In the third study, 25 patients with chronic migraine were injected with 12.5 doses of botox into each trigger point twice, during a period of 3 months. Frequency (main variable), intensity and scales of migraine crises were recorded one month before and one month after the treatment to compare the changes experienced. In addition, side effects were also recorded during the experiment, and they were found to be mild and temporary.
A double-blind, placebo-controlled study enrolled patients who had extended histories of receiving and tolerating BOTOX injections, with prior individualized adjustment of dose. The mean BOTOX dose administered to patients in this study was 236 Units (25th to 75th percentile range of 198 Units to 300 Units). The BOTOX dose was divided among the affected muscles [see Clinical Studies].

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Two years later, Allergan bought Oculinum for $9 million and changed the drug's name to Botox. At the time, Allergan was primarily an ocular-care company that sold products like contact-lens cleaners and prescription solutions for dry eyes, bringing in about $500 million in annual sales. Allergan says it saw Botox as a drug for a niche population: it's estimated that 4% of people in the U.S. have crossed eyes, for which the drug was initially approved, and Allergan made about $13 million in sales from the drug by the end of 1991.
Tell your doctor if you received any other botulinum toxin product in the last 4 months; have received injections of botulinum toxin such as Myobloc®, Dysport®, or Xeomin® in the past (tell your doctor exactly which product you received); have recently received an antibiotic injection; take muscle relaxants; take allergy or cold medicines; take sleep medicine; take aspirin-like products or blood thinners.
"I had 25 units of Botox done by Dr. Goldberg on my forehead and frown lines. Few days later I could see the result with which I was very happy! [...] I have done Botox few times before with other specialists, after which my face would resemble a doll [...] However, after procedure with Dr. Goldberg, I am still able to lift my eyebrows and frown without forming any wrinkles." – from Dinara D.'s review of Alexander Golberg Physician PC in New York.
Ophthalmologists specializing in eye muscle disorders (strabismus) had developed the method of EMG-guided injection (using the electromyogram, the electrical signal from an activated muscle, to guide injection) of local anesthetics as a diagnostic technique for evaluating an individual muscle’s contribution to an eye movement.[44] Because strabismus surgery frequently needed repeating, a search was undertaken for non-surgical, injection treatments using various anesthetics, alcohols, enzymes, enzyme blockers, and snake neurotoxins. Finally, inspired by Daniel Drachman’s work with chicks at Johns Hopkins,[45] Alan B Scott and colleagues injected botulinum toxin into monkey extraocular muscles.[46] The result was remarkable: a few picograms induced paralysis that was confined to the target muscle, long in duration, and without side-effects.
Simply put, "Baby Botox" uses a lower volume of Botox (a.k.a. botulinum toxin injections) than a traditional injection to smooth fine lines and wrinkles. "Instead of using 25 units in an area, you may use 10 units," Melissa Doft, a board-certified plastic surgeon in New York City, tells Allure. "I have many patients who ask for half the normal dose, as they do not want to look frozen but are tired of wrinkles in photos. First-time Botox patients are perfect for this."
As compared to standard-size injections, Baby Botox lowers the risk of your features appearing to be frozen. Take the forehead, for example: "The risk is that you weaken your frontalis muscle, which causes your eyebrows to drop," Darren Smith, a board-certified plastic surgeon in New York City, tells Allure. "If you're getting micro doses of Botox, that's a lot less likely to happen."
The safety and efficacy of onabotulinumtoxinA for CM was demonstrated in the pivotal phase III Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) trial. In this trial, patients were treated every 12 weeks whether or not their headaches had returned to baseline levels and the primary outcome period was after two treatment cycles. At baseline, these patients had more than 19 headache days, and after two treatment cycles, their headaches had been reduced by 8 to 9 days per 28 days. The responder rate analysis of the study population shows that about 25% of patients improved by 75% in terms of a reduction of migraine days. In my practice, I usually do three cycles 12 weeks apart, and only if there is no change in headache frequency after this, do I change treatments. In the pivotal trials, the first statistical separation from placebo occurred in the first 4 weeks. There is a small subgroup of patients who fail to respond to the first two treatments and only start to respond after the third treatment.4-10

