What is platelet-rich plasma (PRP) therapy?

Platelet-rich plasma (PRP) is a concentrate of your own blood containing 3 to 5 times the normal concentration of growth factors and healing proteins, injected into the area of injury or pain.

What is PRF and how does it differ from PRP?

Platelet-rich fibrin (PRF) is a second-generation platelet concentrate that forms a fibrin matrix releasing growth factors over 7 to 10 days, unlike standard PRP. University Pain Consultants offers both.

What conditions can PRP treat?

PRP treats osteoarthritis (knee, hip, shoulder), tendon injuries, ligament sprains, chronic low back pain, sacroiliac joint pain, degenerative disc conditions, plantar fasciitis, and chronic bursitis.

How many PRP injections will I need?

Most patients improve after 1 to 3 injections spaced 4 to 6 weeks apart. Many experience relief lasting 12 to 18 months or longer.

How is PRP different from cortisone injections?

PRP stimulates tissue regeneration and collagen production rather than just suppressing inflammation. Results are more durable and avoid the risks of repeated steroid exposure.

Does insurance cover PRP therapy?

Most insurance plans classify PRP as investigational. Self-pay pricing is available and HSA or FSA funds are generally eligible.

What happens during the PRP procedure?

The visit takes 45 to 60 minutes. Blood is drawn, centrifuged for 10 minutes, and injected under ultrasound guidance. Most patients resume light activity the same day.

Am I a good candidate for PRP?

Ideal candidates have musculoskeletal injury or degenerative joint disease without adequate relief from physical therapy or traditional injections. Dr. Guiang reviews your history at the initial consultation.

What should I avoid before a PRP injection?

Stop NSAIDs (ibuprofen, naproxen, aspirin) and fish oil 5 to 7 days before the procedure. These suppress platelet function. Stay hydrated and do not fast.

How does ketamine relieve chronic pain?

Ketamine is an NMDA receptor antagonist that blocks receptors driving central sensitization. At sub-anesthetic doses it resets aberrant pain signaling, providing relief that outlasts the infusion by weeks to months.

What chronic pain conditions does IV ketamine treat?

IV ketamine treats CRPS, fibromyalgia, neuropathic pain, refractory migraines, central sensitization syndromes, chronic low back pain, post-surgical pain, and treatment-resistant depression co-occurring with chronic pain.

How many ketamine infusions will I need?

The standard protocol is 4 to 6 infusions over 2 to 3 weeks. Most responders notice improvement by the third or fourth infusion. Maintenance infusions follow every 6 to 12 weeks.

What should I expect during a ketamine infusion?

Each infusion runs 40 to 60 minutes with continuous monitoring. Most patients experience mild dissociation that resolves within 30 minutes. A driver is required on infusion days.

Is IV ketamine the same as Spravato (esketamine)?

No. Spravato is intranasal esketamine approved for depression. IV racemic ketamine is the full molecule with a larger evidence base for chronic pain and more precise dosing.

Is ketamine infusion therapy safe?

At sub-anesthetic doses in a monitored setting, IV ketamine has a well-established safety profile. Dr. Guiang is board-certified in anesthesiology. Side effects at pain doses are mild. Addiction risk is very low.

Does insurance cover IV ketamine for pain?

Coverage is limited. Most payers do not cover IV ketamine as a primary pain treatment. Self-pay pricing is available.

Can ketamine treat both chronic pain and depression?

Yes. Ketamine acts on overlapping neurobiology of pain and depression simultaneously. Up to 50 percent of chronic pain patients meet criteria for depression. Dr. Guiang coordinates with your mental health provider.

Who is not a candidate for IV ketamine?

Contraindications include uncontrolled hypertension, active psychosis or schizophrenia, recent stroke, and active ketamine or PCP use disorder. A full intake evaluation is completed before scheduling.

What is low dose naltrexone (LDN)?

Low dose naltrexone (LDN) uses naltrexone at 1.5 to 4.5 mg per day, one-tenth the standard addiction dose. It transiently blocks opioid receptors to upregulate endorphin production and reduce microglial activation, producing anti-inflammatory and pain-relieving effects.

