Botox for Chronic Migraine in Sydney
PBS-listed treatment by a neurologist accredited in the PREEMPT protocol. Trained at Prince of Wales Hospital — Sydney's leading headache centre.
Book a ConsultationBotox for Migraine — The Basics
Botulinum toxin type A (Botox) is a preventative treatment for chronic migraine — not an acute treatment. It works by blocking the release of pain-signalling chemicals at peripheral nerve endings in the scalp and neck, reducing the sensitisation that drives migraine. It has been on the Pharmaceutical Benefits Scheme (PBS) in Australia for chronic migraine since 2014.
Dr Ron Granot is an accredited Botox injector for chronic migraine using the standardised PREEMPT protocol. He trained at Prince of Wales Hospital — Sydney's leading headache and neurology training centre — and has administered many hundreds of Botox cycles for chronic migraine.
PBS Eligibility for Chronic Migraine Botox
Botox is PBS-subsidised for chronic migraine only when specific criteria are met. The criteria define a tightly defined patient group with treatment-resistant chronic migraine.
Patient must meet ALL of the following
- Chronic migraine — 15 or more headache days per month, with at least 8 being migraine, for 3 months or more
- Adequate trials of at least 3 oral preventatives from different classes (e.g. propranolol, topiramate, amitriptyline, candesartan, sodium valproate) — each at adequate dose and duration, discontinued for inefficacy or intolerance
- Treatment prescribed by a neurologist or pain medicine specialist (Dr Granot meets this)
- Not concurrently receiving a PBS-subsidised CGRP monoclonal antibody for migraine prevention
Reassessment — Authority approval is granted for 2 cycles initially; continuation requires demonstrating ≥50% reduction in headache days.
What to Expect at Your Botox Appointment
Pre-treatment consultation
Review of your headache diary, prior preventative trials, and confirmation of PBS eligibility. A baseline assessment is essential — we cannot demonstrate response without documented baseline headache days. If you don't have a recent diary, we'll start one before treatment.
PBS authority application
Dr Granot submits the PBS authority application on your behalf. Approval typically comes through within days. You collect the Botox vial from your pharmacy (or it is provided in-rooms depending on supply).
The injection procedure
31 small intramuscular injections of approximately 155 units of onabotulinumtoxinA into standardised PREEMPT sites: forehead (4), temples (8), back of head (6), neck (6), and upper trapezius (8). The actual injecting takes about 8 minutes. The procedure feels like a series of small pinpricks; most patients finish saying it was nowhere near as bad as what they had expected.
"Follow the pain" technique: beyond the standard PREEMPT sites, additional injections are added at sites of localised pain or trigger points. In Dr Granot's experience this can improve response rate.
After the injection
You can drive home and resume normal activities the same day. Avoid lying flat for 4 hours and avoid massaging the injection sites for 24 hours. Mild neck stiffness for a few days is the most common after-effect.
Follow-up & response assessment
The next cycle is at 12 weeks. Response is formally assessed after cycle 2 using your continuing headache diary. PBS continuation requires ≥50% reduction in headache days from baseline. Most responders notice benefit by cycle 2; a minority respond after cycle 1 or take 3 cycles.
What Response Looks Like — Realistic Expectations
In the original PREEMPT clinical trials, 40–50% of patients achieved >50% reduction in headache days per month with Botox. In post-trial data presented at the Congress of European Neurology (2017), 65% of first-time Botox patients were satisfied or very satisfied with their treatment. Comparable response rates to oral preventatives such as topiramate, valproate and amitriptyline — but with the convenience of 12-weekly dosing and few systemic side effects.
Practical framing: a meaningful proportion of patients see substantial benefit; a smaller proportion see partial benefit; and some are non-responders despite optimal technique. PBS continuation requires demonstrated ≥50% reduction in headache days after cycle 2. Honest framing of these numbers up-front is part of how we discuss treatment.
What Botox is good at
- Reducing total headache days per month
- Reducing severity of headaches that do occur
- Reducing dependence on acute medications (helps medication-overuse cycles)
- Convenient 12-weekly dosing — no daily tablets to remember
- Few systemic side effects compared with oral preventatives
What Botox is not
- Not an acute treatment — doesn't stop a migraine in progress
- Not effective for episodic migraine (<15 headache days/month) under PBS criteria
- Not a cure — discontinuing treatment generally returns headaches to baseline
- Not universally effective — about 50% see meaningful benefit by cycle 2
- Not first-line — used after oral preventatives have failed
Botox vs CGRP — When to Choose Which
Both Botox and CGRP monoclonal antibodies are PBS-listed preventative options for migraine. They work differently and PBS rules currently prevent claiming both simultaneously. The choice depends on individual factors.
| Factor | Botox (PREEMPT) | CGRP mAbs (Emgality, Aimovig, Vyepti) |
|---|---|---|
| PBS indication | Chronic migraine — ≥15 headache days/month with ≥8 migraine days | Chronic migraine — ≥8 headache days/month (3 agents PBS; Aimovig private only) |
| Dosing | Every 12 weeks, in-rooms procedure | Monthly (Emgality, Aimovig) or 3-monthly IV (Vyepti) — usually self-injection at home |
| Time to response | Often after cycle 2 (24 weeks) | Often within 4–8 weeks |
| Onset side effects | Neck stiffness, mild brow heaviness | Injection-site reactions, mild constipation, rare allergic reactions |
| Pregnancy | Relative contraindication | Not recommended (long half-life, washout required before conception) |
| Concurrent use | Not concurrently PBS-subsidised. Sequential trials permitted under authority. | |
Frequently Asked Questions
Considering Botox for Your Migraines?
Book a consultation with Dr Ron Granot — accredited Botox injector and headache specialist neurologist in Bondi Junction.
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