Botox (onabotulinumtoxinA)

Botox generic or biosimilar

Botox is a biologic drug that’s available only as a brand-name medication. It’s not currently available in a generic or biosimilar form.

Biologic medications are made from living cells, so it’s not possible to copy these drugs exactly. A generic, on the other hand, refers to drugs made from chemicals. A generic is an exact copy of the active drug in a brand-name medication.

Biosimilar medications are considered just as safe and effective as their parent drug. And as with generics, biosimilars tend to cost less than brand-name medications.

Botox dosage

The Botox dosage your doctor prescribes will depend on several factors. These include:

• the type and severity of the condition you’re receiving Botox to treat
• your age
• other medical conditions you may have

The following information describes dosages that are commonly used or recommended. However, your doctor will determine the best dosage to fit your needs.

Drug forms and strengths

Botox comes as a powder inside single-use vials. It’s mixed with liquid to form a solution that’s given as an injection. You’ll receive Botox injections from a healthcare professional.

For most of its uses, Botox is given by intramuscular injection. It’s injected into muscles in different areas of your body, depending on the condition being treated.

Botox is available in two strengths: 100 units and 200 units.

Dosage for chronic migraine

The recommended dosage of Botox for chronic migraine is 155 units. This total dose is given as 31 injections of 5 units each, given into certain injection sites.

Botox treatment for chronic migraine is typically repeated once every 12 weeks.

Dosage for OAB

The recommended dosage of Botox for OAB is 100 units. This total dose is given as 20 injections of 5 units each. The injections are given 1 centimeter (cm) apart into your bladder wall.

Botox treatment for OAB may be repeated when the drug’s effect wears off. However, each treatment session must be at least 12 weeks apart.

Dosage for urinary incontinence caused by a nerve disorder

The recommended dosage of Botox for urinary incontinence (involuntary leaking of urine) caused by a nerve disorder is 200 units. This total dose is given as 30 injections of 6.7 units each. The injections are given 1 cm apart into your bladder wall.

Botox treatment for urinary incontinence may be repeated when the drug’s effect wears off. But each treatment session must be at least 12 weeks apart.

Dosage for upper and lower limb spasticity

The typical dosage of Botox for upper limb spasticity in adults is 75–400 units. For lower limb spasticity in adults, the typical dosage of Botox is 300–400 units.

The exact Botox dosage for this use depends on the size, location, and number of muscles affected. It also depends on the severity of your spasticity. The total recommended dosage for spasticity is divided into multiple injections into affected muscles.

Botox treatment for spasticity may be repeated when the drug’s effect wears off. But each treatment session must be at least 12 weeks apart.

Your doctor will start your treatment by giving you the lowest recommended Botox dosage for spasticity. Your dose may change each time you have a session for Botox injections. Your dosage will vary depending on how your body responded to previous injections.

Dosage for cervical dystonia

The dosage of Botox for cervical dystonia depends on the severity of the condition, level of pain it’s causing, and muscles affected. The total recommended dosage of Botox for cervical dystonia is divided into multiple injections into the affected muscles.

In clinical trials, the average dose of Botox given for cervical dystonia was 236 units. Typically, treatment is started with a lower dose that may be increased depending on how your body responds to the drug.

Botox treatment for cervical dystonia may be repeated when the drug’s effect wears off. This time frame is typically 12 weeks after a treatment session.

Dosage for severe axillary hyperhidrosis

The recommended dosage of Botox for severe axillary hyperhidrosis is 50 units per armpit. This total recommended dose for each armpit is split into 10–15 injections. The injections are given 1–2 cm apart over each armpit.

Botox treatment for severe axillary hyperhidrosis may be repeated when the drug’s effect wears off. For this purpose, repeat Botox treatment is typically done at least 8 weeks after the first injection.

Dosage for blepharospasm

The recommended starting dosage of Botox for blepharospasm (uncontrollable blinking) is 1.25–2.5 units. This total recommended dose is given as the following three injections into each affected eye:

• two injections into the upper eyelid
• one injection into the lower eyelid

Botox treatment for blepharospasm may be repeated when the drug’s effect wears off. This time frame is typically 12 weeks after a treatment session.

Your doctor may recommend a higher dose of Botox each time you receive a set of injections. But this depends on how your body responds to previous injections. However, doses that are higher than 5 units per injection site are unlikely to be more effective than lower doses.

Dosage for strabismus

The recommended starting dosage of Botox for strabismus depends on which muscle is affected. However, the typical starting dosage ranges between 1.25 units to 5 units. This total dose is given as one injection into each affected muscle.

Botox treatment for this condition may be repeated when the drug’s effect wears off. The time frame for this is typically 12 weeks after a treatment session. But for strabismus, a single Botox injection may correct the condition.

If you have repeat treatment, your doctor may recommend a higher dosage of Botox each time you receive Botox injections. But this depends on how your body responds to previous injections. The maximum recommended dosage of Botox for this use is 25 units into any one muscle.

Pediatric dosage

Botox is approved for certain uses in children. Below, we list these uses and describe the typical recommended dosage for each of them.

Dosage for upper and lower limb spasticity

Botox is approved to treat upper and lower limb spasticity in children ages 2 years and older. The typical dosage for this use is based on the child’s body weight.

