Novel Concepts for OnabotulinumtoxinA (Botox) Mechanisms of Action: Role in Altering the Molecular Environment in Which Pain Fibers Exist
Phase: PHASE4
Conditions: Migraine
Sponsor: Massachusetts General Hospital

 
 
 
 
 
 
 
STUDY PROTOCOL AND STATISTICAL ANALYSIS PLAN 
Novel concepts for OnabotulinumtoxinA (Botox) mechanisms of 
action: role in altering the molecular environment in which pain 
fibers exist 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
NCT number: 3381261  
Document date: 6.7.2022 
 

1
DETAILED STUDY DESCRIPTION
TITLE OF PROTOCOL
Novel concepts for OnabotulinumtoxinA (Botox) mechanisms 
of action: role in altering the molecular environment in which 
pain fibers exist
Version date: 6/7/22
1.
PURPOSE OF PROTOCOL
Specific Aim  
To compare Botox-treated and Botox-untreated symptomatic tissues (defined as areas where the head 
hurts and the pain is felt) of CM patients using targeted transcriptome and genome-wide epigenome 
analysis.  This aim will test the hypothesis that Botox reverses the abnormal expression of inflammatory 
genes in headache-affected regions and pericranial muscles, fascia, and perineurium of nerves 
supplying them.
2.
SIGNIFICANCE AND BACKGROUND FOR THE STUDY
Background and Rational 
The broad objective of this proposal is to understand better how Botox works and determine whether it 
can attenuate inflammation.  Based on our preliminary findings, we expect the proposed research to 
vastly expand the understanding of Botox MOA, both in migraine prophylaxis and somatic pain 
conditions associated with inflammation.  Scientifically, we expect to gain new insight into the role played 
by Botox in environments that surround relevant peripheral nociceptors – potentially by attenuating local 
expression of pro-inflammatory molecules (mRNA) and their post-transcriptional regulators (non-coding 
RNA).  In the context of migraine, such tissues include the calvarial periosteum, galea aponeurotica, 
pericranial muscles and fascia surrounding extracranial nerves (e.g., occipital, supraorbital, 
auriculotemporal nerves).  In the context of other somatic pains, such tissues include muscles, fascia, 
and the perineurium.  The potential impacts of the proposed research is that if successful, it will broaden 
the clinical use of Botox.  Equally important, it will define a novel framework for conceptualizing about 
Botox MOA and consequently, why and how it may be used to treat other pains and possibly conditions 
associated with abnormal inflammatory and immune responses. 
The goals of the proposed research will be achieved by studying tissues commonly discarded during 
nerve decompression surgeries performed to alleviate neck and head pain in chronic migraineurs.  
These goals were formulated on the basis of two sets of preliminary clinical findings.  The first showed 
that gene transcripts (mRNA) that promote immune and inflammatory responses are significantly 
upregulated in calvarial periosteum of CM patients (as compared to control subjects) and that gene 
transcripts (mRNA) that reduce immune and inflammatory responses are significantly down-regulated in 
calvarial periosteum of CM patients (as compared to control subjects). 
In more detail, there is new evidence of extracranial origins of migraine headache. Clinically, there is 
data that describes an imploding headache (extracranial) versus exploding headache (intracranial) 
[1]. There is evidence that expression of proinflammatory genes (eg, CCL8, TLR2) in the 
calvarial periosteum is  significantly increased in CM patients, whereas expression of genes that 
suppress inflammation and immune cell differentiation (eg, IL10RA, CSF1R) is decreased. It is well 
known that anti- inflammatory drugs improve migraine attacks. It has further been shown that 
extracranial administration of OnabotulinumtoxinA is effective in reducing the number of migraine 
days per month in patients who testified to having ‘imploding’, but not in those who testified to having 
‘exploding’ headache [2]. The identification of extracranial pathophysiologies in chronic migraine 
patients whose headaches are most commonly perceived as imploding, and the finding that imploding 
migraine patients are those who benefit most from prophylactic treatment with OnabotulinumtoxinA 
[1], gave rise to a theory that Botox may help patients with imploding headache due to anti- 
inflammatory properties. 
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1. Jakubowski M, McAllister PJ, Bajwa ZH, Ward TN, Smith P, Burstein R (2006) Exploding vs. 
imploding headache in migraine prophylaxis with Botulinum Toxin A. Pain 125 (3):286-295. 
doi:10.1016/j.pain.2006.09.012
2. Burstein R, Dodick D, Silberstein S (2009) Migraine prophylaxis with botulinum toxin A is 
associated with perception of headache. Toxicon 54 (5):624-627. doi:10.1016/j.toxicon.2009.01.009
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3.
DESCRIPTION OF RESEARCH PROTOCOL
A.
Study Design – Overview, Methods, Procedures
Overall study design:
Patients diagnosed with chronic migraine (fulfill criteria for CM as defined in the ICHD-3 beta), 
especially those complaining about chronic muscle tenderness, are routinely considered good 
candidate to benefit from a surgery in which trapped nerves are decompressed.  In routine clinical 
care, such patients are referred to Dr. Austen (plastic surgeon performing these procedures) to 
determine whether or not they fit to undergo the nerve decompression procedure.   Of great 
importance to the evaluation of the proposed study is the fact that the decision on whether or not to 
operate is unrelated to and independent of any academic study.  Those deemed good candidate for 
the surgery, which include fulfilling all inclusion/exclusion criteria, would be presented with an option 
to hear about the study from a research nurse. Those interested in hearing about the study will be 
presented with all the necessary details required and then given the option to sign (or not to sign).  
They will be given as much time as needed to sign the consent form and have the option to take the 
consent form home and call in interested.
Since the surgery itself is unrelated to the proposed study, all patients (those who sign the informed 
consent and those who chose not take part in the study) are booked for the surgery.  Usual waiting 
time is 3-6 month.  
Those who agree to participate in the study, will be asked to fill out a 15min headache questionnaire 
that contains questions about their headaches. Subjects will also be asked to complete a headache 
diary 3 months prior to botox injections. 
Enrolled subjects will be booked for another visit to Dr. Austen’s clinic 30 days prior to their planned 
surgery.  In this visit, they will be injected with 40 units of Botox in one side of their head/neck as 
detailed below.
During surgery, calvarial periosteum, pericranial muscles and fascia surrounding nerves that are 
routinely removed and discarded, will be collected by Dr. Austen, stored in in RNAlater Solution, 
Ambion, CA, de-identified, frozen, and shipped overnight to Dr. Burstein’s lab at BIDMC, where each 
sample will be recorded, verified, prepared for processing, and analyzed for targeted transcriptome 
and epigenome involved in inflammatory and immune responses.  
  
Clinical Site Study Procedures
The following research study activities will take place exclusively at MGH: 
Those who agree to participate in the study, will be asked to fill out a 15min headache questionnaire 
that contains questions about their headaches. Subjects will also be asked to complete a headache 
diary 3 months prior to botox injections. 
The headache diary will be filled out every day for 3 months prospectively prior to botox injection. 
Subjects will indicate whether they had migraines that day (check date box), what severity the 
migraines were (on a scale of 0-10), what the duration was (hours), what the location was, which 
other symptoms they experienced, which medications they took, how often they went to the ED, saw 
doctors or missed work and how much the total cost was. The total time spent every day filling out the 
diary should not exceed 5min.
Enrolled subjects will be injected with Botox on one side of the back of the head. The FDA-approved 
injection paradigm includes 7 muscles (Frontalis, Corugator, Procerus, Occipitalis, temporalis, Trapezius, 
and the Cervical Paraspinal muscle group), 31 sites and 155 units divided as follows: Frontalis – 4 sites, 
5 units in each; Corrugator – 2 sites, 5 units in each; Procerus – 1 site, 5 units; Occipitalis – 6 sites, 5 
units at each; Temporalis – 8 sites, 5 units in each; Trapezius – 6 sites, 5 units at each; Cervical 
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Paraspinal – 4 sites, 5 units in each.  
Of these muscles, sites and doses, patients will be injected (from a 100 Unit vial of OnabotulinumtoxinA 
reconsituted per product manufacturer label instructions) as follows:
(A)
2 sites in the Occipitalis muscle (5 units each)
(B)
4 sites in the Cervical Paraspinal muscle group (5 units each)
(C)
2 sites in the Trapezius muscle  (5 units each)
These injections will be given into one side only.  This deviates from the standard of care, as Botox is 
usually injected on both sides if pain is experienced on both sides. The selection will be random based 
on subject number. Odd numbers will be injected on the right and even numbers on the left. 
The current standard of care for screening for migraine surgery includes injection of Botox to identify 
nerve triggers. In the occipital region, botox is either injected unilaterally or bilaterally depending on 
where pain occurs. When pain occurs bilaterally, Botox is injected on both sides. Subjects included in 
this study have bilateral occipital pain and would therefore as part of routine standard care be injected 
on both sides. As per this protocol, subjects will only be injected on one side. The risks of unilateral 
injection of botox (in addition to the risk of Botox in general outlined by the FDA) include continued 
pain on the uninjected side and/or injected side and one- sided muscle weakness, one- sided 
bruising, one sided infection on the injected side. More generally, botox injections may cause the 
formation of anti-botox antibodies, which may decrease the effectiveness of botox treatment in other 
areas.
Subjects will be informed that they have the option to be injected with Botox on the uninjected side if 
any unwanted symptoms are experienced on the uninjected side. The cost of injection on the other 
side will be covered by the study funds.
Because the standard surgical procedure involves removal of equal amount of corresponding tissues 
from both sides of the head, an opportunity is created here to analyze identical Botox-treated and Botox-
untreated tissues.  Importantly, all analyzed tissues are discarded as a part of the surgery and none is 
collected for the sake of the study.     
   