How is LDN different from standard naltrexone?

Standard naltrexone (50 mg) fully blocks opioid receptors to treat addiction. LDN uses intermittent partial blockade to reduce neuroinflammation. LDN does not cause sedation, weight gain, or physical dependence.

What is the evidence for LDN in fibromyalgia?

Double-blind, placebo-controlled Stanford trials showed statistically significant reductions in fibromyalgia pain, fatigue, and quality of life, with approximately 30 percent symptom reduction in responders. Additional UK and Israeli trials support these findings.

What other conditions can LDN help with?

LDN has emerging evidence for Crohn's disease, multiple sclerosis, CRPS, lupus, chronic Lyme disease, and long COVID, due to its mechanism of reducing central neuroinflammation.

How long does it take for LDN to work?

LDN typically requires 4 to 12 weeks for meaningful pain relief. A minimum 3-month trial is recommended. Dosing starts at 1.5 mg and titrates upward by 1.5 mg every 2 to 4 weeks.

What are the side effects of LDN?

LDN is very well tolerated. Vivid dreams in the first few weeks is the most common side effect, usually resolving with continued use. It does not cause sedation, cognitive impairment, weight gain, or dependence.

Can I take LDN if I am on opioid pain medication?

No. LDN cannot be taken with opioids or tramadol because it can precipitate acute withdrawal. A supervised opioid taper is required first.

Is LDN covered by insurance and where is it obtained?

LDN is compounded and not covered by insurance. Monthly cost is approximately $30 to $60. University Pain Consultants provides prescriptions to trusted compounding pharmacies.

Naltrexone is FDA-approved at 50 mg. LDN at 1.5 to 4.5 mg is prescribed off-label, which is legal and common. The FDA has not disapproved LDN; no large approval trial exists because naltrexone is generic.

Botox Therapeutic Injections for Pain & Migraine | UPC Regenerative Medicine

UPC Regenerative Medicine • Therapeutic Injections

OnabotulinumtoxinA (Botox®) Therapeutic Botox for Pain & Migraine

FDA-approved for chronic migraine and supported by decades of evidence for a wide range of pain conditions. Precisely administered by our board-certified physician — therapeutic botulinum toxin offers durable, meaningful relief where other treatments have fallen short.

FDA-Approved for Chronic Migraine Physician-Administered 3-Month Duration of Effect No Daily Medication Required

Book a Consultation See Conditions Treated

All therapeutic botulinum toxin injections are administered personally by our board-certified anesthesiologist — a physician with deep expertise in anatomy, pain mechanisms, and precision injection technique. Not delegated to nursing or ancillary staff.

Understanding the Treatment

What Is Therapeutic Botulinum Toxin?

Botulinum toxin type A (onabotulinumtoxinA, marketed as Botox®) is a purified neurotoxin protein derived from Clostridium botulinum. At therapeutic doses — far smaller than those associated with toxicity — it produces highly controlled, reversible, and targeted effects on nerve-muscle junctions and pain-signaling pathways.

When injected into specific muscles or trigger points, botulinum toxin blocks the presynaptic release of acetylcholine at the neuromuscular junction, producing targeted muscle relaxation. Crucially for pain medicine, it also inhibits the release of substance P, CGRP (calcitonin gene-related peptide), and glutamate from peripheral nociceptors — directly suppressing pain signaling independent of its muscle-relaxing effects.

This dual action — neuromuscular blockade plus peripheral pain signal suppression — makes therapeutic botulinum toxin uniquely effective for conditions where muscle hyperactivity and central sensitization overlap: chronic migraine, cervicogenic headache, myofascial pain, cervical dystonia, and spasticity-related pain syndromes.

Duration of effect: A single treatment session typically provides 3 months of meaningful benefit. Most patients schedule injections every 12 weeks. Because the effect is fully reversible as nerve terminals sprout new connections, there is no permanent change — and no risk of dependency.

Important distinction: Therapeutic botulinum toxin injections for pain and migraine are a completely separate indication and protocol from cosmetic Botox for wrinkles. The injection sites, dosing, and goals are entirely different. This page covers the medical/therapeutic use only.