Botox dosage for spasticity depends on the size, location, and number of muscles affected. It also depends on the severity of the child’s spasticity. The total dosage calculated is divided into multiple injections, which are given into the affected muscles.

Botox treatment for spasticity may be repeated when the drug’s effect wears off. However, each treatment session must be at least 12 weeks apart.

Your child’s doctor will start your child’s treatment with the lowest recommended Botox dosage for spasticity. The dosage recommended by the doctor may change each time Botox is given. Dosages will depend on how your child responds to previous injections.

Dosage for upper limb spasticity in children

The recommended dosage for upper limb spasticity is 3–6 units per kilogram (kg) of body weight. The total dose given in one treatment session shouldn’t be higher than either 6 units of Botox per kg of body weight or 200 units, whichever amount is lower.

Dosage for lower limb spasticity in children

The recommended dosage for lower limb spasticity is 4–8 units per kg of body weight. The total dose given in one treatment session shouldn’t be higher than 8 units per kg of body weight or 300 units, whichever amount is lower.

Dosage for limb spasticity affecting more than one limb in children

In some cases, both the right and left leg, or both the arms and legs, are treated with Botox. In these cases, the total Botox dosage in a 3-month period shouldn’t be greater than either 10 units per kg of body weight or 340 units, whichever amount is lower.

Dosage for blepharospasm

The recommended dosage of Botox for blepharospasm (uncontrollable blinking) in children is the same as that for adults. See the section above for details.

Dosage for strabismus

The recommended dosage of Botox for strabismus in children is the same as that for adults. See the section above for details.

What if I miss a dose?

If you miss an appointment for your Botox injections, call your doctor’s office to reschedule.

To help make sure that you don’t miss an appointment for your injections, try setting a reminder on your phone. A note on your calendar may be helpful, too.

Will I need to use this drug long term?

Botox is meant to be used as a long-term treatment for most of its approved conditions. For these conditions, the drug may be given repeatedly as your doctor recommends. But for strabismus, a single Botox injection may correct the condition.

If you and your doctor determine that Botox is safe and effective for you, you’ll likely use the drug long term for most conditions.

Botox uses

The FDA approves prescription drugs such as Botox to treat certain conditions. The use of Botox for treating these conditions is described in detail below.

Botox for chronic migraine

Botox is approved to help prevent headaches in adults with chronic migraine.

With migraine headaches, you’ll usually also have nausea and increased sensitivity to light or sound. Some people also have a sensory aura before or during the headache. Sensory auras may involve changes in your vision, such as having blind spots or seeing light flashes or zigzag lines. With migraine, it’s also possible to experience tingling or buzzing sensations and to have difficulty speaking.

Migraine is considered to be chronic if you have headaches that last at least 4 hours on 15 or more days each month.

Botox is used in chronic migraine management to help prevent headaches and other symptoms. The drug works by stopping certain nerves in your body from sending signals. The nerves affected by Botox are those involved in causing migraine symptoms and producing pain during a migraine headache.

Note: Botox is not used to help prevent symptoms of episodic migraine, which occurs on 14 or fewer days per month.

What to expect with Botox for migraine

For migraine management, you’ll typically receive Botox injections once every 3 months. During your injection visits, your doctor will give you multiple injections of the drug. They’ll typically inject Botox into muscles in the following areas:

• your forehead
• the area around your temples
• the back of your neck

Botox can help reduce the number of migraine attacks you have and how long they last. But the drug won’t completely stop your migraine headaches. In addition, Botox doesn’t work right away, and it doesn’t work for everyone.

Some people start to experience an improvement in their migraine headaches just 2–4 weeks after their first set of Botox injections. But it can take two sets of injections and up to 6 months of treatment before you get the maximum effect from Botox.

Effectiveness for chronic migraine

In two clinical trials, Botox was effective in preventing migraine headaches in adults. For details of these clinical trials, see the Botox prescribing information.

Botox and children with chronic migraine

Botox isn’t approved for use in children with chronic migraine. It’s only approved for use in adults ages 18 years and older with this condition.

One clinical trial looked at children and adolescents who were younger than 18 years of age with chronic migraine. The trial didn’t find Botox to be effective in preventing migraine headaches in this age group.

Botox for overactive bladder

Botox is FDA-approved to treat OAB in adults with the following urinary symptoms:

• urinary incontinence (involuntary leaking of urine)
• urgency
• frequency

OAB is caused by uncontrollable spasms of a muscle in your bladder wall. This muscle is called the detrusor muscle. When the detrusor muscle contracts, it squeezes your bladder. With OAB, detrusor muscle spasms cause you to have sudden and frequent urges to urinate. And these urges can sometimes lead to incontinence if you can’t get to a toilet quickly enough.

Botox is used to treat OAB when drugs called anticholinergics either caused bothersome or severe side effects, or didn’t work well enough. Examples of anticholinergic drugs used for OAB include oxybutynin and tolterodine (Detrol).

Botox can help reduce the number of urinary incontinence episodes you have. And the drug can also decrease the number of times per day that you need to urinate.

To treat OAB, Botox is injected directly into the detrusor muscle in your bladder. The drug works by stopping nerves from sending signals that cause this muscle to contract. These injections are given through a thin tube called a cystoscope that’s inserted into your bladder.

