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Research · Medication

Botulinum toxin

Against placebo, botulinum toxin injections smoothed frown lines, cut chronic migraine by about 2 headache days a month, stopped most underarm sweating and calmed overactive bladders. They did not prevent episodic migraine. Eyelid droop, neck pain and, after bladder injections, urinary infections and retention rose. Labels carry a boxed warning that the toxin can spread beyond the injection site.

Add to Bio HackChecked 2026-11-14
Status
Prescription biologics in the US, injected into a muscle, into the skin (for sweating) or into the bladder wall. FDA-approved uses differ by product: Botox for overactive bladder, bladder overactivity from a neurologic condition, chronic migraine, spasticity, cervical dystonia, severe underarm sweating, blepharospasm and strabismus; Botox Cosmetic, Dysport, Xeomin and others for frown and other facial lines; Dysport for cervical dystonia and spasticity; Xeomin for drooling, upper limb spasticity, cervical dystonia and blepharospasm. Every label carries an FDA boxed warning for distant spread of toxin effect.
Also called
botox, Botox, Botox Cosmetic, onabotulinumtoxinA, Dysport, abobotulinumtoxinA, Xeomin, incobotulinumtoxinA, Jeuveau, prabotulinumtoxinA, Daxxify, daxibotulinumtoxinA, Letybo, letibotulinumtoxinA, Myobloc, rimabotulinumtoxinB, botulinum toxin type A, BoNT-A, neurotoxin, tox, baby botox
Taken for
wrinkles, frown lines, forehead lines, crow's feet, anti-aging, chronic migraine, headaches, excessive sweating, overactive bladder, urinary incontinence, spasticity after stroke, cerebral palsy, neck spasms, cervical dystonia, eyelid twitching, depression, jaw clenching

Strong several reviews agree · Moderate one review or consistent trials · Limited one or a few small studies · Untested no study in people, listed with what it rests on

Shown to help7

Reported risks8

What people take it for, and what was found

Shown to help7

Strong

Frown lines and other facial lines

Shown to improve moderate to severe frown lines against placebo injections, with every approved type A product ahead of placebo in a network analysis.

Compared with placebo injections [1][2][3]

The numbers and sources
Effect
Pooling 7 double-blind trials of a single 20-unit dose injected into the frown muscles, investigator-rated response was far more likely than on placebo (RR 33.54, 95% CI 18.65 to 60.33), lines at rest improved (RR 5.88, 95% CI 3.49 to 9.91), and adverse events did not differ significantly [1]. In a network meta-analysis, onabotulinumtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, prabotulinumtoxinA and daxibotulinumtoxinA were all superior to placebo [2]. Botox Cosmetic is approved for frown lines, crow's feet, forehead lines and neck bands [3].
Population
1,474 adults in 7 RCTs [1]; RCTs of five type A products [2]; label trials in adults aged 18 to 75 [3].
Sources
[1], [2], [3]
Caveats
The effect is temporary, and the label says retreatment more often than every 3 months has not been studied [3]. Trials measured lines about a month after injection [2].
Strong

Chronic migraine

Shown to cut headache days by about 2 a month against placebo in chronic migraine, with high-quality evidence from the two largest trials.

Compared with placebo injections [6][7]; valproate, topiramate and amitriptyline in single trials [7]

The numbers and sources
Effect
In chronic migraine, botulinum toxin lowered migraine days by 3.1 a month against placebo (95% CI -4.7 to -1.4, low quality), or by 2 days (95% CI -2.8 to -1.1, moderate quality) once small trials were removed, and headache days by 1.9 a month (95% CI -2.7 to -1.0, high quality). Migraine attacks did not differ [6]. A second meta-analysis found 2.30 fewer headaches a month in chronic migraine (95% CI -3.66 to -0.94) and 2.06 fewer in chronic daily headache. In single trials, it did not differ from valproate, topiramate or amitriptyline [7].
Population
4,190 participants in 28 trials, 1,384 in the two largest chronic migraine trials [6]; 1,508 patients with chronic migraine in 5 studies [7].
Sources
[6], [7]
Caveats
Most trials were small, and treatment lasted at most three rounds of injections, so long-term effects are unknown [6]. Injections go into 7 head and neck muscles [5].
ModerateVery common

Excessive underarm sweating

Shown to halve underarm sweat in 94% at 4 weeks against 36% on placebo, with effects lasting a median of about 6 to 7 months.