Calcitonin gene-related peptide (CGRP) is a neuropeptide found all over the body, says Dr. Amaal Starling, an Assistant Professor of Neurology at the Mayo Clinic in Phoenix. This neuropeptide attaches to a receptor called a CGRP receptor. CGRP and its receptor are involved in numerous bodily processes—from gastrointestinal movement to the transmission of pain. Over the past few decades, there has been increasing evidence that CGRP plays a role in both migraine and cluster headache. During a migraine attack, researchers have found increased levels of CGRP in patients’ blood and saliva. They discovered migraine medications like sumatriptan reduced levels of CGRP in patients living with migraine. They also found that patients with chronic migraine—meaning 15 or more migraine days per month, eight of which either meet criteria for migraine or are treated with migraine-specific medication—had chronically elevated levels of CGRP. In addition, recent research found that giving a patient with migraine an infusion of CGRP would lead to a migraine-like attack. “All of these studies led to the hypothesis that CGRP and its receptor play a key role in migraine, as well as in cluster headache,” Dr. Starling says.
The patient is placed in a somewhat raised position on the exam table, and the areas to be injected are cleansed with a nonalcohol cleanser, such as Hibiclens or Betadine. Some physicians will apply a topical anesthetic, such as EMLA cream or some alternative, at this time. The Botox is then injected into the desired areas. Typical injection patterns include about four or five areas on each side of the forehead and two or three areas on either eye area. More areas can be injected by skilled physicians, depending on the type of wrinkles and the desired effect for the patient. It is common for pressure to be applied if an area seems to be bleeding after the injection. While ice is sometimes applied beforehand for comfort reasons, direct pressure is much more effective than ice for control of bleeding and bruising.
Besides the three primary U.S. manufacturers, there are numerous other botulinum toxin producers. Xeomin, manufactured in Germany by Merz, is also available for both therapeutic and cosmetic use in the U.S.[67] Lanzhou Institute of Biological Products in China manufactures a BTX-A product; as of 2014 it was the only BTX-A approved in China.[67] BTX-A is also sold as Lantox and Prosigne on the global market.[68] Neuronox, a BTX-A product, was introduced by Medy-Tox Inc. of South Korea in 2009;[69]
In Seattle, the cost usually ranges between 10$ and 16$ per unit. It varies depending on a few things. 1. Expertise of the injector, 2. Who the injector is (physician vs other), 3. Whether an office may be running a special. The number of units placed in an area can vary. For instance, for the frown lines between the eyebrows, studies show that the right amount for most women is 25 units. However, in my practice, I may put in as few as 10 (young female with a very petite forehead) or as many as 30 (larger forehead, strong frown line). We usually have 2-3 "botox" special events per year, and we also have an ongoing special price for VIP patients to reward them for coming to our clinic.
As with the injection of any medication, your body's immune system can develop antibodies to the medication, which render the drug less effective or possibly cause development of an allergy to the drug. The more frequently the drug is injected or the more quantity that is injected, the higher the risk for these antibodies to be formed against the drug.
Although one cannot predict exactly who will respond, I find that those patients who are going to respond will note some improvement in headaches following the first set of injections. Repeat injection sets can be performed on the same patient no sooner than every 3 months, as long as a benefit is seen. Most insurers require that you document at least a 50% improvement in the chronic migraine frequency and/or severity for continued coverage. I usually recommend that my migraine patients have a second set of injections before deciding that this treatment modality is of no benefit to them.

I always tell my patients that you get what you pay for. However, you need to advocate for yourself and understand what you are getting for your dollars. Ensure that your injector is experienced and properly trained; that you are getting FDA approved Botox Cosmetic from Allergan; and know how many units you receive. As well, a physician's office should maintain a medical record of your treatments so you can optimize and customize your Botox to achieve the best effect and value. Good Luck!