Typical Response Timeline

Days 3–7Initial muscle relaxation begins

Weeks 2–4Pain reduction and headache frequency decrease

Weeks 4–12Peak therapeutic effect sustained

~Week 12Effect begins to wane — re-injection scheduled

How It Works

Mechanisms of Pain Relief

Botulinum toxin relieves pain through multiple distinct mechanisms — explaining its efficacy across such a diverse range of pain conditions.

Acetylcholine Blockade at the Neuromuscular Junction

Botulinum toxin cleaves SNAP-25, a protein essential for vesicle docking at the presynaptic nerve terminal. Without SNAP-25, acetylcholine-containing vesicles cannot fuse with the terminal membrane, preventing ACh release. This produces targeted, reversible chemodenervation — selective muscle relaxation in the injected muscle without affecting sensation, coordination, or adjacent muscles when properly dosed.

Peripheral Nociceptor Inhibition

Independent of its muscle-relaxing effects, botulinum toxin inhibits the release of pain-signaling neuropeptides from peripheral sensory nerves — including substance P, CGRP, and glutamate. These molecules sensitize pain receptors and drive central sensitization. By blocking their release, botulinum toxin raises the threshold for pain signaling and reduces the neuroinflammation that perpetuates chronic pain states.

CGRP Inhibition & Migraine Prevention

Calcitonin gene-related peptide (CGRP) is the central mediator of migraine attacks — it dilates cranial blood vessels, sensitizes trigeminal pain fibers, and drives the neurogenic inflammation underlying migraine headache. Botulinum toxin specifically inhibits CGRP release from trigeminal nerve terminals in the scalp and dural blood vessels, directly interrupting the migraine cascade at its source. This is the primary mechanism underlying its FDA approval for chronic migraine prevention.

Reduction of Central Sensitization

Chronic pain conditions are perpetuated by central sensitization — a state of amplified, dysregulated pain processing in the CNS. By reducing the continuous barrage of peripheral pain signals (via CGRP, substance P, and glutamate inhibition), botulinum toxin allows the central nervous system to "reset" its sensitized state over time. This explains why migraine patients often experience not just fewer headaches but reduced severity and improved baseline well-being.

Myofascial Trigger Point Inactivation

Myofascial trigger points — hypersensitive, hyperirritable spots within taut muscle bands — arise from sustained abnormal acetylcholine release at dysfunctional motor endplates. Botulinum toxin injection directly into trigger points normalizes ACh release, resolving the endplate dysfunction responsible for the taut band and referred pain patterns. This is the basis of botulinum toxin use in myofascial pain syndrome, tension headache, and cervicogenic pain.

Reversibility & Safety Advantage

Unlike surgical denervation, botulinum toxin's effects are fully reversible. Nerve terminals sprout new axonal branches over 2–4 months, restoring normal neuromuscular function. This reversibility means the treatment can be repeated indefinitely without cumulative harm, adjusted as the clinical situation evolves, and discontinued at any time if needed. No dependency, no withdrawal, and no permanent anatomic change.

Focus: Chronic Migraine — The FDA-Approved Indication

Botox for Chronic Migraine — The Gold Standard

Chronic migraine — defined as 15 or more headache days per month, with at least 8 meeting migraine criteria — is one of the most disabling neurological conditions worldwide, affecting approximately 2% of the global population. It is the only headache condition for which the FDA has specifically approved onabotulinumtoxinA as a prophylactic treatment.

The approval was based on the landmark PREEMPT program — two large Phase 3, double-blind, randomized, placebo-controlled trials (PREEMPT 1 and 2) involving nearly 1,400 patients. Pooled PREEMPT data showed significantly greater reductions in headache days, migraine days, headache hours, and acute medication use in the onabotulinumtoxinA group vs. placebo across 56 weeks.

A 2022 meta-analysis published in PMC systematically reviewed over 10 years of real-world observational data on onabotulinumtoxinA for chronic migraine, confirming that effectiveness observed in the PREEMPT trials is replicated in routine clinical practice across diverse patient populations worldwide.