Compared with placebo injections [8][9]

The numbers and sources
How common
Very common: more than 1 in 10 people.
Effect
After 50 units per armpit injected into the skin, 94% had at least a 50% drop in sweat production at 4 weeks against 36% on placebo, and 82% against 21% at 16 weeks. Adverse events were reported by 11% and 5% [8]. In a 52-week trial, a 2-point improvement on a 4-point severity scale was reported by 75% on 50 or 75 units and 25% on placebo, and the median effect lasted 205 and 197 days against 96 days [9].
Population
320 adults with primary underarm sweating in 17 clinics [8]; 322 adults over 52 weeks [9].
Sources
[8], [9]
Caveats
The label says safety and effectiveness for sweating elsewhere on the body have not been established, and hand or face injections can weaken hand muscles or droop the eyelid [5].
Moderate

Overactive bladder and urge incontinence

Shown to reduce urge incontinence episodes against placebo when injected into the bladder wall, by about 1.6 more episodes a day in a pivotal trial.

Compared with placebo injections into the bladder [10][5]

The numbers and sources
Effect
Across 19 trials, every study found botulinum toxin injected into the bladder ahead of placebo, with higher doses possibly giving larger, longer-lasting effects but more side effects, and repeat injections did not appear to lose effect [10]. In the OAB-1 trial of 100 units, daily incontinence episodes fell 2.5 from a baseline of 5.5 against 0.9 on placebo at week 12 (difference -1.6, 95% CI -2.1 to -1.2), and daily urinations fell 1.0 more [5].
Population
19 RCTs, mostly in neurogenic overactive bladder [10]; 278 and 272 adults with overactive bladder in the OAB-1 trial [5].
Sources
[10], [5]
Caveats
The Cochrane review could pool little data because designs and outcomes differed [10]. The injection is given through a cystoscope [5].
Strong

Spasticity after stroke

Shown to lower arm muscle tone against placebo after stroke, but not shown to improve active arm function, leg muscle tone or walking speed.

Compared with placebo injections [12][13]

The numbers and sources
Effect
Injected into the arm muscles, botulinum toxin lowered muscle tone against placebo at 4 weeks (SMD -0.98, 95% CI -1.28 to -0.68) and 12 weeks (SMD -0.67), improved a disability scale (WMD -0.54 at 6 weeks), and adverse events did not differ (RR 1.36, 95% CI 0.82 to 2.27) [12]. A second meta-analysis found lower arm tone (SMD -0.76, 95% CI -0.97 to -0.55) without a significant change in active arm function (SMD 0.49, 95% CI -0.08 to 1.07). In the leg, Fugl-Meyer scores rose but tone (SMD -0.12) and walking speed (SMD 0.06) did not change [13].
Population
1,804 adults with arm spasticity after stroke or brain injury in 22 RCTs [12]; 2,793 adults with arm or leg spasticity after stroke in 27 RCTs [13].
Sources
[12], [13]
Caveats
Heterogeneity was moderate at some time points [12]. The Botox label states it has not been shown to improve arm function or range of motion at a joint with fixed contracture [5].
Moderate

Cervical dystonia (neck spasms)

Shown to reduce neck dystonia severity by about 8 points, an 18% improvement, and neck pain against placebo 4 weeks after a single treatment.