Postmarketing safety data from BOTOX and other approved botulinum toxins suggest that botulinum toxin effects may, in some cases, be observed beyond the site of local injection. The symptoms are consistent with the mechanism of action of botulinum toxin and may include asthenia, generalized muscle weakness, diplopia, ptosis, dysphagia, dysphonia, dysarthria, urinary incontinence, and breathing difficulties. These symptoms have been reported hours to weeks after injection. Swallowing and breathing difficulti es can be life threatening and there have been reports of death related to spread of toxin effects. The risk of symptoms is probably greatest in children treated for spasticity but symptoms can also occur in adults treated for spasticity and other conditions, and partic ularly in those patients who have an underlying condition that would predispose them to these symptoms. In unapproved uses, including spasticity in children, and in approved indications, symptoms consistent with spread of toxin effect have been reported at do ses comparable to or lower than doses used to treat cervical dystonia and spasticity. Patients or caregivers should be advised to seek immediate medical care if swallowing, speech or respiratory disorders occur.
BOTOX is indicated for the treatment of upper limb spasticity in adult patients, to decrease the severity of increased muscle tone in elbow flexors (biceps), wrist flexors (flexor carpi radialis and flexor carpi ulnaris) , finger flexors (flexor digitorum profundus and flexor digitorum sublimis), and thumb flexors (adductor pollicis and flexor pollicis longus).
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Allergan Plc engages in the research, development, and manufacture of pharmaceutical products. The firm offers products under the following brands: BOTOX, Juvederm, Linzess, Namenda, Restasis, Latisse, Teflaro, Lo Loestrin Fe, Bystolic, DORYX, Saphris, Fetzima, Namenda XR, Namzaric, Viberzi, Viibryd, Alphagan, LUMIGAN, ESTRACE Cream, Rapaflo, Asacol, DELZICOL, Zenpep, Avycaz, and Dalvance. Its brand portfolio delivers treatments that address unmet medical needs in therapeutic categories such as dermatology and aesthetics;Read More
Why Cheap Shady beauty "bargains" on Injectables Can Be So Dangerous- issues are widespread across the US as demand for injectables grows-"I'd say 1 in 4 [bargain hunters] suffers some kind of complication” Manjula Jegasothy MD @MiamiSkinIns https://www.cosmopolitan.com/style-beauty/beauty/a23417647/the-ugly-side-of-beauty-bargains/ … @Cosmopolitan
Extraocular muscles adjacent to the injection site can be affected, causing vertical deviation, especially with higher do ses 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.

The patient’s neck stability, posture, torsion, and symmetry should be assessed to determine whether he or she may be at increased risk for adverse events prior to the first injection cycle. A patient with preexisting neck pain and/or weakness may be at higher risk for exacerbation of the condition upon injection of the occipitalis, cervical paraspinal, or trapezius muscle groups. Patients with smaller frames may be at higher risk for neck weakness. Indicated injection sites can still be injected with minimal side effects and unwanted outcomes as long as correct injection sites are targeted and treatments are administered using a superficial approach with avoidance of the mid and lower cervical regions. The cervical paraspinal muscle group is made up of multiple muscles including the trapezius, splenius capitis and cervicis, and semispinalis capitus. This group of muscles helps support the neck, including extension of the head.
Botox must be used only under a doctor's care. It's important that injections be placed precisely in order to avoid side effects. Botox therapy can be dangerous if it's administered incorrectly. Ask for a referral from your primary care doctor or look for a doctor who specializes in your condition and who has experience in administering Botox treatments.
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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.
30+ year migraine warrior, wife, mother, corporate exec turned health advocate, Paula is Migraine Again Managing Editor and Chief Encouragement Officer. She champions patient's needs as an American Migraine Foundation Board Member, CHAMP Coalition Leader, IHS Patient Advocate and co-author of CaMEO and My Migraine Voice research studies. In addition to hosting the Migraine Again Podcast and producing the Migraine World Summit, Paula is a frequent speaker at industry, health care and public policy events. She's also the Founder and CEO of the World Health Education Foundation, a 501c3. Follow her on LinkedIn or Facebook.
Botox is mostly performed in a medical setting and is known to be a quick and painless medical procedure.The skin is cleansed with alcohol or another antiseptic and a topical anesthetic ointment is applied to the skin. After ten minutes the physician or nurse injects Botox  or disport with a very fine needle. The procedure should be almost painless and takes only takes about 15 minutes to perform. You can easily walk out of the office and resume your daily activities.The effect of Botox or Dysport will usually take 48 to72 hours before you see the results.

A follow-up visit is most often scheduled at around three months after injection. The team will determine if it was helpful and if the effect is wearing off. The effect on muscle spasticity by botulinum toxin is temporary and can last for up to three to five months. This also varies with the amount of toxin injected, the size of the muscle, the degree of spasticity in the muscle, and treatment such as therapy and bracing.