Note that this injection paradigm does not deviate from the currently approved FDA paradigm and that it 
is given to chronic migraine patients (i.e., for the indication it was approved by the FDA).  Also note that 
one of the standard clinical criteria that these patients must fulfill in order to qualify for the surgical 
decompression procedure (which is unrelated to the study) is to demonstrate that they have failed at 
least 3 attempts to treat their chronic migraine with prophylactics – one of which is Botox.  Thus, all those 
who qualify for the study would have been treated with Botox at least twice before as per the FDA 
approved protocol.     
Thirty days later, patients will undergo a study-unrelated nerve decompression surgery.  This procedure 
involves the removal of different tissues surrounding trapped branches of the occipital nerve.  These 
tissues include muscles, fascia, and periosteum (discarded tissue).  The amount of tissue removed at 
each area is many folds larger than the amount of tissue needed for sampling (less than the size of 1 
grain of rice.  
From the time of informed consent and for 3 months following injection, all sellf-reported adverse 
events will be reviewed by the study physician at each patient contact(patients are followed every 4 
weeks after botox injection and one week, one month, three months, one year and after that yearly 
after surgery).  All serious adverse events will be reported to the IRB and designated safety monitor 
within 24 hours of awareness of the event. 
There will be two visits:
Screening visit: Patients will be screened for eligibility. This will be performed during the regular 
clinical assessment for surgery. The study visit will take 30min. The subject will be asked to complete 
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a 15 min questionnaire and will be asked to fill out a 3m headache diary which may take up to 5min a 
day.
Preoperative visit: will be injected with Botulinum Toxin. This will take 30 minutes.
There will be further routine clinical visits postoperatively (one week, 3 months and 12 months). 
However, these visits are not related to the study but are part of regular follow up. No study materials 
for this study will be collected as part of this visit. 
 
Analysis to be Done at BIDMC
(A) Tissue processing, RNA isolation, genetic processing and mRNA counting will occur in Dr. 
Burstein’s lab at Beth Israel Deaconess Medical Center, Harvard Medical School.
(B) Bioinformatics and biostatistics analyses will be conducted at Dr. Bhasin’s lab at Beth Israel 
Deaconess Medical Center, Harvard Medical School.
B.
Statistical Considerations
Statistical power analysis: In doing the power calculation, we control for false discovery rate (FDR), 
a common method used in genome level analysis to control for multiple testing of a large number of 
genes. The statistical power is also a function of proportion of non-differentially expressed genes 
using the method developed by Liu and Hwang in 2007. Based on our feasibility study findings, we 
used 98% non-differentially genes and effect size of 1.5 for power calculation. With 50 chronic 
migraine (each serving as his/her own control), we will have 95% statistical power to detect effect size 
of 1.5, with stringent FDR of 0.001.
Statistical analysis for main outcome measure:  (A) Comparisons of targeted transcriptome from 
periosteal, muscles and fascia surrounding nerves will be performed between corresponding injected 
and not-injecetd tissues using Wilcoxon’s Matched Pairs Tests.  
Quality controls (QC), normalization and preprocessing analysis of genomics profiling data : Tissues 
genomics profiling data will be analyzed using the following major steps:  
(a) Quality control: We will first assign a quality measure for each sample based on nanostring 
standard QC criteria such as FOV counted, binding density, array mean signal, average background, 
and scaling factor using expert bioinformatician supervision. We will also check for reproducibility of 
the samples using correlation and signal-to-noise ratio (SNR) methods for replicate arrays. Low 
quality arrays will be excluded from further analysis. 
(b) Normalization:  Normalization is the most critical step in the analysis, which is a transformation of 
signal values so that different chip results become comparable. The normalization will be performed 
in three steps: (i) Positive Spike in controls based normalization that will take care of signal variation 
due to different amounts of input RNA, (ii) Negative Spike in controls based background correction, 
(iii) Normalization based of signal values of house keeping genes from the experiments to bring all 
0
5
10
15
20
25
0.0
0.2
0.4
0.6
0.8
1.0
Sample size (n)
Power
0
0.9
0.95
0.98
Figure 2. Power vs. Sample Size with 
fdr=0.001 and Δ/σ=1.5038
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the chips onto a similar expression level. The different normalizations and QCs will be performed 
using the Bioconductor R packages workflows. 
(c) Unsupervised analysis: To identify unbiased patterns of similarity, outlier arrays and batch effects, 
unsupervised learning technique will be performed on the normalized expression profiles of all genes. 
The unsupervised learning will be carried out using the Unweighted Pair Group Method with 
Arithmetic Mean (UPGMA), also referred to as hierarchical clustering. The assumption underlying 
these clustering techniques is that expression profiles that are proximate in Euclidean or correlation 
space are mechanistically related. Additionally attempt to identify outliers will be done using principal 
component analysis. 
Identification of Botox signatures: In this analysis, we will consider the gene expression as the 
dependent variable and the indicator variable of group (e.g. Botox vs. No Botox) as the independent 
variable. The analysis will be performed using Linear Models for Microarray Data (LIMMA) as it 
employs an empirical Bayes approach for parameter estimation. To reduce the false positive, the 
significantly differentially expressed genes will be obtained using Benjamini and Hochberg multiple 
test corrected P value. The genes with P value < 0.01 and absolute fold change of at least 2 folds will 
be considered as differentially expressed. Due to differences in level of expression of gene in different 
tissues, we will perform separate normalization and signature identification for each tissue type. 
Functional and Pathways analysis: The genes from different tissues will be further analyzed in the 
context of biological pathways, Gene Ontology (GO) and functional categories.  The analysis will be 
performed using MATLAB, Bioconductor and commercial packages (e.g. Ingenuity pathways 
Analysis). Identifying significantly over-represented biological pathways is particularly valuable for 
understanding the underline mechanism of action of Botox.
Identification of tissues and pathways that potentially drive Botox effects: The comprehensive 
network generated above will be further analyzed to pin-down the involved tissues and pathways. To 
reach this goal, an effort will be made to find a sub-network with highest number of alterations. Such 
subnetwork will be identified using HotNet package that considers gene as a unit heat source, and 
uses a diffusion process to derive “hot'' subnetworks that contain more alterations than expected by 
random chance. In principle, significant subnetworks are routinely determined by both the frequency 
of alteration of genes and the local topology of the subnetwork. To identify a key pathway(s) in a top 
significant subnetwork, we will use the Biological pathway enrichment analysis.  This analysis will be 
done using various modules of Bioconductor, which uses multiple corrected hypergeometric tests to 
determine significance of pathway or biological process affected. 
C.
Subject Selection
Patients diagnosed with chronic migraine (fulfill criteria for CM  as defined in the ICHD-3 beta), 
especially those complaining about chronic muscle tenderness, are routinely considered good 
candidate to benefit from a surgery in which trapped nerves are decompressed.  In routine clinical 
care, such patients are referred to Dr.Austen to determine whether or not they fit to undergo the nerve 
decompression procedure.   Of great importance to the evaluation of the proposed study is the fact 
that the decision on whether or not to operate is unrelated to and independent of any academic study.  
Those deemed good candidate for the surgery would be presented with an option to hear about the 
study from Dr. Austen, the plastic surgeon responsible for their well-being during the surgery and the 
one handling the discarded tissues.  Those interested in hearing about the study will be presented 
with all the necessary details required by the Western IRB and then given the option to sign (or not to 
sign).  
Accordingly, up to 50 65 chronic migraine patients will be recruited to the study (if they are found fit to 
undergo the surgery) by Dr. Austen, a certified plastic surgeon with enormous experience in 
performing these procedures.  
Inclusion Criteria:
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•
Age 18-65 years
•
Diagnosis of Chronic Migraine consistent with International Classification of Headache 
Disorders (ICHD-III) criteria, with a history of bilateral headache pain and chronic 
tenderness in neck muscles
•
Patient is capable and willing to provide informed consent
•
Female subjects of child bearing potential must have a negative pregnancy test at 
enrollment and agree to remain abstinent or use acceptable methods of birth control (i.e., 
hormonal contraceptives, inrauterindevce, diaphragm with spermicide, cervidal cap or 
spong, condoms or partner has had a vasectomy) for three months following injections of 
Botox
•
Patients referred by their primary Neurologist to the study surgeon and who are 
determined to be candidates for surgical decompression of extracranial sensory nerves.
•
Patient agrees to abstain from protocol-specific excluded medications (see Appendix A) 
beginning 14 days prior to the decompression surgery.
Exclusion Criteria:
•
Patient has hypersensitivity reactions or other intolerance to Botox
•
Patient is pregnant or trying to become pregnant with the timeframe of the study.
•
Infection at proposed injection sites
 