Compared with placebo injections [4]

The numbers and sources
Effect
A single session of injections into the neck muscles lowered the TWSTRS total score by 8.09 points more than placebo at week 4 (95% CI 6.22 to 9.96), about an 18.4% improvement from baseline, and the pain subscore by 2.11 points (95% CI 1.38 to 2.83). No clear dose-response or difference between products was found [4].
Population
1,144 adults with cervical dystonia in 9 RCTs, testing onabotulinumtoxinA 150 to 500 units, incobotulinumtoxinA 120 to 240 units and abobotulinumtoxinA 250 to 1,000 units [4].
Sources
[4]
Caveats
Seven trials excluded poor responders, and only one trial was independently funded [4].
Moderate

Depression

Shown in pooled small trials to reduce depression scores against placebo 6 weeks after injections into the frown muscles, with a large effect size.

Compared with placebo injections [14]; scores before treatment in the same people [15]

The numbers and sources
Effect
Across 5 RCTs in major depressive disorder, botulinum toxin type A lowered depression ratings against placebo at week 6 (Hedges' g -0.82, 95% CI -1.38 to -0.27), with mild, temporary adverse events [14]. A second review of 9 prospective studies found a mean change of -8.39 points at 6 weeks in its 5 RCTs and a standardized change from baseline of -1.61 [15].
Population
417 people with major depressive disorder in 5 RCTs [14]; 9 prospective studies [15].
Sources
[14], [15]
Caveats
Not an FDA-approved use. The trials were small, and results varied with dose and sex [14]. The second review's pooled figure is a change from baseline, not a comparison with placebo [15].

Mixed results2

Moderate

Differences between botulinum toxin products

Mixed results: most products did not differ for frown lines or neck dystonia, while daxibotulinumtoxinA gave more 1-point frown improvements. Units cannot be converted between products.

Compared with other botulinum toxin type A products, indirectly in network and subgroup analyses [2][4]

The numbers and sources
Effect
For frown lines, daxibotulinumtoxinA was the only product that raised the share with at least a 1-point improvement against the other products, and adverse events did not differ among products [2]. In cervical dystonia, the Cochrane review found no difference in effect between onabotulinumtoxinA, incobotulinumtoxinA and abobotulinumtoxinA [4]. The Botox label states its units are not interchangeable with other botulinum toxin products and cannot be converted into their units [5].
Population
RCTs of type A products for frown lines [2]; 1,144 people with cervical dystonia in 9 RCTs [4].
Sources
[2], [4], [5]
Caveats
No head-to-head trial was sourced. Doses differ by product (see Doses studied).
LimitedStudied in women

Urge incontinence, compared with anticholinergic pills

One trial in women found incontinence episodes fell about equally on bladder injections and pills, while complete dryness was more common after the injection, 27% against 13%.

Compared with daily solifenacin or trospium by mouth, with a saline bladder injection [11]

The numbers and sources
Effect
Over 6 months, daily urge incontinence episodes fell from about 5.0 by 3.4 on anticholinergic pills and 3.3 after 100 units of onabotulinumtoxinA into the bladder (P = 0.81). Complete resolution was reported by 13% and 27%. Dry mouth was more common on pills (46% against 31%), and catheter use at 2 months (5% against 0%) and urinary infections (33% against 13%) were more common after the injection [11].
Population
249 women with idiopathic urge incontinence, 5 or more episodes per 3 days [11].
Sources
[11]
Caveats
One trial in women only, funded by the US National Institutes of Health [11].

Not shown to help1

Strong

Episodic migraine and tension headache

Not shown to reduce episodic migraine or chronic tension-type headaches against placebo in pooled trials.

