BTX for Chronic Migraine in Hamburg

Your BTX Treatment for Migraine in Hamburg


Treatment Duration	Approx. 15 minutes
Injection Sites	31 according to the PREEMPT protocol
Treatment Interval	Every 12 weeks


Treatment Monitoring	Using a headache diary
Treatment Goal	Fewer headache days
Assessment	After 2–3 treatments

Attending Doctors

Dr. med. Anna Brandenburg

Specialist in Dermatology

Focus areas: Aesthetic Dermatology, Hair Medicine, Laser Therapy

Dr. med. univ. Pamela Mai

Specialist in Dermatology and Venereology

Focus areas: Aesthetic Dermatology and Laser Medicine, Hair Medicine

When Migraine Dictates Your Life Plans

People living with chronic migraine have to plan their lives differently. A friend’s birthday, a Thursday meeting, a weekend trip – everything becomes uncertain, and there are hardly any symptom-free days between attacks. Many people affected have already tried several preventive medications: some did not provide sufficient relief, while others caused side effects they were no longer willing to tolerate.

Botulinum toxin A is approved for preventive treatment in precisely these circumstances: for adults with chronic migraine who have not responded adequately to preventive migraine medications or have been unable to tolerate them. This application has nothing to do with aesthetics. It is an established component of migraine therapy, as described in the current neurological guidelines.

Chronic Migraine – Who May Be Eligible for BTX Treatment?

When BTX Treatment May Be Appropriate

BTX treatment for migraine may be an option if …

You experience headaches on at least 15 days per month, with migraine features on at least eight of those days.
This condition has persisted for more than three months.
Preventive medications have not provided sufficient relief or have not been tolerated, usually after at least two treatment attempts.
The diagnosis has been confirmed by a neurologist.

When Further Medical Evaluation May Be More Appropriate

If you experience episodic migraine or tension-type headaches.
If your headaches are new, unusually severe, or different from previous episodes – these should first be evaluated by a doctor.
If your symptoms are more likely to result from nighttime teeth clenching – in this case, masseter treatment for bruxism may be more relevant.

How Does Botulinum Toxin Work for Migraine?

In wrinkle treatments, botulinum toxin temporarily relaxes specific facial muscles. For a long time, it seemed reasonable to assume that the same mechanism applied to migraine treatment. However, research now paints a different picture. The key appears to lie in the fine pain-sensing nerve fibers that run through the forehead, temples, back of the head, and neck and are connected to the pain-processing system of the meninges.

At these nerve endings, botulinum toxin inhibits the release of neurotransmitters such as CGRP and substance P, which are involved in the development of migraine pain. At the same time, fewer pain receptors reach the cell surface. As a result, these nerve fibers become less easily activated. The exact mechanism is not yet fully understood, and some findings come from laboratory and animal studies. However, large controlled clinical trials have demonstrated that the treatment is effective for chronic migraine. It follows a specific injection protocol that has little in common with aesthetic BTX treatments.

What Results Can You Expect from Treatment?

The two major PREEMPT trials included a total of 1,384 adults with chronic migraine. After 24 weeks, the average number of headache days per month decreased by 8.4 with botulinum toxin, compared with 6.6 with placebo. This represents an additional benefit of approximately 1.8 fewer headache days per month. A systematic Cochrane review reached a similar conclusion regarding the magnitude of the benefit.

However, such averages reveal little about how much an individual patient may benefit. Some people notice improvements after the first treatment cycle, while others need more time or do not respond sufficiently. Current clinical guidelines recommend assessing the results after two to three treatment cycles, each approximately three months apart. Complete freedom from symptoms cannot be guaranteed.

How BTX Treatment for Migraine Works

Initial Consultation

We review your neurological diagnosis, previous preventive treatments, and headache diary. Before starting treatment, we consider any potential contraindications and relevant medications you are taking.