The effect of Botox injections for OAB lasts at least 12 weeks. After that point, the drug’s effect starts to wear off and repeat treatment may be needed. However, in clinical trials, the drug’s effect lasted for an average of 24 weeks before repeat treatment was needed.

Effectiveness for overactive bladder

In two clinical trials, Botox was effective in treating OAB in adults. For details about these trials, see the Botox prescribing information.

Botox for urinary incontinence caused by a nerve disorder

Botox is FDA-approved to treat urinary incontinence caused by a neurologic condition (nerve disorder). Examples of these nerve disorders include MS and spinal cord injury. For this condition, Botox can be used in adults and children ages 5 years and older.

With urinary incontinence, you have involuntary leaking of urine. This is a common problem in people with certain nerve disorders. The incontinence happens because nerves that aren’t functioning correctly send inappropriate signals to the muscle in your bladder wall. This muscle is called the detrusor muscle. The inappropriate signals make your detrusor muscle contract uncontrollably. And this squeezes your bladder and causes urinary incontinence.

Botox is used for this condition when drugs called anticholinergics either caused bothersome or severe side effects, or they didn’t work well enough. Examples of anticholinergic drugs used for this purpose include oxybutynin and tolterodine (Detrol).

To treat this type of urinary incontinence, Botox is injected directly into the detrusor muscle in your bladder. The drug works by stopping nerves from sending signals that cause this muscle to contract. These injections are given through a thin tube called a cystoscope that’s inserted into your bladder.

Effectiveness for urinary incontinence caused by a nerve disorder

In two clinical trials, Botox was effective in treating urinary incontinence caused by a nerve disorder in adults. For details about these trials, see the Botox prescribing information.

A separate clinical trial found Botox to be safe and effective for treating nerve-related urinary incontinence in children ages 5 years and older.

Botox for upper and lower limb spasticity

Botox is FDA-approved to treat certain types of muscle spasticity in adults and children ages 2 years and older. With this condition, your muscles contract involuntarily and become stiff. Upper and lower limb spasticity can cause stiffness in your elbows, hands, fingers, ankles, or toes. Muscle spasticity can be painful, and it can make it difficult for you to do daily activities.

Upper or lower limb spasticity may occur after someone has a stroke.

But limb spasticity may also be caused by nerve disorders, such as MS and cerebral palsy. Brain or spinal cord injury can also result in limb spasticity. All these conditions can damage nerves in your brain, causing them to malfunction and result in limb spasticity.

To treat limb spasticity, Botox is injected into certain muscles in the affected arm, hand, or leg. The drug works by stopping nerves from sending signals that are causing the muscle spasticity. This action of Botox allows the muscles to relax.

The effect of Botox injections for limb spasticity typically lasts about 12 weeks. After that point, the drug’s effect wears off and repeat treatment may be needed.

Effectiveness for upper and lower limb spasticity

In several clinical trials, Botox was effective in treating limb spasticity in adults and children ages 5 years and older. For details about these trials, see the Botox prescribing information.

Botox for cervical dystonia

Botox is FDA-approved to treat cervical dystonia, which is also called spasmodic torticollis. For this purpose, Botox can be used in adults.

With cervical dystonia, you have involuntary muscle spasms in your neck. The spasms cause repetitive, uncomfortable, twisting movements in your head or neck. These movements place your head in an atypical position and cause pain in your neck.

To treat cervical dystonia, Botox is injected into the affected muscles in your neck or upper back. The drug works by stopping nerves from sending the signals that cause those muscles to contract. This allows the muscles to relax.

The effect of Botox injections for this condition typically lasts about 12 weeks. After that, the effect wears off and repeat treatment may be needed.

Effectiveness for cervical dystonia

In a clinical trial, Botox was effective in treating cervical dystonia in adults. For details about this clinical trial, see the Botox prescribing information.

Botox for blepharospasm

Botox is FDA-approved to treat blepharospasm (uncontrollable blinking) related to dystonia (involuntary muscle spasms). The drug is approved for this use in adults and children ages 12 years and older.

Dystonia describes a range of movement disorders that are caused by problems with nerve messages sent to your muscles. This condition can affect one or many parts of your body.

With blepharospasm, you have muscle spasms in your eyelids. These spasms cause excessive and uncontrollable blinking of both eyes. In severe cases of blepharospasm, you may not be able to open your eyes for several minutes at a time. The condition can irritate your eyes, and it can make them more sensitive to light.

To treat blepharospasm, Botox is injected into the affected muscles in your upper and lower eyelids. The drug works by stopping nerves from sending the signals that are causing those muscles to contract. This weakens the muscles and stops them from causing excessive blinking.

For blepharospasm, Botox’s effect typically lasts about 12 weeks before it wears off. At that time, repeat treatment can be done if needed.

Effectiveness for blepharospasm

In clinical trials, Botox was effective in treating blepharospasm. The majority of people given Botox for this condition had improvement after treatment.

Botox for strabismus

Botox is FDA-approved to treat strabismus in adults and children ages 12 years and older.

Strabismus affects one or more of the muscles on the outside of one eyeball. It causes the affected muscles to contract more strongly than other muscles. This causes the eyeball to turn, so that your eyes are crossed or misaligned and don’t look in the same direction.

To treat strabismus, Botox is injected into the muscles that are pulling your eyeball in the wrong direction. The drug works by stopping nerves from sending signals that are causing the muscles to contract and pull your eyeball.