4.
POSSIBLE BENEFITS
It is not possible to predict whether participants will benefit directly from participation in this study.  
However, their participation may help others in the future as a result of knowledge gained from the 
research
It is important to note that the clinical outcome of the procedure is unrelated to the proposed study.  
While improvement (or lack of improvement) in headache days per month after the procedure is followed 
by Dr. Austen, it is outside the scope of the proposed study and as such will not be collected and/or 
reported.   
5.
POSSIBLE RISKS AND ANALYSIS OF RISK/BENEFIT RATIO
Only subjects who have been selected as a surgical candidate for sensory nerve decompression of 
chronic headache would have their tissue tested. The taking of the periosteal sample would add no 
additional risk to the operation, as we are obtaining tissue discarded during surgery.
Botox therapy is currently approved by the FDA for preventive treatment of migraines. 
All the potential risks of Botox injections as issued by the FDA are as follows. As we are only injecting 
the back of the occiput, symptoms occurring around the eyes, the oropharynx or generalized 
symptoms are very unlikely.
A.  General: 
•
There have been rare spontaneous reports of death, sometimes associated with 
dysphagia, pneumonia, and/or other significant debility, after treatment with botulinum toxin.  
•
There have also been rare reports of adverse events involving the cardiovascular system, 
including arrhythmia and myocardial infarction, some with fatal outcomes.  Some of these 
patients had risk factors including cardiovascular disease. The exact relationship of these events 
to the botulinum toxin injection has not been established.
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•
The following events have been reported since the drug has been marketed and a causal 
relationship to the botulinum toxin injected is unknown: skin rash (including erythema 
multiforme, urticaria and psoriasiform eruption), pruritus, and allergic reaction.  
•
In general, adverse events occur within the first week following injection of BOTOX® and 
while generally transient may have a duration of several months.  Localized pain, tenderness 
and/or bruising may be associated with the injection.  Local weakness of the injected muscle(s) 
represents the expected pharmacological action of botulinum toxin.  However, weakness of 
adjacent muscles may also occur due to spread of toxin.
•
Extraocular muscles adjacent to the injection site can be affected, causing ptosis or 
vertical deviation, especially with higher doses of BOTOX.  The incidence rates of these 
adverse effects in 2058 adults who received a total of 3650 injections for horizontal strabismus 
are 15.7% and 16.9%, respectively.
•
The incidence of ptosis was 0.9% after inferior rectus injection and 37.7% after superior 
rectus injection.
B.  Side effects and discomforts associated with study treatment that you may experience include 
the following and some of these effects may last as long as 3 to 4 months:
•
Drooping of the upper lid
•
Swelling of the eyelid
•
Dryness of the eye
•
Irritation/tearing of the eye
•
Difficulty in closing the upper lid
•
Sensitivity to light
•
Double vision
•
Soreness and/or bruising at the injection sites
•
Skin rash
•
Loss of facial wrinkling
•
Localized muscle weakness in the muscles which have been injected
•
Slight weakness in other muscles in the neck
•
Difficulty swallowing
•
Generalized weakness and fatigue
C.  If you experience any illness or discomfort during the study, you should notify Dr. Austen.  Dr. 
Austen will then evaluate you to determine if you should continue in the study.
D.  There may be side effects or discomforts from the study treatment which are not yet known.  
You could have an allergic reaction to BOTOX.  A severe allergic reaction could be life-
threatening.
E.  Women who are pregnant, nursing a child, or planning a pregnancy during this study period 
may not participate in this study.  You must confirm that, to the best of your knowledge, you 
are not now pregnant, and that you do not intend to become pregnant during the study.  Prior 
to entering the study, you and the study doctor must agree on the method of birth control you 
will use during the study.  If you suspect that you have become pregnant during the study, you 
must notify the study doctor immediately.  The sponsor of the study may need access to your 
medical records regarding your pregnancy and the outcome of your pregnancy.  In addition, if 
you are pregnant or become pregnant during the study, there may be a risk of miscarriage or 
fetal malformation.
F. Treatment with BOTOX for the treatment of migraine headaches may result in the formation of 
antibodies that may reduce the effectiveness of subsequent treatments with BOTOX for other 
purposes. 
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G. Botox injections are associated with pain from the needle prick with pain from the needle prick. A 
bruise may develop at the site, and there is a small chance you might get an infection.
Overall, we believe the risks of this study are sufficiently low and that the benefits of information to be 
gained and the potential benefit of improved migraine treatment outweigh the risks in this study.
Unanticipated problems involving risks to subjects or others including adverse events will be reported to 
the PHRC in accordance with PHRC unanticipated problems reporting guidelines.
6.
RECRUITMENT AND CONSENT PROCEDURES
Recruitment
Patient screening, recruitment and consent will occur at Dr. Austen’s clinic (River Oaks Plastic Surgery 
Center) during a visit that determines their candidacy to undergo the surgery. 
Patients are referred to the investigator or schedule an appointment independently for migraine 
surgery routinely. Subjects will be selected from among the patients that are reffered to the 
investigator.. A research nurse will initially explain participation in the study prior to the visit with the 
investigator. The patient will be given the consent forms and can take us much time as needed to 
consent for the study. The patient can also take the consent form home and call if interested. At the 
scheduled visit with the investigator he will reinforce that participation is voluntary and with their 
patients that participation is voluntary, that they do not have to participate, and the decision not to 
participate will not affect their care, now or in the future. The investigator can answer any questions 
the subject may have.
Subject Protection
Study subjects will not be employees of the study team.
7.
STUDY LOCATION
Clinical Site: Boston
(A) Patient screening, recruitment, and consent will be performed by Dr. Austen at the Division of 
Plastic and Reconstructive Surgery, MGH
(B) Botox injections will be conducted by Dr. Austen at at the Division of Plastic and 
Reconstructive Surgery, MGH
(C) Nerve decompression surgery will occur at the MGH operating rooms
Processing Site: Boston
(C) Tissue processing, RNA isolation, genetic processing and mRNA counting will occur in Dr. 
Burstein’s lab at Beth Israel Deaconess Medical Center, Harvard Medical School.
(D) Bioinformatics and biostatistics analyses will be conducted at Dr. Bhasin’s lab at Beth Israel 
Deaconess Medical Center, Harvard Medical School.
8.
DATA SECURITY
All clinical study records will be stored in a secure location in the office of Dr. Austen, as all research 
activities involving patient data will take place at MGH. 
De-identified discarded tissue will be transferred to Dr. Burstein’s lab at Beth Israel Deaconess 
Medical Center for processing and analysis. No personally identifiable data (including name, date of 
birth, age, and gender) will be shared between the clinical site (Boston) and the processing site 
(BIDMC).
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9.
Dissemination of Research Results
Dr. Austen will provide participants with the option to learn about findings generated as a result of 
their participation. A copy of the final published manuscript will be provided to subjects who express 
interest in receiving a copy of the primary manuscript.
10.
Botox administration
Botox Prior to Surgery
As stated above, patients diagnosed with CM affecting both sides of the head who have been deemed 
candidates for study-unrelated surgical decompression of extracranial sensory nerves will be 
presented with an option to hear about the study and sign the informed consent.  Those who agree to 
participate in the study will be injected with Botox (Fig. 1) on one side of the neck/back of the head per 
FDA approved guidelines for migraine prophylaxis.  Botox treatment will take place 30 days prior to 
surgery.  As before, during surgery, perineurium, fascia, muscle, and periosteum will be collected (in 
RNAlater Solution, Ambion, CA), de identified, frozen, and shipped overnight for processing and 
analysis for targeted transcriptome and epigenome involved in inflammatory and immune responses 
using the advanced nanostring system.  
  
Injection paradigm: 
Occipital - 1 injection of 10 units
Trapezius - 2 injections of 10 units each
Semispinalis - 1 injection of 10 units
Splenius Capitis - 1 injection of 10 units
Ocipitalis
Splenius capitis
Semispinalis capitis
Trapezius
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HIGHLIGHTS OF PRESCRIBING INFORMATION  
These highlights do not include all the information needed to use 
BOTOX® safely and effectively. See full prescribing information for 
BOTOX.  
 
BOTOX (onabotulinumtoxinA) for injection, for intramuscular, 
intradetrusor, or intradermal use  
Initial U.S. Approval: 1989 
 
 
 
 
 
 
  
 
 
  
_________________________RECENT MAJOR CHANGES_________________________ 
x Warnings and Precautions (5.5, 5.7, 5.13, 5.14)                          4/2017 
                  
_________________________INDICATIONS AND USAGE__________________________ 
BOTOX is an acetylcholine release inhibitor and a neuromuscular 
blocking agent indicated for: 
x Treatment of overactive bladder (OAB) with symptoms of urge 
urinary incontinence, urgency, and frequency, in adults who have an 
inadequate response to or are intolerant of an anticholinergic 
medication (1.1) 
x Treatment of urinary incontinence due to detrusor overactivity 
associated with a neurologic condition [e.g., spinal cord injury (SCI), 
multiple sclerosis (MS)] in adults who have an inadequate response to 
or are intolerant of an anticholinergic medication (1.1) 
x Prophylaxis of headaches in adult patients with chronic migraine (≥15 
days per month with headache lasting 4 hours a day or longer) (1.2) 
x Treatment of spasticity in adult patients (1.3) 
x Treatment of cervical dystonia in adult patients, to reduce the severity 
of abnormal head position and neck pain (1.4)  
x Treatment of severe axillary hyperhidrosis that is inadequately 
managed by topical agents in adult patients (1.5) 
x Treatment of blepharospasm associated with dystonia in patients ≥12 
years of age (1.6) 
x Treatment of strabismus in patients ≥12 years of age (1.6) 
Important Limitations: Safety and effectiveness of BOTOX have not 
been established for: 
x Prophylaxis of episodic migraine (14 headache days or fewer per 
month) (1.2) 
x Treatment of upper or lower limb spasticity in pediatric patients (1.3) 
x Treatment of hyperhidrosis in body areas other than axillary (1.5) 
 
