Introduction

This form is designed to provide you, the patient, with important information regarding Botulinum Toxin A therapy for the treatment of chronic migraines and to obtain your consent to undergo this treatment at Perth Migraine Centre by a neurologist.

Purpose of Treatment

Botulinum Toxin A, commonly known as Botox, is a neurotoxin used to reduce the frequency and severity of migraine headaches. This therapy involves injections into specific areas of the head and neck and may offer relief from chronic migraine symptoms.

Procedure Description

• The procedure involves multiple small injections around the head and neck area.

• Each treatment session typically takes about 15-20 minutes.

• Patients may need to repeat treatments every 12 weeks, depending on their response.

Potential Risks and Side Effects

While Botulinum Toxin A is generally safe, potential risks and side effects may include, but are not limited to:

• Pain, swelling, or bruising at the injection sites.

• Weakness in nearby muscles.

• Headache or flu-like symptoms.

• Eyelid drooping or eyebrow asymmetry (temporary).

Alternative Treatments

Alternative treatments for chronic migraines include oral medications, lifestyle changes, stress management techniques, and other forms of therapy. You are encouraged to discuss these options with your healthcare provider.

Consent and Acknowledgement

By signing this form, you acknowledge that you have read and understood the information provided about Botulinum Toxin A therapy. You have had the opportunity to ask questions, and all your questions have been answered to your satisfaction.

Signatory

A legal guardian should be signing the form if the patient is a minor (age < 18 years) or is medically unfit to give consent.