---
title: "Migraines"
---
## Migraine Is Real, Disabling, and Treatable
Migraine is one of the leading causes of disability worldwide and one of the most undertreated medical conditions. Patients we see have often been dealing with migraines for years or decades, often having been told it is just headaches, that they need to manage stress better, or that they should take more ibuprofen. Many have been on standard preventive medications without finding adequate relief.
Migraine is a neurological condition with specific brain pathways, distinct from tension or cervicogenic headache. It is biologically real, often genetic, and disproportionately affects women. The disability burden is substantial: missed work, missed events, disrupted sleep, and the cumulative wear of living with a condition that can derail your day without warning. For patients with chronic migraine specifically, PHI offers the FDA-approved therapeutic neurotoxin protocol along with several other interventional approaches, working alongside your neurologist or primary care physician rather than replacing the broader migraine care you may need.
## Where PHI Fits in Migraine Care
Migraine treatment exists on a spectrum based on frequency and severity. Episodic migraine (fewer than 15 headache days per month) is typically managed by your primary care physician or neurologist with acute and sometimes preventive medications; for most patients with episodic migraine, PHI is not the right starting point. Chronic migraine (15 or more headache days per month with at least 8 migraine days) is a distinct diagnosis with FDA-approved interventional treatment, and this is where PHI's expertise specifically applies. Refractory migraine (chronic or severe migraine that has not responded to multiple preventives including therapeutic neurotoxin) may benefit from additional interventional approaches including ketamine infusion therapy.
This page focuses primarily on chronic and refractory migraine. If you have episodic migraine that has not been adequately evaluated, working with a neurologist familiar with current migraine treatments is typically the right first step.
## Therapeutic Neurotoxin for Chronic Migraine
Therapeutic neurotoxin is one of the most evidence-supported preventive treatments for chronic migraine. OnabotulinumtoxinA is FDA-approved specifically for the prevention of headaches in adults with chronic migraine, based on the PREEMPT clinical trials, which enrolled 1,384 patients and demonstrated significant reductions in headache frequency and severity.
The protocol is specific: the FDA-approved technique involves 155 units delivered across 31 specific injection sites in the head, neck, and upper shoulders, repeated every 12 weeks. PHI follows the FDA-approved PREEMPT protocol with the precise injection technique developed for this indication. This is a medical procedure, not a cosmetic one; the doses, injection sites, and clinical purpose are entirely different from cosmetic neurotoxin, and the brand may be Botox or Xeomin depending on the case. Effects develop over 1 to 2 weeks and typically last 12 weeks per cycle, and most patients require two or three full cycles (6 to 9 months) to fully evaluate response.
## Other Treatments for Refractory Cases
For patients with migraine that has not responded adequately to standard preventives including therapeutic neurotoxin, PHI offers several additional options. Occipital nerve blocks target the greater and lesser occipital nerves at the base of the skull, involved in many migraine patterns, particularly when pain begins or radiates from the back of the head. Ketamine infusion therapy has accumulating evidence for refractory chronic migraine and works through different pathways than standard migraine medications; PHI administers physician-monitored ketamine in a clinic setting. IV therapy, delivered in a clinic setting, provides supportive care for some patients during severe attacks or as part of broader treatment. We coordinate with neurology for ongoing preventive medication management and comprehensive migraine care.
## How PHI Approaches Migraine Treatment
The first step is comprehensive evaluation: confirmation of your migraine diagnosis and frequency pattern, review of preventive medications you have tried and your response, assessment of whether you meet chronic migraine criteria for therapeutic neurotoxin, a discussion of which interventional approach fits your situation, and coordination with your neurologist or primary care physician.
For patients meeting chronic migraine criteria, treatment typically involves the FDA-approved therapeutic neurotoxin protocol every 12 weeks, with response evaluated after two to three full cycles. For patients with refractory migraine, additional approaches including ketamine, occipital nerve blocks, or combinations may be appropriate.