__________________DOSAGE AND ADMINISTRATION________________________ 
x Follow indication-specific dosage and administration 
recommendations; Do not exceed a total dose of 400 Units 
administered in a 3 month interval (2.1) 
x See Preparation and Dilution Technique for instructions on BOTOX 
reconstitution, storage, and preparation before injection (2.2) 
x Overactive Bladder: Recommended total dose 100 Units, as 0.5 mL 
(5 Units) injections across 20 sites into the detrusor (2.3) 
x Detrusor Overactivity associated with a Neurologic Condition: 
Recommended total dose 200 Units, as 1 mL (~6.7 Units) injections 
across 30 sites into the detrusor (2.3) 
x Chronic Migraine: Recommended total dose 155 Units, as 0.1 mL (5 
Units) injections per each site divided across 7 head/neck muscles 
(2.4) 
x Upper Limb Spasticity: Select dose based on muscles affected, 
severity of muscle activity, prior response to treatment, and adverse 
event history; Electromyographic guidance recommended (2.5) 
x Lower Limb Spasticity: Recommended total dose 300 Units to 400 
Units divided across ankle and toe muscles (2.5)  
x Cervical Dystonia: Base dosing on the patient’s head and neck 
position, localization of pain, muscle hypertrophy, patient response,  
   and adverse event history; use lower initial dose in botulinum toxin naïve patients     
   (2.6) 
x Axillary Hyperhidrosis: 50 Units per axilla (2.7) 
x Blepharospasm: 1.25 Units-2.5 Units into each of 3 sites per affected eye (2.8) 
x Strabismus: The dose is based on prism diopter correction or previous response to 
treatment with BOTOX (2.9) 
 
_________________________DOSAGE FORMS AND STRENGTHS_________________________ 
Single-use, sterile 100 Units or 200 Units vacuum-dried powder for reconstitution 
only with sterile, preservative-free 0.9% Sodium Chloride Injection USP prior to 
injection (3) 
 
_________________________________CONTRAINDICATIONS___________________________________ 
x Hypersensitivity to any botulinum toxin preparation or to any of the components in 
the formulation (4.1, 5.4, 6) 
x Infection at the proposed injection site (4.2) 
x Intradetrusor Injections: Urinary Tract Infection or Urinary Retention  (4.3) 
 
___________________________WARNINGS AND PRECAUTIONS___________________________ 
x Potency Units of BOTOX are not interchangeable with other preparations of 
botulinum toxin products (5.1, 11) 
x Spread of toxin effects; swallowing and breathing difficulties can lead to death. 
Seek immediate medical attention if respiratory, speech or swallowing difficulties 
occur (5.2, 5.6) 
x Potential serious adverse reactions after BOTOX injections for unapproved uses 
(5.3) 
x Concomitant neuromuscular disorder may exacerbate clinical effects of treatment 
(5.5) 
x Use with caution in patients with compromised respiratory function (5.6, 5.7, 5.10) 
x Corneal exposure and ulceration  due to reduced blinking may occur with BOTOX 
treatment of blepharospasm  (5.8) 
x Retrobulbar hemorrhages and compromised retinal circulation may occur with 
BOTOX treatment of strabismus (5.9) 
x Bronchitis and upper respiratory tract infections in patients treated for spasticity 
(5.10) 
x Urinary tract infections in patients treated for OAB (5.12) 
x Urinary retention: Post-void residual urine volume should be monitored in patients 
treated for OAB or detrusor overactivity associated with a neurologic condition 
who do not catheterize routinely, particularly patients with multiple sclerosis or 
diabetes mellitus. (5.13)  
 
__________________________________ADVERSE REACTIONS___________________________________ 
The most common adverse reactions (≥5% and >placebo) are (6.1):  
x OAB: urinary tract infection, dysuria, urinary retention 
x Detrusor Overactivity associated with a neurologic condition: urinary tract 
infection, urinary retention  
x Chronic Migraine: neck pain, headache  
x Spasticity: pain in extremity  
x Cervical Dystonia: dysphagia, upper respiratory infection, neck pain, headache, 
increased cough, flu syndrome, back pain, rhinitis  
x Axillary Hyperhidrosis: injection site pain and hemorrhage, non-axillary sweating, 
pharyngitis, flu syndrome  
To report SUSPECTED ADVERSE REACTIONS, contact Allergan at  
1-800-433-8871 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. 
 
_________________________________DRUG INTERACTIONS____________________________________ 
Patients receiving 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 (7) 
 
___________________________USE IN SPECIFIC POPULATIONS___________________________ 
x Pregnancy: Based on animal data, may cause fetal harm. (8.1) 
x Pediatric Use: Safety and efficacy are not established in patients under 18 years of 
age for the prophylaxis of headaches in chronic migraine, treatment of OAB, 
detrusor overactivity associated with a neurologic condition, spasticity, and axillary 
hyperhidrosis; in patients under 16 years of age for treatment of cervical dystonia; 
and in patients under 12 years of age for treatment of blepharospasm and 
strabismus (8.4) 
 
See 17 for PATIENT COUNSELING INFORMATION and Medication 
Guide 
Revised: 4/2017 
WARNING: DISTANT SPREAD OF TOXIN EFFECT 
See full prescribing information for complete boxed warning. 
The effects of BOTOX and all botulinum toxin products may 
spread from the area of injection to produce symptoms consistent 
with botulinum toxin effects. These symptoms have been reported 
hours to weeks after injection. Swallowing and breathing 
difficulties can be life threatening and there have been reports of 
death. The risk of symptoms is probably greatest in children 
treated for spasticity but symptoms can also occur in adults, 
particularly in those patients who have an underlying condition 
that would predispose them to these symptoms. (5.2) 
Page 39 of 92

 
 
 
 
FULL PRESCRIBING INFORMATION: CONTENTS* 
WARNING: DISTANT SPREAD OF TOXIN EFFECT 
1 INDICATIONS AND USAGE 
1.1    Bladder Dysfunction  
1.2    Chronic Migraine  
1.3  Spasticity  
1.4  Cervical Dystonia 
1.5  Primary Axillary Hyperhidrosis 
1.6  Blepharospasm and Strabismus  
2 DOSAGE AND ADMINISTRATION 
2.1 Instructions for Safe Use 
2.2    Preparation and Dilution Technique 
2.3    Bladder Dysfunction   
2.4    Chronic Migraine 
2.5  Spasticity 
2.6 Cervical Dystonia 
2.7 Primary Axillary Hyperhidrosis 
2.8 Blepharospasm 
2.9 Strabismus 
3 DOSAGE FORMS AND STRENGTHS  
4 CONTRAINDICATIONS 
4.1 Known Hypersensitivity to Botulinum Toxin 
4.2  Infection at the Injection Site(s) 
4.3    Urinary Tract Infection or Urinary Retention  
5 WARNINGS AND PRECAUTIONS 
5.1  Lack of Interchangeability between Botulinum Toxin Products 
5.2 Spread of Toxin Effect  
5.3  Serious Adverse Reactions with Unapproved Use  
5.4    Hypersensitivity Reactions 
5.5  Increased Risk of Clinically Significant Effects with Pre-Existing 
Neuromuscular Disorders 
5.6 Dysphagia and Breathing Difficulties  
5.7 Pulmonary Effects of BOTOX in Patients with Compromised 
Respiratory Status Treated for Spasticity or for Detrusor 
Overactivity associated with a Neurologic Condition 
5.8   Corneal Exposure and Ulceration in Patients Treated with BOTOX 
for Blepharospasm 
5.9 Retrobulbar Hemorrhages in Patients Treated with BOTOX for 
Strabismus 
5.10  Bronchitis and Upper Respiratory Tract Infections in Patients 
Treated for Spasticity 
5.11  Autonomic Dysreflexia in Patients Treated for Detrusor 
Overactivity associated with a Neurologic Condition  
 
5.12  Urinary Tract Infections in Patients with Overactive Bladder 
5.13  Urinary Retention in Patients Treated for Bladder Dysfunction  
5.14  Human Albumin and Transmission of Viral Diseases 
6 ADVERSE REACTIONS 
6.1    Clinical Trials Experience 
6.2    Immunogenicity  
6.3    Post-Marketing Experience 
7 DRUG INTERACTIONS 
7.1    Aminoglycosides and Other Agents Interfering with 
Neuromuscular Transmission 
7.2    Anticholinergic Drugs 
7.3    Other Botulinum Neurotoxin Products 
7.4    Muscle Relaxants 
8 USE IN SPECIFIC POPULATIONS 
8.1    Pregnancy 
8.2    Lactation 
8.4    Pediatric Use 
8.5    Geriatric Use 
10 OVERDOSAGE 
11 DESCRIPTION 
12 CLINICAL PHARMACOLOGY 
12.1  Mechanism of Action 
12.3  Pharmacokinetics 
13 NONCLINICAL TOXICOLOGY 
13.1  Carcinogenesis, Mutagenesis, Impairment of Fertility 
13.2  Animal Toxicology and/or Pharmacology 
14 CLINICAL STUDIES 
14.1  Overactive Bladder (OAB) 
14.2  Detrusor Overactivity associated with a Neurologic Condition 
14.3  Chronic Migraine 
14.4  Spasticity 
14.5 Cervical Dystonia 
14.6 Primary Axillary Hyperhidrosis 
14.7 Blepharospasm 
14.8 Strabismus 
16 HOW SUPPLIED/STORAGE AND HANDLING 
17 PATIENT COUNSELING INFORMATION 
 
* Sections or subsections omitted from the full prescribing information 
are not listed. 
 
 
 
 
Page 40 of 92

 
 
FULL PRESCRIBING INFORMATION 
 
 
 
 
 
 
 
 
 
 
 
1 
  INDICATIONS AND USAGE 
 
1.1 
  Bladder Dysfunction 
Overactive Bladder 
BOTOX (onabotulinumtoxinA) for injection is indicated for the treatment of overactive bladder with symptoms of urge urinary 
incontinence, urgency, and frequency, in adults who have an inadequate response to or are intolerant of an anticholinergic medication.   
 
Detrusor Overactivity associated with a Neurologic Condition 
BOTOX is indicated for the treatment of urinary incontinence due to detrusor overactivity associated with a neurologic condition (e.g., 
SCI, MS) in adults who have an inadequate response to or are intolerant of an anticholinergic medication. 
 
