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Use in Adults
OnabotulinumtoxinA

THIS GUIDE PROVIDES A PARTIAL LISTING OF PRESCRIBING INFORMATION FOR THIS MEDICATION. FOR A FULL LISTING OF PRESCRIBING INFORMATION PLEASE REFER TO THE PACKAGE INSERT. CLICK ON THE BRAND NAME® TO VIEW THE LINK TO THE PACKAGE INSERT.
Brands:
  • BOTOX® (OnabotulinumtoxinA) For Complete Prescribing Information Click Here for the Package Insert​
Available Dosages:
  • 200 unit vial
Initial Dose:
  • 155 units injected intramuscularly in 31 pre-specified sites in the head & neck
​Maintenance Dose: 
  • 155 units injected intramuscularly in 31 sites in the head & neck every 12 weeks over 31 sites
Suggested Titration Schedule:
  • No titration necessary
  • A fixed dosage is administered every three months​
Common and Rarer Side Effects:
  • Ptosis in 3-4%
  • Neck pain/weakness, injection site pain
  • Migraines may flare for 2-5 days after injection  
  • Rare systemic spread of toxin (dysphagia, diplopia, vocal cord paralysis, respiratory depression)
Headache Specialist Suggestions:
OnabotulinumtoxinA is used for the prevention of chronic migraine.  
  • Chronic migraine is defined as those with:
    •  Diagnosis of migraine
    • 15 or more headache days per month (includes migraine + non migraine headaches)
    • 8 or more days per month that meet migraine criteria
It is NOT indicated for the prevention of episodic migraine.
Consider its use in: Chronic migraine
  • has no side effects of memory loss or weight gain
  • In those that have medication intolerances
  • with or without medication overuse
  • Avoid its use in:
    • Those with cellulitis overlying the injection sites
    • Neuromuscular disorders such as myasthenia gravis
  • Advantages are:
    • Good efficacy, long track record and moderate side effect profile, when administered by an experienced, well-trained injector
    • Few drug interactions
  • Disadvantages are:
    • Ptosis in 3-4%
    • Patients often lose facial expression, as forehead muscles are paralyzed
    • Cost and need for a prior authorization
    • Need for 31 injections to administer each course of botox
Precautions and Risk:
  • Spread of toxin effects; swallowing and breathing difficulties have rarely led to death 
  • Immediate medical attention may be required in cases of respiratory, speech or swallowing difficulties
  • Use with caution in patients with compromised respiratory function
  • Corneal exposure and ulceration
  • Retrobulbar hemorrhages and compromised retinal circulation
  • Bronchitis and upper respiratory tract infections in patients treated for upper limb spasticity
  • Pregnancy & lactation: lack of definitive safety data; avoid unless benefit clearly outweighs risk
  • Avoid in patients with known generalized neuromuscular disease
Contraindications:
  • Infection at the proposed injection site
  • Neuromuscular disorders, such as myasthenia gravis
Pregnancy & Breast Feeding:
  • Click BOTOX® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
Drug Interactions:
  • Concomitant treatment of BOTOX and aminoglycosides or other agents interfering with neuromuscular transmission (e.g., curare -like agents), or muscle relaxants, should be observed closely because the effect of BOTOX may be potentiated
Counseling Tips: 
  • Please see package insert for recommendations for storage and preparation of drug.
  • OnabotulinumtoxinA injections should be administered in- office by a trained injector.
  • A 29-30 gauge needle and 1 cc syringe should be used
  • Mix 200 units of botox in 4 ccs of 0.9% saline; do not shake, merely roll the vial in one’s hands, until mixed.
  • Inject 0.1 ccs (5 units) into each of the prespecified 31 sites of the head & neck. 
  • The total dosage is 155 units of onabotulinumtoxinA.
  • Benefit should be assessed after two or three treatments (6 – 9 months). Response is generally observed at 3-6 weeks.   Many patients respond to a first treatment, but guidelines suggest that patient should have two cycles of treatment before deciding on response and continuation of drug.
  • OnabotulinumtoxinA paralyzes any muscle in which it is injected.
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  • Home
  • Education
    • CME Modules >
      • Module 1: Diagnose Migraine
      • Module 2: Secondary Headache
      • Module 3: Acute Therapy
      • Module 4: Preventive Therapy
    • Non-CME Modules >
      • Diagnose Migraine
      • Secondary Headache
      • Acute Therapy
      • Prevention
  • Diagnosis Tool
  • Med Guides
    • Acute Treatment Guide >
      • NSAIDs
      • Triptans
      • Gepants
      • Ditans
      • Combinations
      • Ergotamines
    • Preventive Guide >
      • Antidepressants
      • Antihypertensives
      • Antiepileptics
      • CGRP Monoclonal Antibodies
      • OnabotulinumtoxinA
      • CGRP Antagonists - Oral
    • Med-Guide
  • Infographics
    • Diagnose Migraine
    • ABCs of Migraine Management
    • Acute Migraine
    • Prevent Migraine