Procedure Note – Botox Injection for Chronic Migraine
Date: ***
Time: ***
Provider: ***
Pre-Procedure
Indication: Chronic migraine (≥15 headache days/month, ≥4 hours/day)
Diagnosis Code: ***
Informed Consent: Obtained from the patient, including discussion of risks, benefits, and alternatives. The patient understands and agrees to proceed.
Allergies: Reviewed
Pre-Procedure Assessment: No contraindications identified (e.g., infection at injection site, myasthenia gravis, neuromuscular disorders).
Procedure
Preparation:
• The patient was positioned comfortably in a seated position.
• The “PREEMPT” protocol was followed.
• The injection sites were cleansed with alcohol swabs.
Botulinum Toxin Type A (Botox) Injection Details:
• Total Dose: 155 units of onabotulinumtoxinA
• Dilution: 100 units diluted in *** mL preservative-free normal saline
Injection Sites:
• Frontalis (Forehead): 4 sites (5 U each)
• Corrugator & Procerus (Glabellar region): 3 sites (5 U each)
• Temporalis: 8 sites (5 U each)
• Occipitalis: 6 sites (5 U each)
• Cervical Paraspinals (Splenius capitis): 4 sites (5 U each)
• Trapezius: 6 sites (5 U each)
Technique:
• 31-gauge, 0.5-inch needle used.
• Botox was injected at 90-degree angles into targeted muscle groups.
• Aspiration was performed prior to each injection to avoid intravascular administration.
• The patient tolerated the procedure well, with minimal discomfort.
Post-Procedure
• No immediate complications noted (e.g., dysphagia, ptosis, bruising).
• The patient was advised that results may take 7–14 days to be noticeable.
• Follow-up in 12 weeks for repeat treatment if indicated.
• The patient was instructed to avoid rubbing the injection sites, lying flat for 4 hours, or strenuous activity for 24 hours.
• The patient was given return precautions for signs of botulinum toxin spread (e.g., difficulty swallowing, breathing, speaking).
Disposition: Patient tolerated the procedure well and was discharged in stable condition.
Signed: ***