1.2    
Chronic Migraine 
BOTOX is indicated for the prophylaxis of headaches in adult patients with chronic migraine (≥15 days per month with headache 
lasting 4 hours a day or longer). 
 
Important Limitations 
Safety and effectiveness have not been established for the prophylaxis of episodic migraine (14 headache days or fewer per month) in 
seven placebo-controlled studies.   
 
1.3 
Spasticity 
Upper Limb Spasticity 
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). 
 
Lower Limb Spasticity 
BOTOX is indicated for the treatment of lower limb spasticity in adult patients to decrease the severity of increased muscle tone in 
ankle and toe flexors (gastrocnemius, soleus, tibialis posterior, flexor hallucis longus, and flexor digitorum longus). 
 
Important Limitations 
Safety and effectiveness of BOTOX have not been established for the treatment of other upper or lower limb muscle groups. Safety 
and effectiveness of BOTOX have not been established for the treatment of spasticity in pediatric patients under age 18 years. 
BOTOX has not been shown to improve upper extremity functional abilities, or range of motion at a joint affected by a fixed 
contracture. Treatment with BOTOX is not intended to substitute for usual standard of care rehabilitation regimens. 
 
1.4 
Cervical Dystonia 
BOTOX is indicated for the treatment of adults with cervical dystonia, to reduce the severity of abnormal head position and neck pain 
associated with cervical dystonia. 
1.5  
Primary Axillary Hyperhidrosis 
BOTOX is indicated for the treatment of severe primary axillary hyperhidrosis that is inadequately managed with topical agents. 
 
Important Limitations 
The safety and effectiveness of BOTOX for hyperhidrosis in other body areas have not been established. Weakness of hand muscles 
and blepharoptosis may occur in patients who receive BOTOX for palmar hyperhidrosis and facial hyperhidrosis, respectively. 
WARNING: DISTANT SPREAD OF TOXIN EFFECT 
Postmarketing reports indicate that the effects of BOTOX and all botulinum toxin products may spread from the area 
of injection to produce symptoms consistent with botulinum toxin effects. These 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 difficulties can be life 
threatening and there have been reports of death. 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, particularly 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, cases of spread of effect have been reported at doses 
comparable to those used to treat cervical dystonia and spasticity and at lower doses. [See Warnings and Precautions 
(5.2)] 
Page 41 of 92

 
 
Patients should be evaluated for potential causes of secondary hyperhidrosis (e.g., hyperthyroidism) to avoid symptomatic treatment of 
hyperhidrosis without the diagnosis and/or treatment of the underlying disease. 
 
Safety and effectiveness of BOTOX have not been established for the treatment of axillary hyperhidrosis in pediatric patients under 
age 18. 
 
1.6 
Blepharospasm and Strabismus 
BOTOX is indicated for the treatment of strabismus and blepharospasm associated with dystonia, including benign essential 
blepharospasm or VII nerve disorders in patients 12 years of age and above. 
 
2 
  DOSAGE AND ADMINISTRATION 
 
2.1  
Instructions for Safe Use 
The potency Units of BOTOX (onabotulinumtoxinA) for injection are specific to the preparation and assay method utilized. They are 
not interchangeable with other preparations of botulinum toxin products and, therefore, units of biological activity of BOTOX cannot 
be compared to nor converted into units of any other botulinum toxin products assessed with any other specific assay method [see 
Warnings and Precautions (5.1) and Description (11)].  
 
Indication specific dosage and administration recommendations should be followed. When initiating treatment, the lowest 
recommended dose should be used. In treating adult patients for one or more indications, the maximum cumulative dose should not 
exceed 400 Units, in a 3 month interval.  
 
The safe and effective use of BOTOX depends upon proper storage of the product, selection of the correct dose, and proper 
reconstitution and administration techniques. An understanding of standard electromyographic techniques is also required for 
treatment of strabismus, upper or lower limb spasticity, and may be useful for the treatment of cervical dystonia. Physicians 
administering BOTOX must understand the relevant neuromuscular and structural anatomy of the area involved and any alterations to 
the anatomy due to prior surgical procedures and disease, especially when injecting near the lungs. 
 
2.2 
Preparation and Dilution Technique 
Prior to injection, reconstitute each vacuum-dried vial of BOTOX with only sterile, preservative-free 0.9% Sodium Chloride Injection 
USP. Draw up the proper amount of diluent in the appropriate size syringe (see Table 1, or for specific instructions for detrusor 
overactivity associated with a neurologic condition see Section 2.3), and slowly inject the diluent into the vial. Discard the vial if a 
vacuum does not pull the diluent into the vial. Gently mix BOTOX with the saline by rotating the vial. Record the date and time of 
reconstitution on the space on the label. BOTOX should be administered within 24 hours after reconstitution. During this time period, 
reconstituted BOTOX should be stored in a refrigerator (2° to 8°C). 
 
Table 1: Dilution Instructions for BOTOX Vials (100 Units and 200 Units)**  
Diluent* Added 
to 100 Unit Vial 
Resulting Dose 
Units per 0.1 mL 
Diluent* Added 
to 200 Unit Vial 
Resulting Dose 
Units per 0.1 mL 
1 mL 
2 mL 
4 mL 
8 mL 
10 mL 
10 Units 
5 Units 
2.5 Units 
1.25 Units 
1 Unit 
1 mL 
2 mL 
4 mL 
8 mL 
10 mL 
20 Units 
10 Units 
5 Units 
2.5 Units 
2 Units 
*Preservative-free 0.9% Sodium Chloride Injection, USP Only 
**For Detrusor Overactivity associated with a Neurologic Condition Dilution see Section 2.3 
Note: These dilutions are calculated for an injection volume of 0.1 mL. A decrease or increase in the BOTOX dose is also possible by 
administering a smaller or larger injection volume - from 0.05 mL (50% decrease in dose) to 0.15 mL (50% increase in dose). 
An injection of BOTOX is prepared by drawing into an appropriately sized sterile syringe an amount of the properly reconstituted 
toxin slightly greater than the intended dose. Air bubbles in the syringe barrel are expelled and the syringe is attached to an 
appropriate injection needle. Patency of the needle should be confirmed. A new, sterile needle and syringe should be used to enter the 
vial on each occasion for removal of BOTOX. 
Reconstituted BOTOX should be clear, colorless, and free of particulate matter. Parenteral drug products should be inspected visually 
for particulate matter and discoloration prior to administration and whenever the solution and the container permit. 
 
Page 42 of 92

 
 
2.3  
Bladder Dysfunction 
General  
Patients must not have a urinary tract infection (UTI) at the time of treatment. Prophylactic antibiotics, except aminoglycosides, [see 
Drug Interactions (7.1)] should be administered 1-3 days pre-treatment, on the treatment day, and 1-3 days post-treatment to reduce 
the likelihood of procedure-related UTI.  
 
Patients should discontinue anti-platelet therapy at least 3 days before the injection procedure. Patients on anti-coagulant therapy need 
to be managed appropriately to decrease the risk of bleeding.   
 
Appropriate caution should be exercised when performing a cystoscopy. 
 
Overactive Bladder 
An intravesical instillation of diluted local anesthetic with or without sedation may be used prior to injection, per local site practice. If 
a local anesthetic instillation is performed, the bladder should be drained and irrigated with sterile saline before injection. 
 
The recommended dose is 100 Units of BOTOX, and is the maximum recommended dose. The recommended dilution is 100 Units/10 
mL with preservative-free 0.9% Sodium Chloride Injection, USP (see Table 1). Dispose of any unused saline.   
 
Reconstituted BOTOX (100 Units/10 mL) is injected into the detrusor muscle via a flexible or rigid cystoscope, avoiding the trigone. 
The bladder should be instilled with enough saline to achieve adequate visualization for the injections, but over-distension should be 
avoided.   
 
The injection needle should be filled (primed) with approximately 1 mL of reconstituted BOTOX prior to the start of injections 
(depending on the needle length) to remove any air.  
 
The needle should be inserted approximately 2 mm into the detrusor, and 20 injections of 0.5 mL each (total volume of 10 mL) should 
be spaced approximately 1 cm apart (see Figure 1). For the final injection, approximately 1 mL of sterile normal saline should be 
injected so that the remaining BOTOX in the needle is delivered to the bladder. After the injections are given, patients should 
demonstrate their ability to void prior to leaving the clinic. The patient should be observed for at least 30 minutes post-injection and 
until a spontaneous void has occurred. 
 
Patients should be considered for reinjection when the clinical effect of the previous injection has diminished (median time until 
patients qualified for the second treatment of BOTOX in double-blind, placebo-controlled clinical studies was 169 days [~24 weeks]), 
but no sooner than 12 weeks from the prior bladder injection.   
 
Figure 1: Injection Pattern for Intradetrusor Injections for Treatment of Overactive Bladder and Detrusor Overactivity 
associated with a Neurologic Condition 
 
 
Detrusor Overactivity associated with a Neurologic Condition 
An intravesical instillation of diluted local anesthetic with or without sedation, or general anesthesia may be used prior to injection, 
per local site practice. If a local anesthetic instillation is performed, the bladder should be drained and irrigated with sterile saline 
before injection. 
 
The recommended dose is 200 Units of BOTOX per treatment, and should not be exceeded.  
 
Page 43 of 92

 
 
200 Unit Vial of BOTOX 
x 
Reconstitute a 200 Unit vial of BOTOX with 6 mL of preservative-free 0.9% Sodium Chloride Injection, USP and mix the vial 
gently.  
x 
Draw 2 mL from the vial into each of three 10 mL syringes.  
x 
Complete the reconstitution by adding 8 mL of preservative-free 0.9% Sodium Chloride Injection, USP into each of the 10 mL 
syringes, and mix gently. This will result in three 10 mL syringes each containing 10 mL (~67 Units in each), for a total of 200 
Units of reconstituted BOTOX.  
x 
Use immediately after reconstitution in the syringe. Dispose of any unused saline. 
 
