The Cosmetic Side Effects of Botox® in Migraine Treatment

One of the most frequent side effects of using Botox® to treat chronic migraine is its impact on facial appearance. Common issues include eyebrow droopiness, an immobile forehead, and the notorious “caught-in-the-headlights” look. These effects stem from the paralysis of injected muscles, which can alter facial expressions.

In typical migraine treatment protocols, Botox is administered to three key forehead muscles:

Procerus: Located above the nose, contraction of this muscle creates a horizontal crease between the eyebrows.
Corrugator: This eyebrow muscle furrows the brows when it contracts and pulls downward.
Frontalis: Occupying most of the forehead, this muscle lifts the eyebrows and creates forehead wrinkles.
These injections are often standardized, which doesn’t account for individual anatomical differences, potentially leading to both migraine relief and unintended cosmetic changes.

Migraine Botox protocol has pre-determined quantities and locations of injections, and while this ensures some standardization between headache providers, it also ignores the salient differences in the individual’s anatomy and their specific muscle’ needs for Botox. As a result, some patients may experience migraine relief, but at the unfortunate expense of appearance.

Here we will go through some of the most common “unwanted” looks after administering Botox for headache purposes.

Common Cosmetic Concerns and How to Address Them:

Eyebrow Sagging:

This side effect is the most reported adverse event of injecting Botox (R) for chronic migraine. Eyebrow sagging happens when the Botox proceduralist avoids injecting too close to the eye (which, paradoxically, is usually due to their fear of eyebrow sagging), and hence inject the Botox a tad higher, as in the image below. As a result, more Botox ends up in the frontalis muscle than needed, and hence it becomes very weak, unable to lift the eyebrow, so it sags.
Unfortunately, this is often reported as eyelid droopiness, and hence the proceduralist may elect to inject even higher the next time, which can only exacerbate the problem.

Eyelid Droop:

This severe complication arises when Botox inadvertently affects the eyelid muscle rather than the eyebrow. Proper technique and experience are crucial to avoid this issue, which can impair vision. Eyelid droopiness typically happens when Botox spreads into the eyelid muscle itself, rather than to the eyebrow (i.e. the corrugator).
This is rarely encountered in experienced hands. It is more common when the injection is given toward the center of the eyebrow (known by plastic surgeons as the no-go-zone), rather than above the medial of the eyebrow.

Lateral Eyebrow Lift:

The good news about this side effect is that it is not always “unwanted”. Patients frequently do like the lateral eyebrow lift as it is considered aesthetically pleasing.

It usually occurs when the injections in the frontalis are too close together at the center, sparing the outer portions and causing a midline droop with a lateral lift.

The Surprised Look:

This occurs when the muscles pulling the eyebrows down (i.e. the corrugators) are paralyzed, but those lifting them (i.e. the frontal) are not. This is typically due to very high injections in the forehead away from the muscle’s active areas (i.e. the belly of the muscle). Adjusting the injection sites can quickly resolve this issue.

Pro Tips to Minimize Unwanted Effects:

Understand the muscle dynamics and discuss the injection plan with your provider, emphasizing a natural look.
Avoid overcorrection by starting with conservative doses and adjusting based on results.
After treatment, refrain from rubbing the injection sites for the first 24 hours to prevent the spread of Botox to adjacent muscles.
Remember, any undesirable effects from Botox are temporary, usually resolving within 4-6 weeks. By choosing an experienced provider and communicating your aesthetic goals, you can effectively manage migraine symptoms with minimal impact on your appearance.

References:

Klapper, J., Mathew, N., Nett, R. (2001). “Triptans in the treatment of basilar migraine and migraine with prolonged aura.” Headache: The Journal of Head and Face Pain, 41(10), 981-984.
Artto, V., et al. (2007). “Treatment of hemiplegic migraine with triptans.” European Journal of Neurology, 14(9), 1053-1056.
Mathew, P.G., et al. (2016). “A retrospective analysis of triptan and dhe use for basilar and hemiplegic migraine.” Headache: The Journal of Head and Face Pain, 56(5), 841-848.

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