Compared with placebo injections [6][7]

The numbers and sources
Effect
Across 9 studies, episodic migraine did not fall against placebo (0.05 headaches a month, 95% CI -0.26 to 0.36), nor did chronic tension-type headache across 7 studies (-1.43, 95% CI -3.13 to 0.27) [7]. A single trial in episodic migraine found no difference in migraine days [6]. The Botox label states safety and effectiveness have not been established for episodic migraine in seven placebo-controlled studies [5].
Population
1,838 patients with episodic migraine and 675 with chronic tension-type headache [7]; 418 people with episodic migraine in one trial [6].
Sources
[7], [6], [5]
Caveats
Doses and injection sites varied across the older trials [7].

Doses studied

The frown line trials used 20 units of onabotulinumtoxinA into 5 sites [1], and the labels give 20 units for Botox Cosmetic and Xeomin and 50 units for Dysport [3][16][17]. The chronic migraine trials used 155 to 195 units, and the label gives 155 units as 5-unit injections across 7 head and neck muscles [5]. The underarm sweating trials used 50 or 75 units per armpit injected into the skin [8][9]. The overactive bladder trials used 100 units injected into the bladder wall [5][11]. The cervical dystonia trials used 150 to 500 units of onabotulinumtoxinA, 120 to 240 units of incobotulinumtoxinA and 250 to 1,000 units of abobotulinumtoxinA [4]. The Botox label gives up to 400 units for adult arm spasticity and a maximum of 400 units across all uses in 3 months in adults [5]. Units are specific to each product [5].

Risks

Reported risks8

ModerateVery common

Trouble swallowing and neck weakness after neck injections

Shown to raise trouble swallowing to 11% and neck weakness to 14% after injections for cervical dystonia, about 3 times the placebo risk.

The numbers and sources
How common
Very common: more than 1 in 10 people.
Effect
Against placebo, botulinum toxin raised any adverse event (RR 1.23, 95% CI 1.05 to 1.43), neck weakness (14%, RR 3.40, 95% CI 1.19 to 9.71), trouble swallowing (11%, RR 3.19, 95% CI 1.79 to 5.70) and general weakness or tiredness (8%, RR 1.80) [4]. The Botox label reports deaths from severe dysphagia, dysphagia lasting months and needing a feeding tube, and higher risk with smaller neck muscle mass or injections into both sternocleidomastoid muscles [5].
Population
1,144 adults with cervical dystonia in 9 RCTs [4]; label reports [5].
Sources
[4], [5]
Caveats
Doses for neck dystonia are far higher than cosmetic doses [4][3].
ModerateVery common

Urinary infections and urinary retention after bladder injections

Shown to raise urinary tract infections, 18% against 6% on placebo, and urinary retention, 6% against 0%, after bladder injections for overactive bladder.

The numbers and sources
How common
Very common: more than 1 in 10 people.
Effect
After 100 units for overactive bladder, urinary tract infection occurred in 18% against 6%, painful urination in 9% against 7%, and urinary retention in 6% against 0%. In adults with multiple sclerosis not self-catheterizing, 31% on 200 units needed catheterization for retention against 5% on placebo. The label says to treat only people willing to self-catheterize if needed [5]. Against anticholinergic pills, urinary infections were 33% against 13% and catheter use at 2 months 5% against 0% [11].
Population
552 and 542 adults in overactive bladder trials, 86 and 88 with multiple sclerosis [5]; 249 women [11].
Sources
[5], [11]
Caveats
Trials excluded people with frequent urinary infections [5].
ModerateCommon

Drooping eyelid or brow and facial weakness

Shown to cause a drooping eyelid in 3% after frown line injections against 0% on placebo, and in 4% after migraine injections against under 1%.

