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Botox

Botox Side Effects Center

Pharmacy Author: Omudhome Ogbru, PharmD
Medical Editor: Melissa Conrad Stöppler, MD

Botox (onabotulinumtoxinA) is an injectable neuro-toxin used for the treatment of chronic migraines; limb spasticity; axillary hyperhidrosis; cervical dystonia; strabismus; and blepharospasm. Side effects of Botox include allergic reactions, rash, itching, headache, neck pain, difficulty swallowing, shortness of breath, nausea, weakness, and pain or tenderness at the injection site. Drooping of the eyelid (ptosis), inflammation of the cornea (keratitis), eye dryness, double vision, tearing, and sensitivity to light may occur when used for treating blepharospasm.

Botox is administered by injection and dosing depends on the condition that it is used for. Administration of botulinum toxin with other agents (for example, aminoglycosides, curare) that affect neuromuscular function may increase the effect of botulinum toxin. There are no adequate studies of Botox in pregnant women and it has not been evaluated in nursing mothers.

Our Botox Side Effects Drug Center provides a comprehensive view of available drug information on the potential side effects when taking this medication.

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

What is Patient Information in Detail?

Easy-to-read and understand detailed drug information and pill images for the patient or caregiver from Cerner Multum.

Botox in Detail - Patient Information: Side Effects

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; feeling like you might pass out; swelling of your face, lips, tongue, or throat.

The botulinum toxin contained in Botox can spread to other body areas beyond where it was injected. This has caused serious life-threatening side effects in some people receiving botulism toxin injections, even for cosmetic purposes.

Call your doctor at once if you have any of these serious side effects, some of which can occur up to several weeks after an injection:

  • trouble breathing, talking, or swallowing;
  • hoarse voice, drooping eyelids;
  • unusual or severe muscle weakness (especially in a body area that was not injected with the medication);
  • loss of bladder control;
  • problems with vision;
  • crusting or drainage from your eyes;
  • severe skin rash or itching;
  • fast, slow, or uneven heartbeats; or
  • chest pain or heavy feeling, pain spreading to the arm or shoulder, general ill feeling.

Less serious side effects may include:

  • muscle weakness near where the medicine was injected;
  • bruising, bleeding, pain, redness, or swelling where the injection was given;
  • headache, muscle stiffness, neck or back pain;
  • fever, cough, sore throat, runny nose, flu symptoms,
  • dizziness, drowsiness, tired feeling;
  • nausea, diarrhea, stomach pain, loss of appetite;
  • dry mouth, dry eyes, ringing in your ears;
  • increased sweating in areas other than the underarms;
  • itchy or watery eyes, increased sensitivity to light; or
  • eyelid swelling or bruising.

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

Read the entire detailed patient monograph for Botox (Botulinum Toxin Type A) »

What is Patient Information Overview?

A concise overview of the drug for the patient or caregiver from First DataBank.

Botox Overview - Patient Information: Side Effects

SIDE EFFECTS: Because this medication is given at the site of your condition, most of the side effects occur close to where the medication is injected. Redness, bruising, infection, and pain at the injection site may occur.

Dizziness, mild difficulty swallowing, respiratory infections such as cold or flu, pain, nausea, headache, and muscle weakness may occur when this medication is used to relax muscles. Double vision, drooping or swollen eyelid, eye irritation, dry eyes, tearing, reduced blinking, and increased sensitivity to light may also occur.

If any of these effects persist or worsen, notify your doctor or pharmacist promptly. You may require protective eye drops/ointments, an eye patch, or other treatment.

When this medication is used to prevent migraines, side effects such as headache, neck pain, and drooping eyelid may occur.

When this medication is used for excessive sweating, side effects such as non-underarm sweating, respiratory infections such as cold or flu, headache, fever, neck or back pain, and anxiety may occur.

When this medication is used for overactive bladder, side effects such as urinary tract infections, burning/painful urination, fever, or difficulty urinating may occur.

If any of these effects persist or worsen, notify your doctor or pharmacist promptly.

Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

A very serious allergic reaction to this drug is unlikely, but get medical help right away if it occurs. Symptoms of a serious allergic reaction may include: itching/swelling (especially of the face/tongue/throat), rash, severe dizziness, trouble breathing.

This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.

In the US -

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

Read the entire patient information overview for Botox (Botulinum Toxin Type A)»

What is Prescribing information?

The FDA package insert formatted in easy-to-find categories for health professionals and clinicians.

