The FDA has approved injections with Botox ® (Botulinum toxin type A, Allergan) for the treatment of various neurologic conditions including spastic muscle disorders of the neck (cervical dystonia), chronic migraine headaches, and limb spasticity (in patients with stroke, cerebral palsy or multiple sclerosis).
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What is Botox?
Botulinum toxins are produced by the bacteria Clostridium botulinum. When purified and injected in tiny, controlled doses, these toxins can be used to relax excessive muscle contraction. They do this by temporarily reducing or halting muscle activity by blocking the release of the neurotransmitter that transmits the signal telling muscles to contract.
What to Expect
What can I expect on the day of injection?
Your doctor will talk to you about the risks and benefits of the injection, and after obtaining informed consent, will clean the injection sites and proceed with the injections. The procedure is usually a few minutes. No anesthetic or numbing medicine is required. The needle used is very small. It is possible to noticed slight increase in muscle spasticity following the injection for few hours to few days.
Patients receiving Botox injections for chronic migraine will receive injections at 31 sites around their head in a halo-pattern and in neck muscles, based on the established protocol from the Phase III Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) trial, which is the only FDA approved protocol for this injection.
Botox injections for cervical dystonia will be tailored to each individual patient based on head and neck position, localization of pain, muscle hypertrophy, and response to treatment. Botox injections for limb spasticity will be customized for each patient based on the size, number, and location of muscles involved, the severity of spasticity, the presence of local muscle weakness, and the patient’s response to previous treatment.
Response is usually seen 2 to 14 days after injection. Typically, the muscle action will return in 3-5 months, resulting in a return of symptoms. At this point, a repeat treatment will relax the muscle. The realistic goal of Botox injection is to reduce symptoms.
The interval between two injections cannot be less than 90 days due to the risk of antibody production against Botox.
What NOT to do after the injection:
- Do not rub the injected areas for at least 4 hours after injection.
- Do not do any facial or body massages for at least 24 hours after injection.
- Do not do heavy lifting for 12 hours after injection in order to decrease chance of bruising.
- If any injection is given around the eyes, do not lay down for at least 4 hours after the injection.
- Exposure to heat: Botox denaturation will occur if exposed to heat even after injection. Exposure to heat will render Botox ineffective. The following activities are strongly discouraged for 10 -14 days following Botox injection: use of a sauna or hot-tub, and taking very hot shower over the injected areas.
Risks and Complications:
Possible side effects include: transient headache, swelling, bruising, pain during injection, twitching, itching, numbness, asymmetry (unevenness), temporary neck muscle weakness, temporary drooping of eyelids or eyebrows (ptosis), temporary difficulty swallowing. These side effects are rare, but have been reported. In a very small number of individuals, the injection does not work as satisfactorily or for as long as usual. The theoretical risk of unknown complications does exist. Increase risk of bruising may occur after Botox injections if the patient is taking Vitamin E, aspirin, Coumadin, Motrin and other non-steroidal anti-inflammatory drugs.