Botox’s effect for this condition typically lasts about 12 weeks before it wears off. At that time, repeat treatment may be needed.

Effectiveness for strabismus

In a clinical trial, Botox was effective in treating strabismus in people who were given one or more injections of the drug. For details about this trial, see the Botox prescribing information.

Botox for severe axillary hyperhidrosis

Botox is FDA-approved for use in adults with severe primary axillary hyperhidrosis (excessive underarm sweating). Botox can be used to treat this condition when antiperspirants applied to the underarms don’t work well enough to manage sweating.

With hyperhidrosis, you sweat excessively. The sweating can cause discomfort and anxiety. And it can lead to problems with your emotional well-being, relationships, social life, and daily activities.

With primary axillary hyperhidrosis, there’s no apparent cause for the excessive sweating, such as an underlying health condition.

To treat severe primary axillary hyperhidrosis, Botox injections are given into the skin in your armpits. The drug works by stopping nerves from sending signals that activate the sweat glands in that area.

If needed, Botox injections can be repeated after symptoms return. For this purpose, repeat Botox treatment is typically done at least 8 weeks after the first injection.

Note: Botox is only used for hyperhidrosis in the axillary (underarm) area. Botox’s safety and effectiveness for hyperhidrosis in other body areas isn’t known.

Effectiveness for severe axillary hyperhidrosis

In two clinical trials, Botox was effective in treating axillary hyperhidrosis in adults. For details about these trials, see the Botox prescribing information.

Botox and children

Botox is FDA-approved to treat the following conditions in children:

• urinary incontinence (involuntary leaking of urine) caused by a nerve disorder in children ages 5 years and older
• upper or lower limb spasticity (involuntary muscle contraction) in children ages 2 years and older
• blepharospasm (uncontrollable blinking) related to dystonia (involuntary muscle spasms) in children ages 12 years and older
• strabismus (crossed eyes or misaligned eyes) in children ages 12 years and older

To read more about these uses of Botox and its effectiveness in treating them, see the sections above for each condition.

Off-label uses for Botox

In addition to the uses listed above, Botox may be prescribed off-label for other purposes. Off-label drug use is when a drug that’s FDA-approved for one or more uses is prescribed for a different one that’s not approved. Below are examples of off-label uses for Botox:

• tension headaches
• anal fissures
• depression

Botox side effects

Botox can cause mild or serious side effects. The following lists contain some of the key side effects that may occur while taking Botox. These lists don’t include all possible side effects.

For more information on the possible side effects of Botox, you can refer to this article. You can also talk with your doctor or pharmacist. They can give you tips on how to manage any side effects that may be bothersome.

Note: After the Food and Drug Administration (FDA) approves a drug, it tracks and reviews side effects of the medication. Sharing your experience helps make medications safer for everyone by giving doctors and researchers more information about how the drug works in real life. If you develop a side effect while using Botox and want to tell the FDA about it, visit MedWatch or call 800-FDA-1088.

Mild side effects

Some mild side effects of Botox can include:

• pain, tenderness, discoloration, swelling, bruising, bleeding, or infection at Botox injection sites
• unwanted muscle weakness near Botox injection sites
• nausea
• fever
• achy muscles
• upper respiratory tract infections, such as the common cold
• headache
• neck pain
• drooping eyelids
• dry eyes
• dry mouth
• painful urination and urinary tract infection (UTI) in people receiving Botox for urinary incontinence (involuntary leaking of urine)

Most of these side effects may go away within a few days or a couple of weeks. But if they become more severe or don’t go away, talk with your doctor or pharmacist.

Serious side effects

Serious side effects from Botox aren’t common, but they can occur. Contact your doctor right away if you have serious side effects. Call 911 if your symptoms feel life threatening or if you think you’re having a medical emergency.

• corneal ulceration
• urinary retention
• retrobulbar hemorrhage (bleeding behind the eye) in people receiving Botox to treat strabismus
• autonomic dysreflexia (a serious complication of the central nervous system) in people receiving Botox to treat urinary incontinence due to a neurological condition
• spread of toxin effects, which may lead to difficulty breathing or swallowing that may be life threatening

Botox has a boxed warning about the risk of spread of toxin effects. A boxed warning is the most serious warning from the FDA. A boxed warning alerts doctors and patients about drug effects that may be dangerous.

Side effects in children

Botox is approved for use in children with certain conditions. Below, we list these conditions and briefly describe the side effects seen in children who have them.

• Urinary incontinence (involuntary leaking of urine) caused by a nerve disorder: Side effects of Botox in children with urinary incontinence were similar to side effects in adults treated for this condition.
• Upper and lower limb spasticity (involuntary muscle contraction): The most common side effect in children with these conditions is upper respiratory tract infection, such as the common cold. This side effect occurs more often in children with these conditions than it does in adults.
  • Blepharospasm (uncontrollable blinking) and strabismus (crossed eyes): Side effects of Botox in children with these conditions are similar to side effects in adults treated for these conditions.

Allergic reaction

For some people, Botox can cause an allergic reaction.

This side effect was reported in the drug’s studies.

In general, symptoms of an allergic reaction can be mild or serious.

Ways to manage

For mild allergic reaction symptoms, such as a mild rash, call your doctor right away. They may recommend treatments to help manage your symptoms. They’ll also let you know whether you should keep taking the medication.