## Why PHI for Migraine Treatment
## Frequently Asked Questions
**Q: How is therapeutic neurotoxin for migraine different from cosmetic Botox?**
The molecule can be the same, but the doses, injection sites, and purpose are entirely different. Therapeutic migraine treatment uses 155 units across 31 specific medical injection sites in the head, neck, and shoulders. Aesthetic neurotoxin uses much smaller doses in different facial muscles for wrinkle reduction. They are different services performed for different reasons by physicians with different training.
**Q: How effective is therapeutic neurotoxin for chronic migraine?**
For appropriate candidates, the FDA-approved protocol has Phase III clinical trial evidence demonstrating significant reductions in headache frequency, severity, and migraine-related disability. Most patients require two to three full treatment cycles (6 to 9 months) before fully evaluating response, and those who respond well often experience meaningful, sustained improvement.
**Q: How do I know if I have chronic versus episodic migraine?**
Chronic migraine is defined as 15 or more headache days per month, with at least 8 being migraine, for at least three months. Episodic migraine is less frequent. The distinction matters because chronic migraine has FDA-approved interventional treatments that episodic migraine typically does not qualify for.
**Q: How long does it take neurotoxin to work for migraine?**
Effects develop within 1 to 2 weeks of injection, with maximum benefit by 4 to 6 weeks per cycle. Treatment is repeated every 12 weeks, and most patients require two to three full cycles (6 to 9 months) before fully evaluating overall response.
**Q: Will I look different after neurotoxin for migraine?**
The doses and injection sites used for therapeutic migraine treatment are designed to address the underlying neurological mechanism, not to change facial appearance. Most patients do not notice meaningful aesthetic changes. The injection technique is medical, not cosmetic.
**Q: Can ketamine help my migraines?**
Ketamine has accumulating evidence for refractory chronic migraine that has not responded adequately to multiple preventives including therapeutic neurotoxin. It is not a first-line migraine treatment. For most chronic migraine patients, neurotoxin and standard preventives are appropriate first; ketamine becomes more relevant for refractory cases.
**Q: What about CGRP medications? Do you prescribe those?**
CGRP-targeted medications are typically prescribed by neurologists. PHI focuses on interventional treatments rather than oral or injectable preventive medication management. We coordinate with your neurologist on medication management while providing the interventional treatment side of your care, and the two are often used together.
**Q: What if I'm in the middle of a migraine attack right now?**
Acute migraine treatment is not PHI's primary lane. Acute attacks are typically managed by your existing care team or, for severe attacks, in an emergency setting if needed. PHI's role is in prevention. If you are experiencing a severe migraine that is not responding to your usual acute medications, please contact your neurologist or seek emergency care if appropriate.
**Q: Do you take insurance?**
Insurance coverage and payment options may vary. Please contact our office to discuss your specific plan, available options, and pricing. Specifics are discussed at consultation.
**Q: Do you accept international patients?**
Yes. PHI regularly treats patients from outside Los Angeles, including Las Vegas, Palm Springs, London, and other international locations. The 12-week treatment cycle is well-suited to scheduling around travel.
## Treatments We Offer for Migraine
PHI offers evidence-based interventional treatments for chronic migraine and refractory migraine, working alongside your neurologist and broader migraine care team.
- Neurotoxins for Pain, FDA-approved PREEMPT protocol for chronic migraine
- Occipital Nerve Blocks
- Ketamine Infusion Therapy, for refractory cases
- IV Therapy, supportive care
> Botulinum toxin in the management of chronic migraine: clinical evidence and experience. Peer-reviewed via PMC.
— [Escher CM, et al.](https://pmc.ncbi.nlm.nih.gov/articles/PMC5367647/)
> Botox (onabotulinumtoxinA) prescribing information for chronic migraine prevention. U.S. Food and Drug Administration.
— [U.S. Food and Drug Administration](https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/103000s5302lbl.pdf)
> Practice guidelines: treatment of migraine. American Academy of Neurology.
— [American Academy of Neurology](https://www.aan.com/practice/clinical-practice-guidelines/)
## Schedule Your Migraine Consultation
A 60-minute consultation will evaluate whether your migraine pattern is appropriate for PHI's interventional treatments, walk through the protocol options, and coordinate with your neurology team. Call (310) 856-9488 or book online now.
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