Non-Facial Injection Sites for Botox in Migraine Treatment
Botox for chronic migraine is administered to multiple sites across the head and neck following the PREEMPT protocol, with the majority of non-facial injection sites located in the posterior head, neck, and shoulder regions. 1, 2, 3
Standard PREEMPT Injection Protocol
The FDA-approved protocol involves 155-195 units distributed across 31-39 injection sites every 12 weeks, with specific non-facial anatomical locations including: 1, 2, 3
Non-Facial Injection Sites:
Posterior Head and Neck:
- Occipital region - injections into the occipital muscles at the back of the skull 3, 4
- Suboccipital region - the area where the skull meets the upper neck 4
- Temporal region - while partially on the face, extends to the side of the head above and behind the ear 5, 4
Neck and Shoulder:
- Cervical paraspinal muscles - muscles running along the sides of the neck 3
- Trapezius muscles - the large shoulder muscles extending from the neck 3
Additional Sites:
Clinical Application
The PREEMPT protocol is the only evidence-based injection pattern supported by major guidelines, including the 2023 VA/DoD Clinical Practice Guideline and European Headache Federation consensus. 6, 1, 3
Key injection principles:
- Distribution must follow the standardized PREEMPT pattern rather than isolated single-site injections 3
- The protocol specifically targets both facial and non-facial trigger points simultaneously 1, 2
- "Follow-the-pain" patterns may be used as supplementary sites in some patients, though this is less standardized 7
Important Caveats
Single-site injections are not recommended: While older studies explored isolated corrugator supercilii (glabellar/facial) injections, current evidence-based practice requires the full PREEMPT protocol for chronic migraine. 5 The comprehensive multi-site approach is what demonstrated efficacy in Phase III trials. 2
Chronic migraine only: Botox is only indicated for chronic migraine (≥15 headache days per month) and is ineffective for episodic migraine (<15 headache days per month). 6, 2