Date: ***
Time: ***
Provider: ***
Pre-Procedure
Indication: Chronic migraine (≥15 headache days/month, ≥4 hours/day)
Diagnosis Code: ***
Informed Consent: Obtained after discussion of risks, benefits, and alternatives.
Allergies: Reviewed
Pre-Procedure Assessment: No contraindications noted (e.g., infection, myasthenia gravis, neuromuscular disorder)
Procedure Details
Preparation:
• Patient seated comfortably
• PREEMPT protocol followed
• Injection sites cleaned with alcohol swabs
Medication:
• Botulinum toxin type A (onabotulinumtoxinA)
• Total Dose: 155 units
• Dilution: 100 units in *** mL preservative-free normal saline
Injection Sites and Doses:
• Frontalis: 4 sites × 5 U
• Glabellar region: 3 sites × 5 U
• Temporalis: 8 sites × 5 U
• Occipitalis: 6 sites × 5 U
• Cervical paraspinals: 4 sites × 5 U
• Trapezius: 6 sites × 5 U
Technique:
• 31-gauge, 0.5-inch needle
• Injections at 90° angle into target muscles
• Aspiration performed before each injection
• Procedure tolerated with minimal discomfort
Post-Procedure:
• No complications noted
• Advised that onset may take 7–14 days
• Return in 12 weeks if indicated
• Avoid rubbing sites, lying flat for 4 hours, or strenuous activity for 24 hours
• Reviewed signs of botulinum spread
Disposition: Patient tolerated procedure well and was discharged in stable condition.
Signed: ***