There were 214 subjects evaluated for the open label period, of which 170 progressed into the randomized, blinded treatment p eriod (88 in the BOTOX group, 82 in the placebo group). Patient evaluations continued for at least 10 weeks post-injection. The primary outcome for the study was a dual endpoint, requiring evidence of both a change in the Cervical Dystonia Severity Scale (CDSS) and an increase in the percentage of patients showing any improvement on the Physician Global Assessment Scale at 6 weeks after the injection session. The CDSS quantifies the severity of abnormal head positioning and was newly devised for this study. CDSS a llots 1 point for each 5 degrees (or part thereof) of head deviation in each of the three planes of head movement (range of scores up to theoretical maximum of 54). The Physician Global Assessment Scale is a 9 category scale scoring the physician's evaluation of the patients' status compared to baseline, ranging from 4 to +4 (very marked worsening to complete improvement), with 0 indicating no change from baseline and +1 slight improvement. Pain is also an important symptom of cervical dystonia and was evaluated by separate assessments of pain frequency and severity on scales of 0 (no pain) to 4 (constant in frequency or extremely severe in intensity). Study results on the primary endpoints and the pain-related secondary endpoints are shown in Table 35.
The procerus is a small triangular-shaped muscle that intermingles with the inferior aspect of the frontalis muscle. The muscle runs from the aponeurotic fascia on the nasal bones and inserts into the skin of the inferior forehead. The medial portion of the eyebrow and the skin of the lower forehead are drawn down by the procerus muscle, producing transverse wrinkle lines over the bridge of the nose.

Botox should only be injected with sterile instruments in a doctor's office or a medical spa — not at Botox parties at your local nail salon or neighbor's living room. Botox injection is usually performed with some local anesthesia or a numbing cream. You may feel some minimal discomfort from the shot, but today's needles are so thin and fine that the procedure is often painless. Depending on the extent of treatment, the procedure can take anywhere from a few minutes to 20 minutes.


Once the protein stops functioning at the neuromuscular junction, it is broken down into its harmless components (amino acids) and either recycled for use in other proteins or excreted by the kidneys. "The bigger the muscle, the quicker you'll see motion return," says Rowe. "Likewise, the smaller the muscle, the longer the effect of botox lasts." It doesn't have a tolerance effect, either—your body never gets used to Botox.

Other potential adverse events that may occur with breast implant surgery include: asymmetry, breast pain, breast/skin sensation changes, capsular calcification, delayed wound healing, hematoma, hypertrophic scarring/scarring, implant extrusion, implant malposition, implant palpability/visibility, infection, nipple complications, redness, seroma, swelling, tissue/skin necrosis, wrinkling/rippling.

Table 14 presents the most frequently reported adverse reactions in a placebo-controlled, double-blind post-approval 52 week study with BOTOX 100 Units (Study NDO-3) conducted in MS patients with urinary incontinence due to detrusor overactivity associated with a neurologic condition. These patients were not adequately managed with at least one anticholinergic agent and not catheterized at baseline. The table below presents the most frequently reported adverse reactions within 12 weeks of injection.

Baby Botox can also be used as an upkeep strategy. "I really think of it as small maintenance doses of Botox over time instead of standard doses given at three- to six-month intervals," says Smith. "The other term that describes this well is 'tweakment' — subtle changes done over a longer period of time using lower doses of product at each treatment."
The safety and effectiveness for the treatment of anatomic regions other than the mid-face with JUVÉDERM VOLUMA® XC; facial wrinkles and folds with JUVÉDERM® Ultra XC, JUVÉDERM® Ultra Plus XC, and JUVÉDERM VOLLURE™ XC; and the lips and perioral area with JUVÉDERM® Ultra XC and JUVÉDERM VOLBELLA® XC have not been established in controlled clinical studies