100 Unit Vial of BOTOX 
x 
Reconstitute two 100 Unit vials of BOTOX, each with 6 mL of preservative-free 0.9% Sodium Chloride Injection, USP and mix 
the vials gently. 
x 
Draw 4 mL from each vial into each of two 10 mL syringes. Draw the remaining 2 mL from each vial into a third 10 mL syringe 
for a total of 4 mL in each syringe.  
x 
Complete the reconstitution by adding 6 mL of preservative-free 0.9% Sodium Chloride Injection, USP into each of the 10 mL 
syringes, and mix gently. This will result in three 10 mL syringes each containing 10 mL (~67 Units in each), for a total of 200 
Units of reconstituted BOTOX.  
x 
Use immediately after reconstitution in the syringe. Dispose of any unused saline. 
 
Reconstituted BOTOX (200 Units/30 mL) is injected into the detrusor muscle via a flexible or rigid cystoscope, avoiding the trigone. 
The bladder should be instilled with enough saline to achieve adequate visualization for the injections, but over-distension should be 
avoided.  
 
The injection needle should be filled (primed) with approximately 1 mL of reconstituted BOTOX prior to the start of injections 
(depending on the needle length) to remove any air.  
 
The needle should be inserted approximately 2 mm into the detrusor, and 30 injections of 1 mL (~6.7 Units) each (total volume of 
30 mL) should be spaced approximately 1 cm apart (see Figure 1). For the final injection, approximately 1 mL of sterile normal saline 
should be injected so that the remaining BOTOX in the needle is delivered to the bladder. After the injections are given, the saline 
used for bladder wall visualization should be drained. The patient should be observed for at least 30 minutes post-injection. 
 
Patients should be considered for re-injection when the clinical effect of the previous injection diminishes (median time to 
qualification for re-treatment in the double-blind, placebo-controlled clinical studies was 295-337 days [42-48 weeks] for BOTOX 
200 Units), but no sooner than 12 weeks from the prior bladder injection.  
 
2.4           Chronic Migraine 
The recommended dilution is 200 Units/4 mL or 100 Units/2 mL, with a final concentration of 5 Units per 0.1 mL (see Table 1). The 
recommended dose for treating chronic migraine is 155 Units administered intramuscularly using a sterile 30-gauge, 0.5 inch needle as 
0.1 mL (5 Units) injections per each site. Injections should be divided across 7 specific head/neck muscle areas as specified in the 
diagrams and Table 2 below. A one inch needle may be needed in the neck region for patients with thick neck muscles. With the 
exception of the procerus muscle, which should be injected at one site (midline), all muscles should be injected bilaterally with half 
the number of injection sites administered to the left, and half to the right side of the head and neck. The recommended re-treatment 
schedule is every 12 weeks. 
 
Page 44 of 92

 
 
Diagrams 1-4: Recommended Injection Sites (A through G) for Chronic Migraine 
 
1 
                                        2                                                  3 
 
                           4 
 
 
 
Table 2: BOTOX Dosing by Muscle for Chronic Migraine 
 
 
 
 
 
 
 
 
 
 
 
a Each IM injection site = 0.1 mL = 5 Units BOTOX 
b Dose distributed bilaterally 
 
2.5 
Spasticity 
Dosing in initial and sequential treatment sessions should be tailored to the individual based on the size, number and location of 
muscles involved, severity of spasticity, the presence of local muscle weakness, the patient’s response to previous treatment, or 
adverse event history with BOTOX.  
 
The recommended dilution is 200 Units/4 mL or 100 Units/2 mL with preservative-free 0.9% Sodium Chloride Injection, USP (see 
Table 1). The lowest recommended starting dose should be used, and no more than 50 Units per site should generally be administered. 
An appropriately sized needle (e.g., 25-30 gauge) may be used for superficial muscles, and a longer 22 gauge needle may be used for 
deeper musculature. Localization of the involved muscles with techniques such as needle electromyographic guidance or nerve 
stimulation is recommended.   
 
Repeat BOTOX treatment may be administered when the effect of a previous injection has diminished, but generally no sooner than 
12 weeks after the previous injection. The degree and pattern of muscle spasticity at the time of re-injection may necessitate 
alterations in the dose of BOTOX and muscles to be injected. 
 
Upper Limb Spasticity 
In clinical trials, doses ranging from 75 Units to 400 Units were divided among selected muscles (see Table 3 and Figure 2) at a given 
treatment session. 
 
Head/Neck Area 
Recommended Dose (Number of Sitesa) 
Frontalisb 
20 Units divided in 4 sites 
Corrugatorb 
10 Units divided in 2 sites 
Procerus 
5 Units in 1 site 
Occipitalisb 
30 Units divided in 6 sites 
Temporalisb 
40 Units divided in 8 sites 
Trapeziusb 
30 Units divided in 6 sites 
Cervical Paraspinal  
Muscle Groupb 
20 Units divided in 4 sites 
Total Dose: 
155 Units divided in 31 sites 
Page 45 of 92

 
 
Table 3: BOTOX Dosing by Muscle for Upper Limb Spasticity 
 
Muscle 
Recommended Dose 
Total Dosage (Number of Sites) 
Biceps Brachii 
100 Units-200 Units divided in 4 sites 
Flexor Carpi Radialis 
12.5 Units-50 Units in 1 site 
Flexor Carpi Ulnaris 
12.5 Units-50 Units in 1 site 
Flexor Digitorum Profundus 
30 Units-50 Units in 1 site 
Flexor Digitorum Sublimis 
30 Units-50 Units in 1 site 
Adductor Pollicis 
20 Units in 1 site 
Flexor Pollicis Longus 
20 Units in 1 site 
 
Figure 2: Injection Sites for Upper Limb Spasticity 
 
 
Lower Limb Spasticity 
The recommended dose for treating lower limb spasticity is 300 Units to 400 Units divided among 5 muscles (gastrocnemius, soleus, 
tibialis posterior, flexor hallucis longus and flexor digitorum longus) (see Table 4 and Figure 3). 
 
Table 4: BOTOX Dosing by Muscle for Lower Limb Spasticity 
Muscle 
Recommended Dose 
Total Dosage (Number of Sites) 
Gastrocnemius medial head 
75 Units divided in 3 sites 
Gastrocnemius lateral head 
75 Units divided in 3 sites 
Soleus 
75 Units divided in 3 sites 
Tibialis Posterior 
75 Units divided in 3 sites 
Flexor hallucis longus 
50 Units divided in 2 sites 
Flexor digitorum longus 
50 Units divided in 2 sites 
 
Page 46 of 92

 
 
Figure 3: Injection Sites for Lower Limb Spasticity 
 
2.6 
Cervical Dystonia 
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 
(14.5)].  
 
Dosing in initial and sequential treatment sessions should be tailored to the individual patient based on the patient’s head and neck 
position, localization of pain, muscle hypertrophy, patient response, and adverse event history. The initial dose for a patient without 
prior use of BOTOX should be at a lower dose, with subsequent dosing adjusted based on individual response. Limiting the total dose 
injected into the sternocleidomastoid muscle to 100 Units or less may decrease the occurrence of dysphagia [see Warnings and 
Precautions (5.2, 5.5, 5.6)]. 
 
The recommended dilution is 200 Units/2 mL, 200 Units/4 mL, 100 Units/1 mL, or 100 Units/2 mL with preservative-free 0.9% 
Sodium Chloride Injection, USP, depending on volume and number of injection sites desired to achieve treatment objectives (see 
Table 1). In general, no more than 50 Units per site should be administered using a sterile needle (e.g., 25-30 gauge) of an appropriate 
length. Localization of the involved muscles with electromyographic guidance may be useful. 
 
Clinical improvement generally begins within the first two weeks after injection with maximum clinical benefit at approximately six 
weeks post-injection. In the double-blind, placebo-controlled study most subjects were observed to have returned to pre-treatment 
status by 3 months post-treatment. 
 
2.7 
Primary Axillary Hyperhidrosis 
The recommended dose is 50 Units per axilla. The hyperhidrotic area to be injected should be defined using standard staining 
techniques, e.g., Minor’s Iodine-Starch Test. The recommended dilution is 100 Units/4 mL with 0.9% preservative-free sterile saline 
(see Table 1). Using a sterile 30 gauge needle, 50 Units of BOTOX (2 mL) is injected intradermally in 0.1 to 0.2 mL aliquots to each 
axilla evenly distributed in multiple sites (10-15) approximately 1-2 cm apart. 
 
Repeat injections for hyperhidrosis should be administered when the clinical effect of a previous injection diminishes. 
 
Instructions for the Minor’s Iodine-Starch Test Procedure: 
Patients should shave underarms and abstain from use of over-the-counter deodorants or antiperspirants for 24 hours prior to the test. 
Patient should be resting comfortably without exercise, hot drinks for approximately 30 minutes prior to the test. Dry the underarm 
area and then immediately paint it with iodine solution. Allow the area to dry, then lightly sprinkle the area with starch powder. Gently 
blow off any excess starch powder. The hyperhidrotic area will develop a deep blue-black color over approximately 10 minutes.  
 
Each injection site has a ring of effect of up to approximately 2 cm in diameter. To minimize the area of no effect, the injection sites 
should be evenly spaced as shown in Figure 4. 
 
