Botox - it's not just for wrinkles!

The other day I was talking to a physician colleague about botulinum toxin (usually called by its brand name, Botox).  I mentioned that I use this “drug” a lot in my practice for pain and other medical problems.  This doctor was surprised and said, “I thought botulinum toxin was only for wrinkles!”  For those of us who use neurotoxins in clinical practice, the idea that they are only good for cosmetic issues is a very outdated concept indeed. 

In 1989, the Food and Drug Administration (FDA) licensed Botox in the United States for the treatment of several different kinds of muscular movement disorders.  Since that time, both botulinum toxin A (Botox, available in the United States, and Dysport, available in other countries such as the United Kingdom and New Zealand) and B (Myobloc) have been studied for many different medical problems, including treating pain.  Although the FDA has not formally approved these drugs for treating pain, they are frequently used “off-label”, and the scientific evidence is quite good that they work well in some patients. 

The term botulinum toxin actually describes several potent nerve toxins that may cause paralysis, respiratory arrest, and even death when ingested. These toxins are produced by the bacteria Clostridium botulinum. While it is lethal in its oral form, botulinum toxin is remarkably safe to use as an injection.

When injected into muscle, botulinum toxin blocks the release of acetylcholine, a substance necessary for muscular contractionIn the first couple of days after injection, there is no clinical effect.  Functional muscular weakness (localized paralysis) peaks at 2 weeks and lasts approximately 12 weeks.  The amount of medication used typically depends on the size of the muscles being injected.  Generally a practitioner will inject several areas of a muscle during a single office visit.

If the underlying condition remains unchanged, then the injection will need to be repeated. When botulinum toxin is used to treat muscular pain and spasm, however, a single set of injections might break the cycle and essentially produce a “cure.”  On the other hand, there are many pain conditions (e.g., migraines) which are ongoing, so repeated injections are often needed.

Botulinum toxin is expensive and is often tried after other therapies have been tried without success.  This is true for almost all injections—because they are somewhat invasive, other treatments are usually attempted first.  Before undertaking any injection, it  is important to consider the interventions that have been tried prior to considering botulinum toxin as an option. For example before botulinum toxin is used to prevent migraines, most doctors will recommend trying oral medications first. 

Botulinum toxin is often combined with other therapies.  For instance, in the case of someone who has decreased neck range of motion either from surgery or from a whiplash injury, botulinum toxin may be used along with physical therapy to decrease muscle spasm and pain and improve neck range of motion.   

The good news is that botulinum toxin is generally safe to use and is often the most effective treatment for a given problem.

Here are some examples of ways that botulinum toxin is being used and studied:

• To prevent migraine headaches
• To reduce severe muscle spasms (often called spasticity)in patients with stroke, multiple sclerosis, spinal cord injuries, and other central nervous system disorders
• To improve refractory low back pain that is associated with muscle spasms
• To lessen bladder muscle spasm (often called an “overactive” or “irritable” bladder).
• To treat excessive sweating (hyperhidrosis)
• To reduce tremors and other symptoms associated with Parkinson’s disease
• To improve sleep in people with restless leg syndrome (RLS)
• To relax the muscles around the anus to heal breaks in the skin (anal fissures).
• To improve neck range of motion after surgery (e.g., in head and neck cancer patients) or after a whiplash injury.
• One study found that it improved urine flow among men with prostate enlargement.

I could go on and on with more examples of how botulinum toxin is being used, but the bottom line is that the drug is not just for erasing wrinkles—it has a remarkable number of therapeutic uses.  Moreover, it’s generally safe and well tolerated.  Insurance companies usually cover the cost of these injections when they are given for appropriate medical (rather than cosmetic) conditions.  If you have a condition that you think might be able to be treated with botulinum toxin injections, talk to your doctor. 

 Do you have any questions on how botulinum toxin works or what it’s used for?  I’m happy to answer them!

Julie K. Silver, M.D., is an assistant professor in the Department of Physical Medicine and Rehabilitation at Harvard Medical School. She is also the Chief Editor of Books for Harvard Health Publications.

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