Richard Clark, a plastic surgeon from Sacramento (CA), was the first to document a cosmetic use for botulinum toxin.[51] He treated forehead asymmetry caused by left sided forehead nerve paralysis that occurred during a cosmetic facelift. Since the injured nerve could possibly regenerate by 24 months, a two-year waiting period was necessary before definitive surgical treatment could be done. Clark realized that botulinum toxin, which had been previously used only for cross eyed babies and facial tics, could also be injected to smooth the wrinkles of the right forehead to match her paralyzed left. He received FDA approval for this cosmetic application of the toxin and successfully treated the person and published the case study in 1989.[51]
BOTOX blocks neuromuscular transmission by binding to acceptor sites on motor or sympathetic nerve terminals, entering the nerve terminals, and inhibiting the release of acetylcholine. This inhibition occurs as the neurotoxin cleaves SNAP -25, a protein integral to the successful docking and release of acetylcholine from vesicles situated within nerve endings. When injected intramuscularly at therapeutic doses, BOTOX produces partial chemical denervation of the muscle resulting in a localized reduction in muscle act ivity. In addition, the muscle may atrophy, axonal sprouting may occur, and extrajunctional acetylcholine receptors may develop. There is evidence that reinnervation of the muscle may occur, thus slowly reversing muscle denervation produced by BOTOX.
Botox for migraines has been something that has flown under the radar, as many people know Botox as a procedure simply aimed at hiding fine lines. We turned to Matthew S. Robbins, MD, director of inpatient services at Montefiore Headache Center and the chief of neurology at the Jack D. Weiler Hospital, Montefiore, to break down the procedure for us. Scroll down to see what he has to say.
The correct way to inject Botox is to always customize the treatment plan to solve the aesthetic issues that bother the person. Some patients need only limited areas injected such as the vertical lines between their brows, their “crow’s feet” at the outer aspects of their eyelids, the “bunny” lines that radiate on the sides of their nose, vertical and horizontal lip lines and rarely patients request a correction of their “gummy” smile where their upper gums show when a person smile. Yes, you usually can pay for specific areas of treatment or by the number of units injected. But if you only want single line or area of your forehead injected you may not be satisfied with the results in the end. Why? -because when Botox or Dysport is injected it will weaken only the muscles that are treated, there may be muscles that were not treated that are pulling in an opposite direction that will produce undesirable results(an example of an undesirable  effect occurs when treating just the glabella “11” lines between your eyebrows that may produce an overarched brow contour that resembles Mr. Spock.) Therefore, a complete treatment plan that includes all muscle groups should be treated to balance the pull and counter-pull of facial muscles.In addition, injections around the mouth must be performed by an experienced injector because there is the potential for the mouth to droop afterwards which can cause you to drool or may impact your ability to eat, pucker and smile. These adverse effect  may last several weeks.

Last time I went in for my Botox treatment, my doctor asked me if I wanted to try Aimovig. Amgen and Novartis, the two manufacturers, were offering two free injections before I could access the drug through my health insurance. I declined. I didn’t want to start a new treatment that I’ll likely be booted from in a few months because of how expensive it is. Plus, the Botox is working great. I just wish I could have gotten it when I first went to see a migraine specialist, two and half years ago.
BOTOX increases the incidence of urinary tract infection [see ADVERSE REACTIONS]. Clinical trials for overactive bladder excluded patients with more than 2 UTIs in the past 6 months and those taking antibiotics chronically due to recurrent UTIs. Use of BOTOX for the treatment of overactive bladder in such patients and in patients with multiple recurrent UTIs during t reatment should only be considered when the benefit is likely to outweigh the potential risk.
For blepharospasm, reconstituted BOTOX is injected using a sterile, 27-30 gauge needle without electromyographic guidance. The initial recommended dose is 1.25 Units-2.5 Units (0.05 mL to 0.1 mL volume at each site) injected into the medial and lateral pre tarsal orbicularis oculi of the upper lid and into the lateral pre-tarsal orbicularis oculi of the lower lid. Avoiding injection near the levator palpebrae superioris may reduce the complication of ptosis. Avoiding medial lower lid injections, and thereby reducin g diffusion into the inferior oblique, may reduce the complication of diplopia. Ecchymosis occurs easily in the soft eyelid tissues. This can be prevented by applying pressure at the injection site immediately after the injection.
The most frequently reported adverse reactions following injection of BOTOX for adult lower limb spasticity appear in Table 17. Two hundred thirty one patients enrolled in a double-blind placebo controlled study (Study 6) received 300 Units to 400 Units of BOTOX, and were compared with 233 patients who received placebo. Patients were followed for an average of 91 days after injection.

Reduced blinking from BOTOX injection of the orbicularis muscle can lead to corneal exposure, persistent epithelial defect, and corneal ulceration, especially in patients with VII nerve disorders. Vigorous treatment of any epithelial defect should be employed. This may require protective drops, ointment, therapeutic soft contact lenses, or closure of the eye by patching or other me ans.


If you are seeking a Botox specialist, I have more than thirty years experience injecting Botox in New York City and New Jersey. I am a recognized oculoplastic surgeon – you can find me on Google as Dr. Joel E. Kopelman. I have authored several peer reviewed articles regarding the efficacy and safety of Botox injections. You can easily make an appointment to see me in consultation at our office +1 (212) 831-8333 to set up a consultation with me in either New York or New Jersey.
Autonomic dysreflexia in patients treated for overactive bladder due to neurologic disease. Autonomic dysreflexia associated with intradetrusor injections of BOTOX® could occur in patients treated for detrusor overactivity associated with a neurologic condition and may require prompt medical therapy. In clinical trials, the incidence of autonomic dysreflexia was greater in patients treated with BOTOX® 200 Units compared with placebo (1.5% versus 0.4%, respectively).
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