For severe allergic reaction symptoms, such as swelling or trouble breathing, call 911 or your local emergency number right away. These symptoms require immediate medical care because they can become life threatening. If you’ve had a serious allergic reaction to x drug, your doctor may recommend a different medication instead.

Botox cost and savings

As with all medications, the cost of Botox can vary. The actual price you’ll pay depends on your insurance plan, your location, and what condition you’re taking the drug for.

You won’t pick up Botox from a pharmacy. You’ll receive Botox injections from a healthcare professional. To find out how much Botox treatment will likely cost, talk with your doctor or their office staff.

Your insurance company may require you to get prior authorization before approving coverage for Botox. This means that your doctor and insurance company will need to communicate about your prescription before the insurance company will cover the drug. The insurance company will review the prior authorization request and decide whether the drug will be covered.

If you’re not sure whether you’ll need to get prior authorization for Botox, contact your insurance plan.

If you have Medicare, this article about Medicare coverage for Botox may be helpful.

Financial and insurance assistance

If you need financial support to pay for Botox, or if you need help understanding your insurance coverage, help is available.

A Botox Savings Program is available, and it may help lower the cost of your treatment. For more information and to find out if you’re eligible for support, call 800-44-BOTOX (800-442-6869) or visit the program website.

How Botox works

Botox is made from a toxin that’s produced by Clostridium botulinum bacteria. It’s a type of drug called a neurotoxin. Botox works by stopping nerves from functioning.

Typically, nerves communicate with other parts of your body, such as your muscles. Your nerves do this by releasing a neurotransmitter (chemical messenger) called acetylcholine. Botox works by stopping nerve endings from releasing acetylcholine. This leaves the nerves temporarily unable to send signals.

When it’s injected into specific muscles, Botox stops nerves from sending the signals that cause those muscles to contract or spasm. This weakens or paralyzes the muscle. Botox works to treat certain conditions when injected into specific muscles, as follows:

• Limb spasticity: Botox stops the muscle contractions in your arm, hand, or leg that are causing stiffness.
• Cervical dystonia: Botox stops the muscle contractions in your neck that are causing atypical head and neck position.
• Blepharospasm: Botox reduces blinking.
• Strabismus: Botox stops the affected muscles from turning your eye in the wrong direction.
• Urinary incontinence: Botox stops excessive muscle contractions in your bladder wall that cause urinary leakage.
• Migraine: Botox stops certain nerves from sending signals that are involved in causing migraine attacks.

When it’s injected into your skin, as it is with excessive sweating, Botox stops certain nerves from sending signals. These signals activate your sweat glands and cause you to sweat.

Botox’s effect wears off gradually as your nerves develop new endings and start to release acetylcholine again. This process typically takes about 3 months. But if recommended by your doctor, Botox injections can be repeated when the drug’s effect goes away.

How long does it take for Botox to work?

Botox starts to have its effect on nerve endings in your body within 24–72 hours after it’s injected. But it typically takes up to 2 weeks before the drug has its full effect and you notice a difference in your symptoms. However, for some people, it can take longer than 2 weeks for this to occur.

How Botox is given

Botox is given during treatment sessions. At each session, you’ll likely receive several injections of the drug. The injections are given into different areas of the body, depending on the condition being treated.

Botox injection sites

For most of its uses, Botox is given by intramuscular injection. It’s injected into muscles in different areas of your body, depending on the condition being treated.

For OAB and urinary incontinence (involuntary leaking of urine) due to nerve disorders, Botox is injected into the detrusor muscle of the bladder. This injection is done using a thin tube called a cystoscope that’s inserted into your bladder.

And for excessive underarm sweating, Botox is injected into the skin of your armpit.

Injection sites for chronic migraine

For chronic migraine, you’ll receive two or more Botox injections in each of the following areas of your body:

• lower part of your forehead, just above your nose and the inside edge of each eyebrow
• middle of your forehead, above each eye
• behind each temple, above the ear
• back of your head, behind each ear
• back of your neck, at the base of your skull on both your right and left side
• between your shoulder and your neck on both your right and left side

Injection sites for other conditions

Below, we describe Botox injection sites for the following conditions:

• OAB: For OAB, Botox injections are given into the wall of your bladder. The injections are given through a thin tube called a cystoscope that’s inserted into your bladder through your urethra. The procedure may be done under a local anesthetic or general anesthetic.
• Urinary incontinence caused by a nerve disorder: As with OAB, Botox injections are given into the wall of your bladder for urinary incontinence. These injections are also given through a cystoscope with either local or general anesthetic.
• Upper limb spasticity: For upper limb spasticity, Botox injections are given just above the elbow, in the forearm, and near the thumb.
• Lower limb spasticity: For lower limb spasticity, Botox injections are given in the calf.
• Cervical dystonia: For cervical dystonia, Botox injections are given in the neck.
• Severe axillary hyperhidrosis: For hyperhidrosis, Botox injections are given in the armpits.
• Blepharospasm: For blepharospasm (uncontrollable blinking), Botox injections are given in the upper and lower eyelids.
• Strabismus: For strabismus, Botox injections are given in the muscles that move your eye. This procedure may be done with a local anesthetic.