Figure 4: Injection Pattern for Primary Axillary Hyperhidrosis 
 
 
 
Page 47 of 92

 
 
 
 
Each dose is injected to a depth of approximately 2 mm and at a 45° angle to the skin surface, with the bevel side up to minimize 
leakage and to ensure the injections remain intradermal. If injection sites are marked in ink, do not inject BOTOX directly through the 
ink mark to avoid a permanent tattoo effect. 
 
2.8 
Blepharospasm 
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 reducing 
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 recommended dilution to achieve 1.25 Units is 100 Units/8 mL; for 2.5 Units it is 100 Units/4 mL (see Table 1). 
 
In general, the initial effect of the injections is seen within three days and reaches a peak at one to two weeks post-treatment. Each 
treatment lasts approximately three months, following which the procedure can be repeated. At repeat treatment sessions, the dose 
may be increased up to two-fold if the response from the initial treatment is considered insufficient, usually defined as an effect that 
does not last longer than two months. However, there appears to be little benefit obtainable from injecting more than 5 Units per site. 
Some tolerance may be found when BOTOX is used in treating blepharospasm if treatments are given any more frequently than every 
three months, and is rare to have the effect be permanent. 
 
The cumulative dose of BOTOX treatment for blepharospasm in a 30-day period should not exceed 200 Units. 
 
2.9 
Strabismus 
BOTOX is intended for injection into extraocular muscles utilizing the electrical activity recorded from the tip of the injection needle 
as a guide to placement within the target muscle. Injection without surgical exposure or electromyographic guidance should not be 
attempted. Physicians should be familiar with electromyographic technique. 
 
To prepare the eye for BOTOX injection, it is recommended that several drops of a local anesthetic and an ocular decongestant be 
given several minutes prior to injection. 
 
The volume of BOTOX injected for treatment of strabismus should be between 0.05-0.15 mL per muscle. 
 
The initial listed doses of the reconstituted BOTOX [see Dosage and Administration (2.2)] typically create paralysis of the injected 
muscles beginning one to two days after injection and increasing in intensity during the first week. The paralysis lasts for 2-6 weeks 
and gradually resolves over a similar time period. Overcorrections lasting over six months have been rare. About one half of patients 
will require subsequent doses because of inadequate paralytic response of the muscle to the initial dose, or because of mechanical 
factors such as large deviations or restrictions, or because of the lack of binocular motor fusion to stabilize the alignment. 
 
Initial Doses in Units  
Use the lower listed doses for treatment of small deviations. Use the larger doses only for large deviations. 
x 
For vertical muscles, and for horizontal strabismus of less than 20 prism diopters: 1.25 Units-2.5 Units in any one muscle. 
x 
For horizontal strabismus of 20 prism diopters to 50 prism diopters: 2.5 Units-5 Units in any one muscle. 
x 
For persistent VI nerve palsy of one month or longer duration: 1.25 Units-2.5 Units in the medial rectus muscle. 
 
Subsequent Doses for Residual or Recurrent Strabismus 
x 
It is recommended that patients be re-examined 7-14 days after each injection to assess the effect of that dose. 
x 
Patients experiencing adequate paralysis of the target muscle that require subsequent injections should receive a 
dose  
       comparable to the initial dose. 
x 
Subsequent doses for patients experiencing incomplete paralysis of the target muscle may be increased up to two-
fold   
       compared to the previously administered dose. 
x 
Subsequent injections should not be administered until the effects of the previous dose have dissipated as evidenced 
by   
       substantial function in the injected and adjacent muscles. 
x 
The maximum recommended dose as a single injection for any one muscle is 25 Units. 
 
The recommended dilution to achieve 1.25 Units is 100 Units/8 mL; for 2.5 Units it is 100 Units/4 mL (see Table 1). 
Page 48 of 92

 
 
 
3              DOSAGE FORMS AND STRENGTHS 
Single-use, sterile 100 Units or 200 Units vacuum-dried powder for reconstitution only with sterile, preservative-free 0.9% Sodium 
Chloride Injection USP prior to injection. 
 
4              CONTRAINDICATIONS 
 
4.1  
Known Hypersensitivity to Botulinum Toxin 
BOTOX is contraindicated in patients who are hypersensitive to any botulinum toxin preparation or to any of the components in the 
formulation [see Warnings and Precautions (5.4)]. 
 
4.2  
Infection at the Injection Site(s) 
BOTOX is contraindicated in the presence of infection at the proposed injection site(s). 
 
4.3 
Urinary Tract Infection or Urinary Retention  
Intradetrusor injection of BOTOX is contraindicated in patients with overactive bladder or detrusor overactivity associated with a 
neurologic condition who have a urinary tract infection. Intradetrusor injection of BOTOX is also contraindicated in patients with 
urinary retention and in patients with post-void residual (PVR) urine volume >200 mL, who are not routinely performing clean 
intermittent self-catheterization (CIC). 
 
5 
WARNINGS AND PRECAUTIONS 
 
5.1 
Lack of Interchangeability between Botulinum Toxin Products 
The potency Units of BOTOX are specific to the preparation and assay method utilized. They are not interchangeable with other 
preparations of botulinum toxin products and, therefore, units of biological activity of BOTOX cannot be compared to nor converted 
into units of any other botulinum toxin products assessed with any other specific assay method [see Description (11)].  
 
5.2           Spread of Toxin Effect 
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 difficulties 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 particularly 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 doses 
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. 
 
No definitive serious adverse event reports of distant spread of toxin effect associated with BOTOX for blepharospasm at the 
recommended dose (30 Units and below), severe primary axillary hyperhidrosis at the recommended dose (100 Units), strabismus, or 
for chronic migraine at the labeled doses have been reported. 
  
5.3 
Serious Adverse Reactions with Unapproved Use 
Serious adverse reactions, including excessive weakness, dysphagia, and aspiration pneumonia, with some adverse reactions 
associated with fatal outcomes, have been reported in patients who received BOTOX injections for unapproved uses. In these cases, 
the adverse reactions were not necessarily related to distant spread of toxin, but may have resulted from the administration of BOTOX 
to the site of injection and/or adjacent structures. In several of the cases, patients had pre-existing dysphagia or other significant 
disabilities. There is insufficient information to identify factors associated with an increased risk for adverse reactions associated with 
the unapproved uses of BOTOX. The safety and effectiveness of BOTOX for unapproved uses have not been established. 
 
5.4 
Hypersensitivity Reactions 
Serious and/or immediate hypersensitivity reactions have been reported. These reactions include anaphylaxis, serum sickness, 
urticaria, soft tissue edema, and dyspnea. If such a reaction occurs, further injection of BOTOX should be discontinued and 
appropriate medical therapy immediately instituted. One fatal case of anaphylaxis has been reported in which lidocaine was used as 
the diluent, and consequently the causal agent cannot be reliably determined. 
 
5.5 
Increased Risk of Clinically Significant Effects with Pre-Existing Neuromuscular Disorders 
Individuals with peripheral motor neuropathic diseases, amyotrophic lateral sclerosis or neuromuscular junction disorders (e.g., 
myasthenia gravis or Lambert-Eaton syndrome) should be monitored when given botulinum toxin. Patients with known or 
unrecognized neuromuscular disorders  or neuromuscular junction disorders may be at increased risk of clinically significant effects 
Page 49 of 92

 
 
including generalized muscle weakness, diplopia, ptosis, dysphonia, dysarthria, severe dysphagia and respiratory compromise from 
therapeutic doses of BOTOX [see Warnings and Precautions (5.2, 5.6)].  
 
5.6 
Dysphagia and Breathing Difficulties  
Treatment with BOTOX and other botulinum toxin products can result in swallowing or breathing difficulties. Patients with pre-
existing swallowing or breathing difficulties may be more susceptible to these complications. In most cases, this is a consequence of 
weakening of muscles in the area of injection that are involved in breathing or oropharyngeal muscles that control swallowing or 
breathing [see Warnings and Precautions (5.2)].  
 
Deaths as a complication of severe dysphagia have been reported after treatment with botulinum toxin. Dysphagia may persist for 
several months, and require use of a feeding tube to maintain adequate nutrition and hydration. Aspiration may result from severe 
dysphagia and is a particular risk when treating patients in whom swallowing or respiratory function is already compromised. 
 
Treatment with botulinum toxins may weaken neck muscles that serve as accessory muscles of ventilation. This may result in a critical 
loss of breathing capacity in patients with respiratory disorders who may have become dependent upon these accessory muscles. There 
have been postmarketing reports of serious breathing difficulties, including respiratory failure. 
 
Patients with smaller neck muscle mass and patients who require bilateral injections into the sternocleidomastoid muscle for the 
treatment of cervical dystonia have been reported to be at greater risk for dysphagia. Limiting the dose injected into the 
sternocleidomastoid muscle may reduce the occurrence of dysphagia. Injections into the levator scapulae may be associated with an 
increased risk of upper respiratory infection and dysphagia. 
 
Patients treated with botulinum toxin may require immediate medical attention should they develop problems with swallowing, speech 
or respiratory disorders. These reactions can occur within hours to weeks after injection with botulinum toxin [see Warnings and 
Precautions (5.2)]. 
 
5.7 
Pulmonary Effects of BOTOX in Patients with Compromised Respiratory Status Treated for Spasticity or for 
Detrusor Overactivity associated with a Neurologic Condition 
Patients with compromised respiratory status treated with BOTOX for spasticity should be monitored closely. In a double-blind, 
placebo-controlled, parallel group study in patients treated for upper limb spasticity with stable reduced pulmonary function (defined 
as FEV1 40-80% of predicted value and FEV1/FVC ≤ 0.75), the event rate in change of Forced Vital Capacity (FVC) ≥15% or ≥20% 
was generally greater in patients treated with BOTOX than in patients treated with placebo (see Table 5). 
 