The numbers and sources
How common
Common: between 1 in 100 and 1 in 10 people.
Effect
After frown line injections, eyelid ptosis occurred in 13 of 405 (3%) against 0 of 130 on placebo, and facial pain, facial paresis and muscle weakness each in 1%. With forehead and frown lines treated together, headache occurred in 9% against 5%, eyelid ptosis in 2% and brow ptosis in 2% against 0% [3]. In the chronic migraine trials, eyelid ptosis occurred in 4% against under 1%, and facial paresis in 2% against 0% [5].
Population
405 and 130 adults in frown line trials, 665 and 315 in forehead line trials [3]; 687 and 692 adults in chronic migraine trials [5].
Sources
[3], [5]
Caveats
Label trial pools [3][5].
StrongCommon

Neck pain and muscle weakness after migraine injections

Shown to raise adverse events about 30% against placebo in migraine trials, with neck pain in 9% against 3% and muscle weakness in 4% against under 1%.

The numbers and sources
How common
Common: between 1 in 100 and 1 in 10 people.
Effect
In the chronic migraine trials, neck pain occurred in 9% against 3%, musculoskeletal stiffness in 4% against 1%, muscle weakness in 4% against under 1%, and severe worsening of migraine needing hospital care in about 1% against 0.3% [5]. Pooled migraine trials found 60 adverse events per 100 participants on botulinum toxin against 47 on placebo (RR 1.28, 95% CI 1.12 to 1.47) [6]. A second meta-analysis found more drooping eyelids, skin tightness, tingling, neck stiffness, muscle weakness and neck pain than placebo [7].
Population
687 and 692 adults with chronic migraine [5]; 28 trials [6]; RCTs of headache [7].
Sources
[5], [6], [7]
Caveats
Withdrawal for adverse events was 72% less likely than with oral preventives in two small trials [6].
LimitedHow often is not known

FDA boxed warning: distant spread of toxin effect

FDA states the effects of all botulinum toxin products may spread beyond the injection site, causing swallowing and breathing difficulties that can be life threatening, with reported deaths.

The numbers and sources
How common
How often is not known: the sources give no rate.
Effect
The boxed warning, based on postmarketing reports, lists general weakness, double vision, drooping eyelids, trouble swallowing, voice and speech changes, urinary incontinence and breathing difficulties appearing hours to weeks after injection. It says the risk is probably greatest in children treated for spasticity, and that spread has been reported in approved and unapproved uses at doses like those for cervical dystonia and spasticity and at lower doses [5]. The cosmetic label carries the same boxed warning [3].
Population
Postmarketing reports [5][3].
Sources
[5], [3]
Caveats
Postmarketing reports give no rate [5].
ModerateHow often is not known

Antibodies and loss of effect

Linked to neutralizing antibodies and later treatment failure more often after abobotulinumtoxinA or onabotulinumtoxinA than incobotulinumtoxinA in neck dystonia and spasticity.

The numbers and sources
How common
How often is not known: the sources give no rate.
Effect
Across 29 studies, the share developing secondary treatment failure, and depending on the test the share with neutralizing antibodies, was significantly higher after abobotulinumtoxinA or onabotulinumtoxinA than after incobotulinumtoxinA for cervical dystonia or spasticity, and rose with higher mean doses. No one treated only with incobotulinumtoxinA developed immune-related treatment failure or lasting antibodies [18].
Population
29 studies in cervical dystonia, spasticity and blepharospasm [18].
Sources
[18]
Caveats
Antibody tests differed between studies, and the abstract gives no pooled rate [18].
LimitedHow often is not known

Counterfeit and unlicensed products

Case reports: an unlicensed, highly concentrated toxin caused botulism in 9 people in Egypt, with weakness, swallowing trouble and drooping eyelids needing antitoxin.

The numbers and sources
How common
How often is not known: the sources give no rate.
Effect
Nine patients developed botulism 5 to 10 days after injections into muscle of 200 to 300 units of an imported unlicensed product for cerebral palsy, spastic dystonia or sweating. They had limb weakness, swallowing trouble, double vision and drooping eyelids, were treated with antitoxin, and needed 6 to 12 weeks to recover fully. No one needed a ventilator [19].
Population
9 patients in one outbreak, 5 with detailed records [19].
Sources
[19]
Caveats
One outbreak from one unlicensed product [19].
LimitedHow often is not known

With aminoglycoside antibiotics and other drugs that weaken muscles

The label warns that aminoglycoside antibiotics and other drugs affecting nerve-muscle signals, muscle relaxants and other botulinum toxins may add to the toxin's weakening effect.