For strabismus, limb spasticity, and cervical dystonia, your doctor will measure the electrical activity in your muscles before giving Botox injections. Doing this allows your doctor to determine exactly which muscles are affected. They can then place Botox injections precisely where they’re needed.

Botox and pregnancy, breastfeeding, and birth control

If you can become pregnant, are breastfeeding, or are using birth control, it’s important to consider whether Botox is a safe choice for you.

You can refer to this article for more information. If you have additional questions, talk with your doctor.

Common questions about Botox

Here are answers to some frequently asked questions about Botox.

Does Botox cause hair loss?

Possibly. You may have hair loss after receiving Botox, but this side effect isn’t very common. In fact, hair loss wasn’t reported during clinical trials of Botox.

However, a few cases of hair loss have been reported since Botox was approved for use and became available on the market. But it’s not known how often these cases of hair loss occurred. And it’s not known whether the hair loss was caused by Botox.

If you’re concerned about hair loss with Botox, talk with your doctor.

Does Botox for migraine help to reduce wrinkles?

It may, depending on where the wrinkles are. But Botox for migraine isn’t approved for this use.

Botox, which is approved to manage migraine and other health conditions, is a different medication than Botox Cosmetic. Both medications contain the same drug. However, Botox Cosmetic is approved to reduce wrinkles.

For migraine treatment, Botox is injected into some of the same places on your forehead where Botox Cosmetic is injected. Like Botox Cosmetic injections, Botox injections can help reduce frown lines between your eyebrows. The injections can also reduce horizontal creases in your forehead.

However, Botox is unlikely to help reduce wrinkles around your eyes (called crow’s feet lines) because it’s not injected into the areas that would help reduce these wrinkles.

If you have questions about Botox and Botox Cosmetic, talk with your doctor.

Similar drugs

Examples of other drugs that may be prescribed to prevent headaches from chronic migraine include:

• certain beta-blockers, such as:
  • propranolol (Inderal LA)
  • metoprolol (Lopressor, Toprol XL)
• certain calcium channel blockers, such as:
  • verapamil
  • nifedipine
• certain antidepressants, such as:
  • amitriptyline
  • venlafaxine (Effexor XR)
• certain seizure medications, such as:
  • topiramate (Topamax, Trokendi XR)
  • divalproex sodium (Depakote)
  • sodium valproate
• calcitonin gene-related peptide (CGRP) antagonists, such as:
  • erenumab-aooe (Aimovig)
  • fremanezumab-vrfm (Ajovy)
  • galcanezumab-gnlm (Emgality)

Alternatives for urinary or bladder disorders

Examples of other drugs that may be prescribed to treat urinary or bladder disorders include:

• anticholinergic drugs, such as:
  • oxybutynin
  • solifenacin (Vesicare)
  • tolterodine (Detrol)
  • fesoterodine (Toviaz)
  • trospium
  • darifenacin
• imipramine
• mirabegron (Myrbetriq)

Alternatives for upper and lower limb spasticity

Examples of other drugs that may be prescribed to treat upper and lower limb spasticity include:

• baclofen (Gablofen, Lioresal, Ozobax DS)
• gabapentin (Neurontin)
• diazepam (Valium)
• dantrolene sodium (Dantrium)
• abobotulinumtoxinA (Dysport)
• incobotulinumtoxinA (Xeomin)

Alternatives for cervical dystonia

Examples of other drugs that may be prescribed to treat cervical dystonia include:

• diazepam (Valium)
• topiramate (Topamax)
• trihexyphenidyl
• benztropine
• levodopa/carbidopa (Sinemet)
• abobotulinumtoxinA (Dysport)
• incobotulinumtoxinA (Xeomin)
• rimabotulinumtoxinB (Myobloc)

Alternatives for severe axillary hyperhidrosis

Examples of other drugs that may be prescribed to treat severe axillary hyperhidrosis include:

• oxybutynin
• benztropine
• glycopyrronium (Qbrexza)

Alternatives for eye muscle problems, such as blepharospasm or strabismus

Examples of other drugs that may be prescribed to treat eye muscle problems, such as blepharospasm (uncontrollable blinking) or strabismus (crossed eyes or misaligned eyes), include:

• incobotulinumtoxinA (Xeomin)

Botox vs. Topamax

You may wonder how Botox compares with other medications that are prescribed for similar uses. Here we look at how Botox and Topamax are alike and different.

Ingredients

Botox contains the drug onabotulinumtoxinA, while Topamax contains the drug topiramate. These drugs belong to different classes of medications. (A medication class describes a group of drugs that work in the same way.)

Uses

Botox is FDA-approved for the following uses:

• preventing headaches in adults with chronic migraine
• treating OAB in adults with urinary incontinence (involuntary leaking of urine), urgency, and frequency
• treating urinary incontinence caused by a nerve disorder, such as MS or spinal cord injury, in adults and children ages 5 years and older
• treating upper or lower limb spasticity (involuntary muscle contractions) in adults and children ages 2 years and older
• treating cervical dystonia (involuntary muscle spasms in the neck) in adults
• treating blepharospasm (uncontrollable blinking) related to dystonia (involuntary muscle spasms) in adults and children ages 12 years and older
• treating strabismus (crossed eyes or misaligned eyes) in adults and children ages 12 years and older
• treating severe axillary hyperhidrosis (excessive underarm sweating) in adults

Topamax is approved for the following uses:

• preventing migraine in adults and children ages 12 years and older
• treating epilepsy (specifically, focal onset seizures or primary generalized tonic-clonic seizures) in adults and children ages 2 years and older*
• treating epilepsy (specifically, focal onset seizures, primary generalized tonic-clonic seizures, or seizures associated with Lennox-Gastaut syndrome) in adults and children ages 2 years and older (For this purpose, Topamax is taken in combination with other treatments.)

