed muscle stops squeezing the nerve

The greater occipital nerve threads through the trapezius and semispinalis at the base of the skull. Chronically tight muscle compresses it, and that irritation is felt over the back of the head and behind the eye.

It quietens the pain nerves directly

Botulinum toxin also blocks release of pain chemicals such as CGRP and substance P from nerve endings. This is thought to be the main reason it helps in chronic migraine, where the problem is a sensitised pain system.

What the evidence says

Strong

Chronic migraine

Two large trials (PREEMPT, 2010) showed around 8 to 9 fewer headache days a month against 6 to 7 with placebo. Recommended by NICE (TA260) once other preventives have failed. Licensed use in the UK.

Mixed

Cervicogenic headache

Small trials point both ways and a Cochrane review of Botox for neck pain found little clear benefit. Works well for some people and not for others.

Weak

Episodic tension type headache

A 2012 JAMA meta analysis found no meaningful benefit. Conservative treatment should come first.

The procedure

What happens, start to finish

Suitability appointment

A doctor takes your headache history, examines your neck and checks for red flags. If stretching, physiotherapy or medication is the better first step, we say so.

Mapping the muscles

We press along the trapezius, splenius and base of the skull to find the tender bands that reproduce your headache. These are the targets.

The injections

Typically 8 to 16 tiny injections with a very fine needle, sometimes with steroid and local anaesthetic around the greater occipital nerve. Around 20 minutes.

Aftercare and review

Stay upright for four hours and avoid heavy neck work that day. Effect starts within one to two weeks and peaks at four to six. Review at six weeks, repeat at three months if it has helped.

Risks and side effects

What can go wrong, and how often

Botulinum toxin has been used medically for over 30 years and has a good safety record at these doses. The neck is less forgiving than the face, so we use conservative doses and place injections carefully.

We will not treat you if

Pregnant or breastfeeding
Myasthenia gravis, Lambert Eaton syndrome or motor neurone disease
Infection at the injection site
Previous allergy to botulinum toxin or human albumin
Taking aminoglycoside antibiotics
Uninvestigated red flag symptoms

Common

Most people, settles within days

Soreness or bruising at the injection sites for a few days
Heaviness or weakness in the neck or shoulders for a week or two
A mild headache or flu like ache for a day or two

Less common

A minority, settles within weeks

Noticeable neck weakness, including difficulty holding the head up for long periods
Shoulder weakness affecting lifting
A drooping brow or eyelid if muscles near the forehead are treated
Difficulty swallowing if toxin spreads to the front of the neck

Rare

Reported, very unusual at these doses

Allergic reaction to the toxin or its carrier protein
Antibodies developing over repeated treatments, reducing the effect
Spread of toxin causing generalised weakness or breathing problems. A formal warning on all botulinum toxin products, extremely rare at these doses

If steroid is included

A patch of skin thinning or lightening at the site
Temporary rise in blood sugar for people with diabetes
Facial flushing or disturbed sleep for a day or two
Menstrual irregularity in the following cycle

Questions

Frequently asked

Is Botox for headaches the same as cosmetic Botox?

It is the same medicine, botulinum toxin type A, injected into different muscles for a different purpose. For headaches it goes into the upper back, neck and base of the skull rather than the face, so it does not change your appearance.

How long does it last?

The effect starts within 5 to 14 days, peaks at around 4 to 6 weeks and usually lasts 3 to 4 months. If it helps, treatments are typically repeated every 12 weeks.

Does Botox work for tension headaches?

The honest answer is that the evidence is mixed. Botox has strong evidence for chronic migraine. For tension type and neck driven headaches some people get excellent relief and others notice little change. We recommend stretching, physiotherapy and simple medication first and will tell you plainly if we do not think Botox is likely to help.

What is a cervicogenic headache?

A headache that starts in the neck. The upper neck joints, muscles and nerves share a relay station in the brainstem with the nerve that supplies the head, so pain from the neck is felt in the head, often at the back of the skull, the temple or behind the eye. It is usually one sided and worse with neck movement or sustained posture.

Is the steroid always included?

No. We add a small dose of steroid with local anaesthetic around the greater occipital nerve when the nerve itself is irritated and tender. Botox alone is used when the problem is mainly muscle tightness. We decide this with you at the suitability appointment.

How much does it cost?

Treatment is from £360 per session. All procedures need an initial suitability appointment first, which is £80. There is no obligation to go ahead afterwards.

Can I have this on the NHS?

NHS Botox is available for chronic migraine through a specialist headache or neurology clinic once at least three preventive medications have failed, in line with NICE guidance. It is not routinely available on the NHS for tension type or cervicogenic headache.

Who carries out the injections?

A GMC registered doctor at our Norwich clinic. This is an in person procedure and cannot be done remotely.

Sources

Start with a suitability appointment

£80, in person in Norwich. A doctor takes your history, examines your neck and tells you honestly whether Botox, physiotherapy, medication or something else is the right next step. No obligation to go ahead.

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