The FDA-approved protocol — the PREEMPT injection paradigm — administers 155 units across 31 injection sites in 7 specific head and neck muscle areas, repeated every 12 weeks. Most patients see progressive improvement with successive treatment cycles.

10-Year Real-World Meta-analysis — OnabotulinumtoxinA (PMC 2022) PREEMPT 56-Week Pooled Analysis (PMC) BoNT in Chronic Migraine — Clinical Evidence Review (PMC) BoNT in Headache & Facial Pain — Updated Review (PMC 2025)

~8–9

Mean reduction in headache days per month in the PREEMPT pivotal trials — from a baseline of ~20 headache days to approximately 11–12 days

51%

Of early patients in open-label trials reported complete response to onabotulinumtoxinA; 28% reported partial response — nearly 80% experiencing meaningful benefit

FDA

Approved since 2010 for prophylactic treatment of chronic migraine (≥15 headache days/month) in adults — the only botulinum toxin with this specific approval

12 wks

Treatment interval — repeat injections every 3 months maintain and often build on the benefit of prior treatment cycles

Conditions Treated

Pain Conditions We Treat with Therapeutic Botox

Our physician evaluates each patient individually to determine whether therapeutic botulinum toxin is appropriate for their specific condition. Indications marked FDA are specifically approved; others represent well-supported off-label use.

Chronic Migraine FDA Approved

15+ headache days/month. PREEMPT protocol: 155 units across 31 sites in 7 head and neck muscle areas every 12 weeks.

Cervical Dystonia FDA Approved

Involuntary neck muscle contractions causing abnormal head posture and severe neck pain. First-line FDA-approved therapy.

Myofascial Pain Syndrome

Injection into trigger points resolves abnormal motor endplate dysfunction — the source of taut bands, referred pain, and regional pain syndromes.

Cervicogenic Headache

Headache originating from neck muscles and cervical joints. Botulinum toxin targets the specific cervical muscles driving referred head pain.

Tension-Type Headache

Chronic tension headache driven by pericranial muscle hyperactivity responds to targeted botulinum toxin injection in scalp and neck muscles.

Post-Traumatic Headache

Persistent headache following head or neck injury. RCT evidence supports PREEMPT protocol for post-traumatic headache with significant reduction in headache frequency and intensity.

Trigeminal Neuralgia

Botulinum toxin injection reduces trigeminal nerve excitability and pain signal transmission — providing meaningful relief in drug-refractory cases.

Chronic Neck & Shoulder Pain

Myofascial and muscle-mediated neck pain responds to targeted injection with significant reductions in pain frequency and VAS scores vs. placebo in double-blind trials.

Temporomandibular Pain (TMJ)

Masseter and temporalis injection reduces jaw muscle tension, bruxism-related pain, and TMJ-mediated headache.

Occipital Neuralgia

Greater and lesser occipital nerve-related pain at the base of the skull responds to targeted injection in the suboccipital muscle region.

Upper Limb Spasticity & Pain FDA Approved

OnabotulinumtoxinA is FDA-approved for upper and lower limb spasticity — reducing painful muscle overactivity in neurological conditions.

Complex Regional Pain Syndrome (CRPS)

Case series and retrospective data show 43% mean pain score reduction in CRPS patients treated with botulinum toxin targeting involved muscle groups.

The Procedure

What to Expect at Your Injection Visit

A therapeutic botulinum toxin session is performed entirely in-office and takes approximately 20–45 minutes. No sedation or recovery time is required. Most patients return to normal activities immediately.

Physician Assessment

Your physician reviews your pain pattern, prior treatments, and response to previous injections (if any) to refine your injection map.

Injection Map Design

Target muscles and trigger points are identified by palpation and clinical assessment. The PREEMPT protocol is followed for migraine; customized maps for other pain conditions.

Injection

Using a fine 30-gauge needle, botulinum toxin is injected precisely into each target site. Most patients describe a mild pinching sensation. The procedure takes 20–30 minutes.