Drug forms and administration

Botox comes as a powder inside single-use vials. It’s mixed into a solution and given as an injection by healthcare professionals.

For most of its uses, Botox is given by intramuscular injection. It’s injected into muscles in different areas of your body, depending on the condition being treated.

For OAB and urinary incontinence caused by a nerve disorder, Botox is injected into the detrusor muscle of the bladder. This injection is done using a thin tube called a cystoscope that’s inserted into your bladder.

And for excessive sweating, Botox is injected into the skin of your armpit.

Botox injections are typically given once every 12 weeks.

Topamax comes as tablets and capsules that are taken by mouth. It’s taken twice each day.

Side effects and risks

Botox and Topamax can cause some similar and some different side effects. Below are examples of these side effects.

Mild side effects

These lists contain up to 10 of the most common mild side effects that can occur with Botox, with Topamax, or with both drugs (when taken individually).

• Can occur with Botox:
  • pain, tenderness, discoloration, swelling, bruising, bleeding, or infection at Botox injection sites
  • unwanted muscle weakness near Botox injection sites
  • achy muscles
  • neck pain
  • drooping eyelids
• Can occur with Topamax:
  • pins and needles sensations in your body
  • loss of appetite
  • weight loss
  • diarrhea
  • problems with concentration, memory, or speech
  • changes in taste
  • sleepiness
• Can occur with both Botox and Topamax:
  • nausea
  • fever
  • headache
  • dizziness
  • upper respiratory tract infections, such as the common cold

Serious side effects

These lists contain examples of serious side effects that can occur with Botox, with Topamax, or with both drugs (when taken individually).

• Can occur with Botox:
  • spread of toxin effects, which may lead to difficulty breathing or swallowing that may be life threatening*
  • corneal ulceration (open sore on the clear covering over the front of the eye) due to reduced blinking in people receiving Botox for blepharospasm
  • urinary retention (inability to empty the bladder) in people receiving Botox for urinary incontinence
  • retrobulbar hemorrhage (bleeding behind the eye) in people receiving Botox to treat strabismus
  • autonomic dysreflexia (a serious complication of the central nervous system) in people receiving Botox to treat urinary incontinence due to a neurological condition
• Can occur with Topamax:
  • eye problems, such as vision changes or raised pressure in the eye
  • reduced sweating and increased body temperature
  • metabolic acidosis (increased level of acid in the blood)
  • high level of ammonia in the blood
  • suicidal thoughts or actions
  • serious skin reactions
  • kidney stones
  • fetal harm if taken during pregnancy
• Can occur with both Botox and Topamax:
  • severe allergic reaction

* Botox has a boxed warning about this risk. This is the most serious warning from the Food and Drug Administration (FDA). A boxed warning alerts doctors and patients about drug effects that may be dangerous.

Effectiveness

Botox and Topamax have different FDA-approved uses, but they’re each used to help prevent headaches caused by chronic migraine. (Topiramate is also approved to help prevent headaches from episodic migraine, while Botox is not.)

The use of Botox and Topamax for migraine prevention has been directly compared in a 2019 clinical trial. In this study, Botox was more effective in preventing chronic migraine headaches.

If you’re interested in taking one of these drugs to prevent migraine headaches, talk with your doctor about which drug is right for you.

Costs

The actual price you’ll pay for either drug depends on your insurance plan and your location. If you’re prescribed Botox, it also depends on the cost of the visit to your healthcare professional to receive doses of this drug.

Botox and Topamax are both brand-name drugs. A generic form of Topamax is available. However, there’s currently no biosimilar form of Botox.

Botox and alcohol

Botox isn’t known to interact with alcohol. Alcohol doesn’t affect how this drug works. However, drinking alcohol after having Botox injections could increase your risk of certain side effects. Examples of these side effects include:

• headache
• dizziness
• tiredness
• blurred vision

If you drink alcohol, talk with your doctor about how much is safe for you to drink while you’re receiving Botox.

Botox interactions

Botox can interact with several other medications. Different interactions can cause different effects. For instance, some interactions can interfere with how well a drug works. Other interactions can increase side effects or make them more severe.

Botox and other medications

Below are lists of medications that can interact with Botox. These lists don’t contain all the drugs that may interact with Botox.

Before taking Botox, talk with your doctor and pharmacist. Tell them about all prescription, over-the-counter, and other drugs you take. Also tell them about any vitamins, herbs, and supplements you use. Sharing this information can help you avoid potential interactions.

If you have questions about drug interactions that may affect you, ask your doctor or pharmacist.

Botox and blood thinners

Botox injections can cause bruising or bleeding. But the injections are more likely to do this if you also take blood thinning drugs.

