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Pain and Spine Medicine

Combination botulinum toxin and trigger point injections in chronic migraine: A Case Report

Thursday, October 23, 2025
5:00 PM - 6:30 PM MT
Location: Open Kiosks

    Poster Presenter(s)

  • Luke Tsai, MD (he/him/his)

    Resident Physician
    University of Wisconsin Hospitals and Clinics PM&R Program
    Madison, Wisconsin

  • AT

    Amy Tran (she/her/hers)

    Medical Student
    University of Wisconsin School of Medicine and Public Health
    Madison, Wisconsin

    • Co-Author(s)

  • MP

    Michelle Poliak-Tunis, MD

    Associate Professor
    University of Wisconsin Hospitals and Clinics PM&R Program
    Madison, Wisconsin

Disclosure(s):
Michelle Poliak-Tunis, MD: No financial relationships to disclose
Case Diagnosis: This is the case of a 41-year-old female who was treated with trigger point injections in conjunction with botulinum toxin type A (Botox) injections to treat uncontrolled chronic migraine.

Case Description or Program Description: A 41-year-old female presented with worsening chronic migraines that started in her early 20s. Her migraines were also associated with chronic left-sided neck and shoulder pain in addition to aura, nausea, and photophobia. She was having approximately 20 headaches per month and had failed multiple first-line treatment options including propanolol, amitriptyline, and topiramate. She was eventually started on botulinum toxin type A (Botox) injections, which significantly reduced her headache frequency to 5-10 per month. Due to persistent neck and shoulder pain, she was also later started on trigger point injections (TPI). After starting a consistent regimen of Botox injections every 3 months and TPI every 6 weeks, the patient reported a significant reduction in headaches to 0-3 per month.

Setting: The case is set in an outpatient Pain Management clinic through UWHealth in Madison, Wisconsin.

Assessment/Results: After starting a consistent regimen of Botox injections every 3 months and TPI every 6 weeks, the patient reported a significant reduction in headaches from 20 to 0-3 per month. Though Botox itself reduced her headache frequency significantly, the patient reports that the addition of TPI further reduced her headache frequency and provided 4-6 weeks of relief from headache, neck, and shoulder pain.

Discussion (relevance): Though Botox injections are a first-line treatment for chronic migraines, the use of TPI by itself has inconclusive evidence and efficacy for chronic migraines. This case suggests that there may be a synergistic benefit with TPI and Botox injections in the treatment of chronic migraines.

Conclusions: This case demonstrates the possible efficacy of TPI use in conjunction with Botox injections to treat uncontrolled chronic migraine.