Observation & Follow-Up

Brief post-injection observation. Follow-up at 4–6 weeks to assess early response and adjust protocol for subsequent sessions if needed.

After your injection: Mild soreness at injection sites is normal and typically resolves within 24–48 hours. Do not rub or massage injection sites for 4 hours. Avoid strenuous exercise and lying flat for 4 hours post-injection. Therapeutic effects begin within 3–7 days and peak at 2–4 weeks. If you have any concerns about your response, call our office promptly.

Clinical Overview

Benefits & Risks

Potential Benefits

Significant reduction in headache frequency and severity in chronic migraine

FDA-approved, evidence-based treatment with decades of safety data

No daily medication required — a single in-office session provides approximately 3 months of relief

Targets the source of pain rather than masking symptoms with systemic drugs

Reduction in acute rescue medication use — less reliance on triptans, NSAIDs, opioids

Effective for patients who have failed conventional preventive medications

Improved quality of life, function, and ability to work

No systemic side effects associated with oral preventive medications

Fully reversible — nerve terminals regenerate, effect wears off in 3 months

Can be combined with other pain management strategies safely

Risks & Limitations

Injection site pain, bruising, or tenderness — mild and resolves within days

Neck pain or stiffness — most common reported adverse event in PREEMPT trials; usually mild

Temporary muscle weakness in treated areas — expected and dose-dependent; resolves as effect wears off

Transient eyelid drooping (ptosis) — rare; resolves spontaneously within weeks

Headache following injection — paradoxical, usually mild and brief

Dysphagia (swallowing difficulty) — rare; more common with cervical dystonia injections near throat muscles

Non-response in approximately 20–30% of patients

Delayed response — full benefit may take 2–4 weeks and may improve with successive treatment cycles

Antibody development with repeated use — rare but can reduce efficacy over time

Generally not covered by insurance for pain indications other than chronic migraine and cervical dystonia

Patient Safety

Contraindications & Precautions

A thorough physician evaluation is essential before botulinum toxin treatment. The following conditions require careful consideration or preclude treatment.

Known Hypersensitivity to Botulinum Toxin Absolute

Anaphylaxis or hypersensitivity to any formulation of botulinum toxin or its excipients is an absolute contraindication.

Infection at the Proposed Injection Site Absolute

Active skin or soft tissue infection at or near the injection target must be treated and resolved before proceeding.

Neuromuscular Junction Disorders Absolute

Myasthenia gravis, Lambert-Eaton syndrome, and amyotrophic lateral sclerosis (ALS) dramatically increase risk of serious weakness and respiratory compromise.

Pregnancy Absolute

Botulinum toxin is Pregnancy Category C. Its use is contraindicated during pregnancy. Women of childbearing age should use effective contraception.

Aminoglycoside Antibiotics Relative

Aminoglycosides potentiate neuromuscular blockade and may increase the effect and duration of botulinum toxin. Use with caution; delay treatment if recently administered.

Anticoagulant Therapy Relative

Increased bleeding and bruising risk at injection sites. Warfarin, DOACs, and high-dose aspirin should be discussed with your prescribing physician.

Dysphagia or Breathing Difficulties Relative

Patients with pre-existing swallowing or respiratory difficulties require careful site selection — particularly with cervical dystonia injections near the throat.

History of Prior Botulinum Toxin Neutralizing Antibodies Relative

Documented immunoresistance from prior treatments requires evaluation; a different formulation or extended interval may restore responsiveness.

Peer-Reviewed Research

Key Published Evidence

Therapeutic botulinum toxin for chronic migraine and pain has one of the most robust evidence bases in pain medicine, spanning two decades and thousands of patients.

PREEMPT 1 & 2 Pivotal Trials — OnabotulinumtoxinA for Chronic Migraine | Cephalalgia 2010

Aurora et al. (PREEMPT 1) and Diener et al. (PREEMPT 2): Two Phase 3, double-blind, randomized, placebo-controlled trials forming the basis of FDA approval. Pooled analysis across nearly 1,400 patients demonstrated significantly greater reduction in headache days, migraine days, acute medication use, and headache-related disability vs. placebo over 56 weeks. The PREEMPT protocol of 155 units across 31 sites was established.