The numbers and sources
How common
How often is not known: the sources give no rate.
Effect
The Botox label says giving it with aminoglycosides or curare-like compounds may potentiate the toxin, that anticholinergic drugs given afterward may add to anticholinergic effects, that a second botulinum toxin before the first wears off may worsen weakness, and that muscle relaxants may exaggerate weakness. It advises against aminoglycosides as antibiotic cover for bladder injections [5].
Population
Label [5].
Sources
[5]
Caveats
A label precaution, with no rate given [5].

Checked, no increase found1

LimitedStudied in pregnancy

Use in pregnancy

Limited evidence: among 152 live births after onabotulinumtoxinA exposure in or just before pregnancy, major birth defects were 0.7%, within the general population rate.

The numbers and sources
How common
How often is not known: the sources give no rate.
Effect
Of 195 prospective pregnancies, 77.2% ended in live birth and 22.8% in fetal loss. Among 152 live births, major fetal defects occurred in 0.7% (1 of 152) and any fetal defect in 2.6%, against 3% to 6% for major defects in the general population [20]. The label states there are no adequate human data and that animal studies at clinically relevant doses lowered fetal weight and bone formation alongside maternal toxicity [5].
Population
913 pregnancies in the maker's global safety database over 29 years, 397 with known outcomes [20]; animal studies [5].
Sources
[20], [5]
Caveats
A company safety database subject to reporting bias, with little data on second and third trimester exposure [20].

Claims tested and not found

  1. That botulinum toxin prevents episodic migraine. Across 9 studies, episodic migraine did not fall against placebo (0.05 headaches a month) [7].
  2. That it eases chronic tension-type headache. The pooled reduction of 1.43 headaches a month was not significant (95% CI -3.13 to 0.27) [7].
  3. That it outperforms migraine preventive pills. Single trials found no difference from valproate, topiramate or amitriptyline [7].
  4. That it restores arm function after stroke. Arm tone fell, but active arm function did not change significantly (SMD 0.49, 95% CI -0.08 to 1.07) [13].

