Alternatives to Botox for Headache Treatment

Introduction to Migraine Treatment

The American College of Physicians suggests using oral preventive medications before CGRP-mAbs primarily based on cost differences rather than efficacy differences 1
The American Headache Society recommends CGRP monoclonal antibodies for both chronic and episodic migraine 2

Topiramate is suggested for prevention of chronic migraine with a weak recommendation and should be tried before Botox 1, 2
Beta-blockers (propranolol) are recommended for migraine prevention with a weak recommendation 1
Amitriptyline and venlafaxine are alternative oral preventive options that should be considered before injectable therapies 1
Valproate is another oral preventive medication option, though it is contraindicated in pregnancy planning 1
CGRP monoclonal antibodies have strong recommendations for chronic migraine prevention 2

Triptans are the primary migraine-specific acute treatment, with rizatriptan having a strong recommendation for acute migraine treatment 1
NSAIDs (nonsteroidal anti-inflammatory drugs) are effective for acute episodic migraine 3
CGRP antagonists-gepants (rimegepant, ubrogepant, zavegepant) are newer alternatives for acute treatment 3
Lasmiditan (a 5-HT1F agonist) is another newer acute treatment option 3
Combination therapy with a triptan plus NSAID or acetaminophen is superior to monotherapy 3

CGRP monoclonal antibodies have strong recommendations for episodic migraine prevention 2
Oral preventive medications (topiramate, propranolol, amitriptyline) can be used for episodic migraine if attacks are frequent enough to warrant prevention 1

Do not use Botox for episodic migraine—the VA/DoD Clinical Practice Guideline specifically suggests against it, and research shows it is ineffective for fewer than 15 headache days per month 1, 2
Do not use Botox for tension-type headaches—it is probably ineffective and should not be offered 1
Avoid gabapentin for migraine prevention, as guidelines suggest against its use with a weak recommendation 2
Monitor for medication overuse headache—limit simple analgesics to fewer than 15 days per month and triptans to fewer than 10 days per month to prevent this complication 1

Start with oral preventive medications (topiramate, propranolol, amitriptyline, or valproate) unless contraindicated 1
If 2-3 oral medications fail or are not tolerated, consider CGRP monoclonal antibodies or Botox (for chronic migraine only) 1, 2
For patients preferring oral routes, continue trying different oral preventives, as patients probably prefer oral treatments over injectables when effectiveness is similar 1
Address medication overuse concurrently with preventive therapy if present, as withdrawal and preventive therapy can be managed in parallel 1