View PREEMPT Pooled Analysis (PMC)

10-Year Real-World Effectiveness Meta-analysis | PMC 2022

Systematic review and meta-analysis of observational data from 1 January 2010 to 31 March 2021 — evaluating real-world effectiveness of onabotulinumtoxinA for chronic migraine outside the controlled trial setting. Used the PREEMPT endpoints. Confirmed that real-world effectiveness mirrors the pivotal trial results across diverse international patient populations, supporting the generalizability of clinical trial findings.

View Full Text (PMC)

BoNT in Chronic Migraine — Clinical Evidence Review | PMC

Comprehensive review of the history of botulinum neurotoxin in chronic migraine and current clinical evidence. Confirms onabotulinumtoxinA is effective in reducing headache frequency and severity and is well-tolerated. Describes the early open-label evidence where 51% of true migraineurs reported complete response and 28% reported partial response — with nearly 80% experiencing meaningful benefit.

View Full Text (PMC)

BoNT in Headache & Facial Pain — Updated Review 2025 | PMC / MDPI Toxins

Narrative review covering the use of botulinum toxin in primary and secondary headaches and facial pain disorders. Summarizes highest levels of evidence for each indication: chronic migraine (multicenter RDBPC studies), trigeminal neuralgia (double-blind placebo-controlled studies), post-traumatic headache (RDBPC cross-over trial showing −1.6 headache days/week vs. +0.01 in placebo, p = 0.48 frequency and p = 0.006 intensity), and cluster headache (open-label trials).

View Full Text (PMC)

BoNT for Chronic Pain Conditions — ScienceDirect Review

Comprehensive review of botulinum toxin use across chronic pain conditions beyond migraine. Highlights myofascial pain, CRPS, and neuropathic pain applications. Notably, in a retrospective review of 37 CRPS patients injected with BoNT-A, mean pain scores were reduced by 43% with 97% of subjects reporting reduction in pain at 4 weeks. Confirms high safety profile with few significant adverse events across all pain indications reviewed.

View Abstract (ScienceDirect)

AAP / AAN Assessment — BoNT in Autonomic Disorders & Pain | Neurology 2008

Evidence-based review by the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology assessing botulinum toxin across autonomic disorders and pain conditions. Established the evidence framework that guided subsequent FDA approval decisions and remains a foundational reference for the use of botulinum toxin in pain medicine. Cited extensively in subsequent clinical guidelines.

View on PubMed

Transparent Pricing

Session Pricing

Each session includes physician assessment, preparation, and administration of therapeutic botulinum toxin using the appropriate protocol for your condition.

Therapeutic Botox Session

$1,200

per treatment session • Repeated every 12 weeks

Physician assessment and injection map review at each visit
Full therapeutic dose — PREEMPT protocol for migraine (155 units, 31 sites) or customized pain protocol
Fine 30-gauge needle — minimal discomfort technique
Post-injection observation and discharge instructions
4–6 week follow-up call to assess response and refine protocol
Coordination with your other pain management providers as needed

Therapeutic botulinum toxin for chronic migraine may be covered by insurance — we recommend checking with your insurer prior to your appointment.
For other pain indications, coverage varies significantly. HSA/FSA cards may be accepted — please inquire at your consultation.

Consultation Credit: The $95 initial consultation fee will be fully credited toward your first treatment session. Your consultation fee is never lost.

Ready to Break the Migraine Cycle?

Schedule a consultation with our physician to determine whether therapeutic botulinum toxin is right for your condition.

Book My Consultation

Medical Disclaimer: OnabotulinumtoxinA (Botox®) is FDA-approved for the prophylactic treatment of chronic migraine, cervical dystonia, and upper/lower limb spasticity. Its use for other pain conditions described on this page represents off-label use, which is a common and legal medical practice. Results vary between individuals and are not guaranteed. This page is for informational purposes only and does not constitute medical advice. Treatment decisions are made on an individual basis following a comprehensive medical evaluation. Botox® is a registered trademark of AbbVie Inc.