Sources

  1. Guo Y, Lu Y, Liu T, et al. Efficacy and Safety of Botulinum Toxin Type A in the Treatment of Glabellar Lines: A Meta-Analysis of Randomized, Placebo-Controlled, Double-Blind Trials. Plastic and Reconstructive Surgery. 2015. https://doi.org/10.1097/prs.0000000000001544
  2. Li X, Sui C, Xia X, Chen X. Efficacy and Safety of Botulinum Toxin Type A for Treatment of Glabellar Lines: A Network Meta-Analysis of Randomized Controlled Trials. Aesthetic Plastic Surgery. 2023. https://doi.org/10.1007/s00266-022-03018-y
  3. Botox Cosmetic (onabotulinumtoxinA) for injection, for intramuscular use, prescribing information (Allergan). 2026. DailyMed, US National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=485d9b71-6881-42c5-a620-a4360c7192ab
  4. Rodrigues FB, Duarte GS, Marques RE, et al. Botulinum toxin type A therapy for cervical dystonia. Cochrane Database of Systematic Reviews. 2020. https://doi.org/10.1002/14651858.cd003633.pub4
  5. Botox (onabotulinumtoxinA) for injection, prescribing information (Allergan). 2026. DailyMed, US National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=33d066a9-34ff-4a1a-b38b-d10983df3300
  6. Herd CP, Tomlinson CL, Rick C, et al. Botulinum toxins for the prevention of migraine in adults. Cochrane Database of Systematic Reviews. 2018. https://doi.org/10.1002/14651858.cd011616.pub2
  7. Jackson JL, Kuriyama A, Hayashino Y. Botulinum toxin A for prophylactic treatment of migraine and tension headaches in adults: a meta-analysis. JAMA. 2012. https://doi.org/10.1001/jama.2012.505
  8. Naumann M, Lowe NJ. Botulinum toxin type A in treatment of bilateral primary axillary hyperhidrosis: randomised, parallel group, double blind, placebo controlled trial. BMJ. 2001. https://doi.org/10.1136/bmj.323.7313.596
  9. Lowe NJ, Glaser DA, Eadie N, et al. Botulinum toxin type A in the treatment of primary axillary hyperhidrosis: a 52-week multicenter double-blind, randomized, placebo-controlled study of efficacy and safety. Journal of the American Academy of Dermatology. 2007. https://doi.org/10.1016/j.jaad.2007.01.009
  10. Duthie JB, Vincent M, Herbison GP, et al. Botulinum toxin injections for adults with overactive bladder syndrome. Cochrane Database of Systematic Reviews. 2011. https://doi.org/10.1002/14651858.cd005493.pub3
  11. Visco AG, Brubaker L, Richter HE, et al. Anticholinergic therapy vs. onabotulinumtoxinA for urgency urinary incontinence. New England Journal of Medicine. 2012. https://doi.org/10.1056/nejmoa1208872
  12. Dong Y, Wu T, Hu X, Wang T. Efficacy and safety of botulinum toxin type A for upper limb spasticity after stroke or traumatic brain injury: a systematic review with meta-analysis and trial sequential analysis. European Journal of Physical and Rehabilitation Medicine. 2017. https://doi.org/10.23736/s1973-9087.16.04329-x
  13. Sun LC, Chen R, Fu C, et al. Efficacy and Safety of Botulinum Toxin Type A for Limb Spasticity after Stroke: A Meta-Analysis of Randomized Controlled Trials. BioMed Research International. 2019. https://doi.org/10.1155/2019/8329306
  14. Qian H, Shao F, Lenahan C, et al. Efficacy and Safety of Botulinum Toxin vs. Placebo in Depression: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Frontiers in Psychiatry. 2020. https://doi.org/10.3389/fpsyt.2020.603087
  15. Crowley JS, Silverstein ML, Reghunathan M, Gosman AA. Glabellar Botulinum Toxin Injection Improves Depression Scores: A Systematic Review and Meta-Analysis. Plastic and Reconstructive Surgery. 2022. https://doi.org/10.1097/prs.0000000000009240
  16. Dysport (abobotulinumtoxinA) for injection, for intramuscular use, prescribing information (Ipsen Biopharmaceuticals). 2023. DailyMed, US National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=97513722-8426-4ce3-b85d-0e08e436a140
  17. Xeomin (incobotulinumtoxinA) for injection, for intramuscular or intraglandular use, prescribing information (Merz). 2026. DailyMed, US National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=3f35d6e0-3450-4abc-a0da-cc7b277e7c6e
  18. Walter U, Albrecht P, Carr W, Hefter H. Systematic Review and Meta-Analysis of Secondary Treatment Failure and Immunogenicity With Botulinum Neurotoxin A in Multiple Indications. European Journal of Neurology. 2025. https://doi.org/10.1111/ene.70289
  19. Rashid EAMA, El-Mahdy NM, Kharoub HS, et al. Iatrogenic Botulism Outbreak in Egypt due to a Counterfeit Botulinum Toxin A Preparation: A Descriptive Series of Patient Features and Outcome. Basic & Clinical Pharmacology & Toxicology. 2018. https://doi.org/10.1111/bcpt.13048
  20. Brin MF, Kirby RS, Slavotinek A, et al. Pregnancy Outcomes in Patients Exposed to OnabotulinumtoxinA Treatment: A Cumulative 29-Year Safety Update. Neurology. 2023. https://doi.org/10.1212/wnl.0000000000207375

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