Botox FDA Prescribing Information: Side Effects
(Adverse Reactions)

SIDE EFFECTS

The following adverse reactions to BOTOX (onabotulinum toxin A) For Injection are discussed in greater detail in other sections of the labeling:

Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, the adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.

BOTOX and BOTOX Cosmetic contain the same active ingredient in the same formulation, but with different labeled Indications and Usage. Therefore, adverse reactions observed with the use of BOTOX Cosmetic also have the potential to be observed with the use of BOTOX.

In general, adverse reactions occur within the first week following injection of BOTOX and while generally transient, may have a duration of several months or longer. Localized pain, infection, inflammation, tenderness, swelling, erythema, and/or bleeding/bruising may be associated with the injection. Needle-related pain and/or anxiety may result in vasovagal responses (including e.g., syncope, hypotension), which may require appropriate medical therapy.

Local weakness of the injected muscle(s) represents the expected pharmacological action of botulinum toxin. However, weakness of nearby muscles may also occur due to spread of toxin [see WARNINGS AND PRECAUTIONS].

Overactive Bladder

Table 10 presents the most frequently reported adverse reactions in double-blind, placebo-controlled clinical trials for overactive bladder occurring within 12 weeks of the first BOTOX treatment.

Table 10: Adverse Reactions Reported by ≥ 2% of BOTOX treated Patients and More Often than in Placebo-treated Patients Within the First 12 Weeks after Intradetrusor Injection, in Double-blind, Placebo-controlled Clinical Trials in Patients with OAB

Adverse Reactions BOTOX 100 Units
(N=552)
Placebo
(N=542)
Urinary tract infection 99 (18%) 30 (6%)
Dysuria 50 (9%) 36 (7%)
Urinary retention 31 (6%) 2 (0%)
Bacteriuria 24 (4%) 11 (2%)
Residual urine volume* 17 (3%) 1 (0%)
*Elevated PVR not requiring catheterization. Catheterization was required for PVR ≥ 350 mL regardless of symptoms, and for PVR ≥ 200 mL to < 350 mL with symptoms (e.g. voiding difficulty).

A higher incidence of urinary tract infection was observed in patients with diabetes mellitus treated with BOTOX 100 Units and placebo than in patients without diabetes, as shown in Table 11.

Table 11: Proportion of Patients Experiencing Urinary Tract Infection following an Injection in Double-blind, Placebo-controlled Clinical Trials in OAB according to history of Diabetes Mellitus

  Patients with Diabetes Patients without Diabetes
Botox 100 Units
(N=81)
Placebo
(N=69)
Botox 100 Units
(N=526)
Placebo
(N=516)
Urinary tract infection (UTI) 25 (31%) 8 (12%) 135 (26%) 51 (10%)

The incidence of UTI increased in patients who experienced a maximum post-void residual (PVR) urine volume > 200 mL following BOTOX injection compared to those with a maximum PVR < 200 mL following BOTOX injection, 44% versus 23%, respectively. No change was observed in the overall safety profile with repeat dosing during an open-label, uncontrolled extension trial.

Detrusor Overactivity associated with a Neurologic Condition

Table 12 presents the most frequently reported adverse reactions in double-blind, placebo-controlled studies within 12 weeks of injection for detrusor overactivity associated with a neurologic condition.

Table 12: Adverse Reactions Reported by ≥ 2% of BOTOX treated Patients and More Frequent than in Placebo-treated Patients Within the First 12 Weeks after Intradetrusor Injection in Double-blind, Placebo-controlled Clinical Trials

Adverse Reactions BOTOX 200 Units
(N=262)
Placebo
(N=272)
Urinary tract infection 64 (24%) 47 (17%)
Urinary retention 45 (17%) 8 (3%)
Hematuria 10 (4%) 8 (3%)

The following adverse reactions with BOTOX 200 Units were reported at any time following initial injection and prior to re-injection or study exit (median duration of 44 weeks of exposure): urinary tract infections (49%), urinary retention (17%), constipation (4%), muscular weakness (4%), dysuria (4%), fall (3%), gait disturbance (3%), and muscle spasm (2%).

In the MS patients enrolled in the double-blind, placebo-controlled trials, the MS exacerbation annualized rate (i.e., number of MS exacerbation events per patient-year) was 0.23 for BOTOX and 0.20 for placebo.

No change was observed in the overall safety profile with repeat dosing.

Chronic Migraine

In double-blind, placebo-controlled chronic migraine efficacy trials (Study 1 and Study 2), the discontinuation rate was 12% in the BOTOX treated group and 10% in the placebo-treated group. Discontinuations due to an adverse event were 4% in the BOTOX group and 1% in the placebo group. The most frequent adverse events leading to discontinuation in the BOTOX group were neck pain, headache, worsening migraine, muscular weakness and eyelid ptosis.