Examples of blood thinning drugs include:

• anticoagulants, such as:
  • warfarin
  • rivaroxaban (Xarelto)
  • apixaban (Eliquis)
• antiplatelets, such as:
  • aspirin
  • dipyridamole

If you take a blood thinning drug, talk with your doctor about your risk of bruising or bleeding with Botox. Your doctor may recommend that you stop the blood thinner temporarily before you receive Botox injections.

Botox and anticholinergics

Anticholinergics are used to treat a variety of conditions, including urinary incontinence and movement disorders such as Parkinson’s disease.

Taking an anticholinergic drug while receiving Botox injections can increase your risk of certain side effects. These side effects include blurred vision, dry mouth, dry eyes, and difficulty urinating.

Examples of anticholinergic drugs that can increase your risk of side effects with Botox include:

• oxybutynin
• solifenacin (Vesicare)
• tolterodine (Detrol)
• fesoterodine (Toviaz)
• trospium
• darifencin
• trihexyphenidyl
• benztropine

If you take an anticholinergic drug, talk with your doctor before starting Botox. They can recommend whether you should continue taking the drug while you’re receiving Botox injections.

Botox and muscle relaxants

Botox can cause unwanted muscle weakness around the area where the drug is injected. And taking a muscle relaxant medication before or after having a Botox injection can increase your risk of this side effect.

Examples of muscle relaxants include:

• baclofen (Gablofen, Lioresal, Ozobax DS)
• diazepam (Valium)
• dantrolene sodium (Dantrium)

If you take a muscle relaxant, talk with your doctor. They can recommend whether you should continue taking it while you’re having Botox injections.

Keep in mind that certain muscle relaxants are sometimes given with anesthesia during surgical procedures. If you have any surgeries, be sure to tell your doctor if you’re receiving Botox.

Botox and certain antibiotics

Certain antibiotics can increase the risk of side effects such as unwanted muscle weakness from Botox.

Examples of these antibiotics include:

• neomycin
• amikacin
• gentamicin
• tobramycin

If you’ve recently had treatment with one of these antibiotics, be sure to tell your doctor before receiving Botox injections. Your doctor will recommend whether it’s safe for you to have Botox.

If you need treatment with one of these antibiotics, let your doctor know if you’re receiving Botox. Your doctor will advise whether the antibiotic is safe for you to take or if you should take a different antibiotic instead.

Botox and other botulinum toxin products

Botox contains the drug onabotulinumtoxinA. It’s made from a toxin that’s produced by Clostridium botulinum bacteria. If Botox is given at the same time as, or within a few months of, other botulinum toxin products, it can cause severe muscle weakness.

Examples of other botulinum toxin products include:

• rimabotulinumtoxinB (Myobloc)
• abobotulinumtoxinA (Dysport)
• incobotulinumtoxinA (Xeomin)

If you’ve received any other botulinum toxin product, be sure to tell your doctor before getting a Botox injection. Botox should not be given until the effects of the other product have worn off.

Botox and herbs and supplements

There aren’t any herbs or supplements that have been specifically reported to interact with Botox. However, you should still check with your doctor or pharmacist before using any of these products while taking Botox.

Botox and foods

There aren’t any foods that have been specifically reported to interact with Botox. If you have any questions about eating certain foods with Botox, talk with your doctor.

Botox precautions

This drug comes with several precautions.

FDA warning: Spread of toxin effects

This drug has a boxed warning. This is the most serious warning from the Food and Drug Administration (FDA). A boxed warning alerts doctors and patients about drug effects that may be dangerous.

In some cases, Botox’s effects may spread away from the site where it’s injected. This can cause a serious condition called botulism, which may lead to symptoms such as:

• low energy
• muscle weakness all over your body
• drooping eyelids
• double vision
• loss of bladder control
• hoarse voice
• difficulty speaking
• difficulty breathing
• difficulty swallowing

These symptoms can occur hours, days, or weeks after you’ve had a Botox injection. Be sure to tell your doctor if you develop any symptoms of botulism, even if they do not occur right after you receive a Botox injection.

It’s important to note that breathing and swallowing problems caused by Botox can sometimes be life threatening. The risk of these problems is higher in people who already have breathing or swallowing problems.

If you have difficulty breathing, swallowing, or speaking after having a Botox injection, contact your doctor right away. But if your symptoms feel life threatening, call 911 or your local emergency number.

Other precautions

Before taking Botox, talk with your doctor about your health history. Botox may not be right for you if you have certain medical conditions or other factors affecting your health. These include:

• infection at a planned injection site
• UTI
• difficulty emptying your bladder
• lung problems
• difficulty breathing or swallowing
• neuromuscular condition, such as amyotrophic lateral sclerosis (ALS), myasthenia gravis (MG), or Lambert-Eaton syndrome
• planned surgery
• previous allergic reaction
• pregnancy
• breastfeeding

Note: For more information about the potential negative effects of Botox, see the “Botox side effects” section above.

Disclaimer: Medical News Today has made every effort to make certain that all information is factually correct, comprehensive, and up to date. However, this article should not be used as a substitute for the knowledge and expertise of a licensed healthcare professional. You should always consult your doctor or another healthcare professional before taking any medication. The drug information contained herein is subject to change and is not intended to cover all possible uses, directions, precautions, warnings, drug interactions, allergic reactions, or adverse effects. The absence of warnings or other information for a given drug does not indicate that the drug or drug combination is safe, effective, or appropriate for all patients or all specific uses.