Treatment Planning

The treatment is based on the PREEMPT protocol: typically 155 units injected at 31 predefined sites, with the option to increase the dose to a maximum of 195 units across up to 39 injection sites if medically necessary. Dosage is specific to the botulinum toxin product used.

Injection

Using a very fine needle, we inject small amounts into the forehead, temples, back of the head, neck, and upper shoulders. The procedure takes approximately 15 minutes, and you can usually return to your normal daily activities afterwards.

Follow-Up

We repeat the treatment every 12 weeks. Your headache diary helps track how your migraine develops over time. After two to three treatment cycles, we evaluate the results together with your neurologist.

Possible Side Effects and Contraindications

The treatment has been extensively studied but can cause side effects. These most commonly affect the injection sites or the treated muscle groups. Possible side effects include:

Neck pain, muscle stiffness, or temporary muscle weakness
Headaches or a temporary worsening of migraine symptoms
Pain, redness, or minor bruising at the injection sites
Temporary drooping of the upper eyelid or changes in eyebrow position
- Itching or skin rash

Occasionally, jaw discomfort or difficulty swallowing may occur. If the effects spread beyond the injection area, serious complications are also possible. Important: If you experience difficulty swallowing, speaking, or breathing after treatment, seek immediate medical attention.

Contraindications:

Hypersensitivity to any of the ingredients in the botulinum toxin preparation
Infections in the planned injection area
Neuromuscular disorders or pre-existing swallowing difficulties
Use of certain antibiotics from the aminoglycoside group
Pregnancy and breastfeeding

One Component of a Comprehensive Approach – BTX as Part of an Overall Treatment Plan

Preventive Treatment	Administration	Frequency	Good to Know
Botulinum toxin (BTX)	Injections at 31 to 39 predefined sites on the head, neck, and shoulders	Every 12 weeks	Only for chronic migraine; acts locally and may therefore be suitable for many patients taking other medications or with cardiovascular risk factors
Preventive medications, e.g. topiramate, beta blockers, amitriptyline	Oral tablet	Daily	Usually the first step in migraine prevention; tolerability and contraindications vary depending on the medication
CGRP monoclonal antibodies	Subcutaneous injection, with one medication administered by infusion	Monthly or every 3 months	For episodic and chronic migraine; target the CGRP neurotransmitter or its receptor
Gepants, e.g. atogepant	Oral tablet	Daily	A newer class of medications that also target the CGRP system
Non-pharmacological approaches: endurance exercise, regular sleep-wake cycle, relaxation techniques, behavioural therapy	Integrated into daily life	Ongoing	Effective according to clinical guidelines; complement all forms of preventive treatment

Your BTX Treatment Appointment for Migraine in Hamburg

You do not have to assess your frequent headache days on your own. If you have been diagnosed with chronic migraine, we will review your medical findings and previous treatments together and determine whether BTX is a suitable addition to your neurological treatment plan. Please bring your headache diary, neurological reports, and a list of your current medications. At our practice on Heilwigstraße, between Eppendorf and Harvestehude, we take the time to discuss your options so that you understand both the potential benefits and the limitations of treatment.

Frequently Asked Questions About BTX Treatment for Migraine

Is the Treatment Also Suitable for Migraine with Aura?

Yes. The deciding factor is whether you have chronic migraine, based on the number of headache days, your medical history, and previous treatments, rather than whether your attacks occur with or without aura. If you experience aura symptoms for the first time or notice significant changes in your usual aura, these should be evaluated by a neurologist regardless of your treatment.

Are the Injections Painful?

The needle is very fine, and each injection is brief and generally well tolerated. Some people find injections in the neck and temples slightly more uncomfortable. With 31 injections, it is usually the cumulative sensation rather than any individual injection that is noticeable. The procedure is over in approximately 15 minutes. Local anaesthesia is generally not necessary. If you have a fear of needles or are prone to faintness or circulatory reactions, please let us know beforehand.

Does BTX Replace My Medication for Acute Migraine Attacks?