The most frequently reported adverse reactions following injection of BOTOX for chronic migraine appear in Table 13.

Table 13: Adverse Reactions Reported by ≥ 2% of BOTOX treated Patients and More Frequent than in Placebo-treated Patients in Two Chronic Migraine Double-blind, Placebo-controlled Clinical Trials

  BOTOX 155 Units-195 Units
(N=687)
Placebo
(N=692)
Nervous system disorders
  Headache 32 (5%) 22 (3%)
  Migraine 26 (4%) 18 (3%)
  Facial paresis 15 (2%) 0 (0%)
Eye disorders
  Eyelid ptosis 25 (4%) 2 ( < 1%)
Infections and Infestations
  Bronchitis 17 (3%) 11 (2%)
Musculoskeletal and connective tissue disorders
  Neck pain 60 (9%) 19 (3%)
  Musculoskeletal stiffness 25 (4%) 6 (1%)
  Muscular weakness 24 (4%) 2 ( < 1%)
  Myalgia 21 (3%) 6 (1%)
  Musculoskeletal pain 18 (3%) 10 (1%)
  Muscle spasms 13 (2%) 6 (1%)
General disorders and administration site conditions
  Injection site pain 23 (3%) 14 (2%)
Vascular Disorders
  Hypertension 11 (2%) 7 (1%)

Other adverse reactions that occurred more frequently in the BOTOX group compared to the placebo group at a frequency less than 1% and potentially BOTOX related include: vertigo, dry eye, eyelid edema, dysphagia, eye infection, and jaw pain. Severe worsening of migraine requiring hospitalization occurred in approximately 1% of BOTOX treated patients in Study 1 and Study 2, usually within the first week after treatment, compared to 0.3% of placebo-treated patients.

Upper Limb Spasticity

The most frequently reported adverse reactions following injection of BOTOX for adult spasticity appear in Table 14.

Table 14: Adverse Reactions Reported by ≥ 2% of BOTOX treated Patients and More Frequent than in Placebo-treated Patients in Adult Spasticity Double-blind, Placebo-controlled Clinical Trials

Adverse Reactions by System Organ Class BOTOX 251 Units- 360 Units
(N=115)
BOTOX 150 Units- 250 Units
(N=188)
BOTOX < 150 Units
(N=54)
Placebo
(N=182)
Gastrointestinal disorder
  Nausea 3 (3%) 3 (2%) 1 (2%) 1 (1%)
General disorders and administration site conditions
  Fatigue 4 (3%) 4 (2%) 1 (2%) 0
Infections and infestations
  Bronchitis 4 (3%) 4 (2%) 0 2 (1%)
Musculoskeletal and connective tissue disorders
  Pain in extremity 7 (6%) 10 (5%) 5 (9%) 8 (4%)
  Muscular weakness 0 7 (4%) 1 (2%) 2 (1%)

Cervical Dystonia

In cervical dystonia patients evaluated for safety in double-blind and open-label studies following injection of BOTOX, the most frequently reported adverse reactions were dysphagia (19%), upper respiratory infection (12%), neck pain (11%), and headache (11%).

Other events reported in 2-10% of patients in any one study in decreasing order of incidence include: increased cough, flu syndrome, back pain, rhinitis, dizziness, hypertonia, soreness at injection site, asthenia, oral dryness, speech disorder, fever, nausea, and drowsiness. Stiffness, numbness, diplopia, ptosis, and dyspnea have been reported.

Dysphagia and symptomatic general weakness may be attributable to an extension of the pharmacology of BOTOX resulting from the spread of the toxin outside the injected muscles [see WARNINGS AND PRECAUTIONS].

The most common severe adverse reaction associated with the use of BOTOX injection in patients with cervical dystonia is dysphagia with about 20% of these cases also reporting dyspnea [see WARNINGS AND PRECAUTIONS]. Most dysphagia is reported as mild or moderate in severity. However, it may be associated with more severe signs and symptoms [see WARNINGS AND PRECAUTIONS].

Additionally, reports in the literature include a case of a female patient who developed brachial plexopathy two days after injection of 120 Units of BOTOX for the treatment of cervical dystonia, and reports of dysphonia in patients who have been treated for cervical dystonia.

Primary Axillary Hyperhidrosis

The most frequently reported adverse reactions (3-10% of adult patients) following injection of BOTOX in double-blind studies included injection site pain and hemorrhage, non-axillary sweating, infection, pharyngitis, flu syndrome, headache, fever, neck or back pain, pruritus, and anxiety.