No. BTX is a preventive treatment and does not stop a migraine attack that is already underway. You should therefore continue taking your acute migraine medication as agreed with your neurologist. Existing preventive medication is not automatically discontinued either. Your neurologist will decide whether it should be continued, reduced, or replaced. Please do not stop taking any medication without medical advice.

Will the Treatment Change My Appearance?

Slightly, yes. Because injections are also administered to the forehead and the area between the eyebrows, expression lines in these areas often become smoother for several weeks. In rare cases, an eyebrow or upper eyelid may droop slightly, or the outer eyebrows may become somewhat elevated. These changes resolve as the effects of the treatment wear off. However, aesthetic improvement is not the purpose of this treatment.

What Happens If the Treatment Does Not Work?

In that case, we carefully assess your progress using your headache diary. If the number of headache days has not decreased by at least approximately 30% after two to three treatment cycles, medical societies generally recommend discontinuing treatment. This does not mean you have failed in any way. Together with your neurologist, other preventive treatment options can then be considered, such as monoclonal antibodies targeting the CGRP system.

Quellenangaben

Baraldi, C., Lo Castro, F., Ornello, R., Sacco, S., Pani, L. & Guerzoni, S. (2023). OnabotulinumtoxinA: Still the Present for Chronic Migraine. Toxins, 15(1), 59. https://www.mdpi.com/2072-6651/15/1/59

Bendtsen, L., Sacco, S., Ashina, M., Mitsikostas, D., Ahmed, F., Pozo-Rosich, P. & Martelletti, P. (2018). Guideline on the use of onabotulinumtoxinA in chronic migraine: a consensus statement from the European Headache Federation. The Journal Of Headache And Pain, 19(1), 91. https://link.springer.com/article/10.1186/s10194-018-0921-8

Deutsche Gesellschaft für Neurologie & Deutsche Migräne- und Kopfschmerzgesellschaft. (2025). Therapie der Migräneattacke und Prophylaxe der Migräne (S1-Leitlinie, AWMF-Register-Nr. 030/057, Version 7.1). https://register.awmf.org/assets/guidelines/030-057l_S1_Therapie-der-Migraeneattacke-Prophylaxe-der-Migraene_2025-11.pdf

Dodick, D. W., Turkel, C. C., DeGryse, R. E., Aurora, S. K., Silberstein, S. D., Lipton, R. B., Diener, H. & Brin, M. F. (2010c). OnabotulinumtoxinA for Treatment of Chronic Migraine: Pooled Results From the Double‐Blind, Randomized, Placebo‐Controlled Phases of the PREEMPT Clinical Program. Headache The Journal Of Head And Face Pain, 50(6), 921–936. https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/j.1526-4610.2010.01678.x

Fachinformation BOTOX® 50/100/200 Allergan-Einheiten. (2026, August). AbbVie Deutschland. https://www.fachinfo.de/fi/pdf/020408

Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. (2018). Cephalalgia, 38(1), 1–211. https://journals.sagepub.com/doi/10.1177/0333102417738202

Herd, C. P., Tomlinson, C. L., Rick, C., Scotton, W. J., Edwards, J., Ives, N., Clarke, C. E. & Sinclair, A. (2018). Botulinum toxins for the prevention of migraine in adults. Cochrane Database Of Systematic Reviews, 2018(6), CD011616. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011616.pub2/full

Pozo-Rosich, P., Alpuente, A., Silberstein, S. D. & Burstein, R. (2024). Insights from 25 years of onabotulinumtoxinA in migraine — mechanisms and management. Nature Reviews Neurology, 20(9), 555–568. https://www.nature.com/articles/s41582-024-01002-5

Ruscheweyh, R., Förderreuther, S., Gaul, C., Gendolla, A., Holle-Lee, D., Jürgens, T., Neeb, L. & Straube, A. (2018). Therapie der chronischen Migräne mit Botulinumneurotoxin A. Der Nervenarzt, 89(12), 1355–1364. https://link.springer.com/article/10.1007/s00115-018-0534-0