The data reflect 346 patients exposed to BOTOX 50 Units and 110 patients exposed to BOTOX 75 Units in each axilla.

Blepharospasm

In a study of blepharospasm patients who received an average dose per eye of 33 Units (injected at 3 to 5 sites) of the currently manufactured BOTOX, the most frequently reported adverse reactions were ptosis (21%), superficial punctate keratitis (6%), and eye dryness (6%).

Other events reported in prior clinical studies in decreasing order of incidence include: irritation, tearing, lagophthalmos, photophobia, ectropion, keratitis, diplopia, entropion, diffuse skin rash, and local swelling of the eyelid skin lasting for several days following eyelid injection.

In two cases of VII nerve disorder, reduced blinking from BOTOX injection of the orbicularis muscle led to serious corneal exposure, persistent epithelial defect, corneal ulceration and a case of corneal perforation. Focal facial paralysis, syncope, and exacerbation of myasthenia gravis have also been reported after treatment of blepharospasm.

Strabismus

Extraocular muscles adjacent to the injection site can be affected, causing vertical deviation, especially with higher doses of BOTOX. The incidence rates of these adverse effects in 2058 adults who received a total of 3650 injections for horizontal strabismus was 17%.

The incidence of ptosis has been reported to be dependent on the location of the injected muscles, 1% after inferior rectus injections, 16% after horizontal rectus injections and 38% after superior rectus injections.

In a series of 5587 injections, retrobulbar hemorrhage occurred in 0.3% of cases.

Immunogenicity

As with all therapeutic proteins, there is a potential for immunogenicity. Formation of neutralizing antibodies to botulinum toxin type A may reduce the effectiveness of BOTOX treatment by inactivating the biological activity of the toxin.

In a long term, open-label study evaluating 326 cervical dystonia patients treated for an average of 9 treatment sessions with the current formulation of BOTOX, 4 (1.2%) patients had positive antibody tests. All 4 of these patients responded to BOTOX therapy at the time of the positive antibody test. However, 3 of these patients developed clinical resistance after subsequent treatment, while the fourth patient continued to respond to BOTOX therapy for the remainder of the study.

One patient among the 445 hyperhidrosis patients (0.2%), two patients among the 380 adult upper limb spasticity patients (0.5%), no patients among 406 migraine patients, no patients among 615 overactive bladder patients, and no patients among 475 detrusor overactivity associated with a neurologic condition patients with analyzed specimens developed the presence of neutralizing antibodies.

The data reflect the patients whose test results were considered positive or negative for neutralizing activity to BOTOX in a mouse protection assay. The results of these tests are highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of neutralizing activity to BOTOX with the incidence of antibodies to other products may be misleading.

The critical factors for neutralizing antibody formation have not been well characterized. The results from some studies suggest that BOTOX injections at more frequent intervals or at higher doses may lead to greater incidence of antibody formation. The potential for antibody formation may be minimized by injecting with the lowest effective dose given at the longest feasible intervals between injections.

Post-Marketing Experience

The following adverse reactions have been identified during post-approval use of BOTOX. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. These reactions include: abdominal pain; alopecia, including madarosis; anorexia; aspiration pneumonia; brachial plexopathy; denervation/muscle atrophy; diarrhea; dry mouth; dysarthria; dyspnea; facial palsy; facial paresis; hyperhidrosis; hypoacusis; hypoaesthesia; localized numbness; malaise; muscle weakness; myalgia; myasthenia gravis; nausea; paresthesia; peripheral neuropathy; pruritis; pyrexia; radiculopathy; respiratory depression and/or respiratory failure; skin rash (including erythema multiforme, dermatitis psoriasiform, and psoriasiform eruption); strabismus; syncope; tinnitus; vertigo; vision blurred; visual disturbances; and vomiting.

There have been spontaneous reports of death, sometimes associated with dysphagia, pneumonia, and/or other significant debility or anaphylaxis, after treatment with botulinum toxin [see WARNINGS AND PRECAUTIONS].

There have also been reports of adverse events involving the cardiovascular system, including arrhythmia and myocardial infarction, some with fatal outcomes. Some of these patients had risk factors including cardiovascular disease. The exact relationship of these events to the botulinum toxin injection has not been established.

New onset or recurrent seizures have also been reported, typically in patients who are predisposed to experiencing these events. The exact relationship of these events to the botulinum toxin injection has not been established.

Read the entire FDA prescribing information for Botox (Botulinum Toxin Type A) »

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Botox - User Reviews

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