Table 5: Event Rate Per Patient Treatment Cycle Among Patients with Reduced Lung Function Who Experienced at Least a 
15% or 20% Decrease in FVC From Baseline at Week 1, 6, 12 Post-injection with Up to Two Treatment Cycles with BOTOX 
or Placebo 
 
BOTOX 
360 Units 
BOTOX 
240 Units 
Placebo 
>15% 
>20% 
>15% 
>20% 
>15% 
>20% 
Week 1 
4% 
0% 
3% 
0% 
7% 
3% 
Week 6 
7% 
4% 
4% 
2% 
2% 
2% 
Week 12 
10% 
5% 
2% 
1% 
4% 
1% 
Differences from placebo were not statistically significant 
 
In spasticity patients with reduced lung function, upper respiratory tract infections were also reported more frequently as adverse 
reactions in patients treated with BOTOX than in patients treated with placebo [see Warnings and Precautions (5.10)]. 
 
In a double-blind, placebo-controlled, parallel group study in adult patients with detrusor overactivity associated with a neurologic 
condition and restrictive lung disease of neuromuscular etiology [defined as FVC 50-80% of predicted value in patients with spinal 
cord injury between C5 and C8, or MS] the event rate in change of Forced Vital Capacity ≥15% or ≥20% was generally greater in 
patients treated with BOTOX than in patients treated with placebo (see Table 6). 
 
Page 50 of 92

 
 
Table 6: Number and Percent of Patients Experiencing at Least a 15% or 20% Decrease in FVC From Baseline at Week 2, 6, 
12 Post-injection with BOTOX or Placebo 
 
BOTOX  
200 Units 
Placebo 
>15% 
>20% 
>15% 
>20% 
Week 2 
0/15 (0%) 
0/15 (0%) 
1/11 (9%) 
0/11 (0%) 
Week 6 
2/13 (15%) 
1/13 (8%) 
0/12 (0%) 
0/12 (0%) 
Week 12 
0/12(0%) 
0/12 (0%) 
0/7 (0%) 
0/7 (0%) 
 
5.8 
Corneal Exposure and Ulceration in Patients Treated with BOTOX for Blepharospasm 
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 means. 
 
5.9 
Retrobulbar Hemorrhages in Patients Treated with BOTOX for Strabismus 
During the administration of BOTOX for the treatment of strabismus, retrobulbar hemorrhages sufficient to compromise retinal 
circulation have occurred. It is recommended that appropriate instruments to decompress the orbit be accessible.  
 
5.10 
Bronchitis and Upper Respiratory Tract Infections in Patients Treated for Spasticity 
Bronchitis was reported more frequently as an adverse reaction in patients treated for upper limb spasticity with BOTOX (3% at 251 
Units-360 Units total dose), compared to placebo (1%). In patients with reduced lung function treated for upper limb spasticity, upper 
respiratory tract infections were also reported more frequently as adverse reactions in patients treated with BOTOX (11% at 360 Units 
total dose; 8% at 240 Units total dose) compared to placebo (6%). In adult patients treated for lower limb spasticity, upper respiratory 
tract infections were reported more frequently as an adverse event in patients treated with BOTOX (2% at 300 Units to 400 Units total 
dose) compared to placebo (1%). 
 
5.11 
Autonomic Dysreflexia in Patients Treated for Detrusor Overactivity associated with a Neurologic Condition  
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). 
 
5.12 
Urinary Tract Infections in Patients with Overactive Bladder   
BOTOX increases the incidence of urinary tract infection [see Adverse Reactions (6.1)]. 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 treatment should only be 
considered when the benefit is likely to outweigh the potential risk.  
 
5.13 
Urinary Retention in Patients Treated for Bladder Dysfunction  
Due to the risk of urinary retention, treat only patients who are willing and able to initiate catheterization post-treatment, if required, 
for urinary retention.  
 
In patients who are not catheterizing, post-void residual (PVR) urine volume should be assessed within 2 weeks post-treatment and 
periodically as medically appropriate up to 12 weeks, particularly in patients with multiple sclerosis or diabetes mellitus. Depending 
on patient symptoms, institute catheterization if PVR urine volume exceeds 200 mL and continue until PVR falls below 200 mL. 
Instruct patients to contact their physician if they experience difficulty in voiding as catheterization may be required. 
 
The incidence and duration of urinary retention is described below for patients with overactive bladder and detrusor overactivity 
associated with a neurologic condition who received BOTOX or placebo injections.  
 
Overactive Bladder 
In double-blind, placebo-controlled trials in patients with OAB, the proportion of subjects who initiated clean intermittent 
catheterization (CIC) for urinary retention following treatment with BOTOX or placebo is shown in Table 7. The duration of post-
injection catheterization for those who developed urinary retention is also shown.  
 
 
 
 
 
Page 51 of 92

 
 
Table 7: Proportion of Patients Catheterizing for Urinary Retention and Duration of Catheterization Following an Injection in 
Double-blind, Placebo-controlled Clinical Trials in OAB 
 
 
 
 
 
 
 
 
 
 
 
Patients with diabetes mellitus treated with BOTOX were more likely to develop urinary retention than those without diabetes, as 
shown in Table 8. 
 
Table 8. Proportion of Patients Experiencing Urinary Retention Following an Injection in Double-blind, Placebo-controlled 
Clinical Trials in OAB According to History of Diabetes Mellitus 
 
Patients with Diabetes 
Patients without Diabetes 
BOTOX 100 Units 
(N=81) 
Placebo 
(N=69) 
BOTOX 100 Units 
(N=526) 
Placebo 
(N=516) 
Urinary retention 
12.3% (n=10) 
0 
6.3% (n=33) 
0.6% (n=3) 
 
Detrusor Overactivity associated with a Neurologic Condition 
In two double-blind, placebo-controlled trials in patients with detrusor overactivity associated with a neurologic condition (NDO-1 
and NDO-2), the proportion of subjects who were not using clean intermittent catheterization (CIC) prior to injection and who 
subsequently required catheterization for urinary retention following treatment with BOTOX 200 Units or placebo is shown in Table 
9. The duration of post-injection catheterization for those who developed urinary retention is also shown.  
 
Table 9: Proportion of Patients Not Using CIC at Baseline and then Catheterizing for Urinary Retention and Duration of 
Catheterization Following an Injection in Double-blind, Placebo-controlled Clinical Trials 
 
 
 
 
 
 
 
 
Among patients not using CIC at baseline, those with Multiple Sclerosis (MS) were more likely to require CIC post-injection than 
those with Spinal Cord Injury (SCI) (see Table 10).  
Table 10: Proportion of Patients by Etiology (MS and SCI) Not Using CIC at Baseline and then Catheterizing for Urinary 
Retention Following an Injection in Double-blind, Placebo-controlled Clinical Trials  
Timepoint 
MS 
SCI 
BOTOX 200 Units 
(N=86) 
Placebo 
(N=88) 
BOTOX 200 Units 
(N=22) 
Placebo 
(N=16) 
At any time during 
complete treatment cycle 
31% (n=27) 
5% (n=4) 
27% (n=6) 
19% (n=3) 
 
A placebo-controlled, double-blind post-approval 52 week study with BOTOX 100 Units (Study NDO-3) was conducted in non-
catheterizing MS patients with urinary incontinence due to detrusor overactivity associated with a neurologic condition. 
Catheterization for urinary retention was initiated in 15.2% (10/66) of patients following treatment with BOTOX 100 Units versus 
2.6% (2/78) on placebo at any time during the complete treatment cycle.  The median duration of post-injection catheterization for 
those who developed urinary retention was 64 days for BOTOX 100 Units and 2 days for placebo.  
 
 
 Timepoint 
BOTOX 100 Units 
(N=552) 
Placebo 
(N=542) 
Proportion of Patients Catheterizing for Urinary Retention 
At any time during complete treatment 
cycle  
6.5% (n=36) 
0.4% (n=2) 
Duration of Catheterization for Urinary Retention (Days) 
Median  
63 
11 
Min, Max 
1, 214 
3, 18 
Timepoint 
BOTOX 200 Units 
(N=108) 
Placebo 
(N=104) 
Proportion of Patients Catheterizing for Urinary Retention 
At any time during complete treatment cycle 
30.6% (n=33) 
6.7% (n=7) 
Duration of Catheterization for Urinary Retention (Days) 
Median 
289 
358 
Min, Max 
1, 530 
2, 379 
Page 52 of 92

 
 
5.14 
Human Albumin and Transmission of Viral Diseases 
This product contains albumin, a derivative of human blood. Based on effective donor screening and product manufacturing processes, 
it carries an extremely remote risk for transmission of viral diseases and variant Creutzfeldt-Jakob disease (vCJD). There is a 
theoretical risk for transmission of Creutzfeldt-Jakob disease (CJD), but if that risk actually exists, the risk of transmission would also 
be considered extremely remote. No cases of transmission of viral diseases, CJD or vCJD have ever been identified for licensed 
albumin or albumin contained in other licensed products. 
 
6 
ADVERSE REACTIONS 
The following adverse reactions to BOTOX (onabotulinumtoxinA) for injection are discussed in greater detail in other sections of the 
labeling: 
x 
Spread of Toxin Effects [see Warnings and Precautions (5.2)] 
x 
Serious Adverse Reactions with Unapproved Use [see Warnings and Precautions (5.3)] 
x 
Hypersensitivity Reactions [see Contraindications (4.1) and Warnings and Precautions (5.4)] 
x 
Increased Risk of Clinically Significant Effects with Pre-Existing Neuromuscular Disorders [see Warnings and Precautions 
(5.5)] 
x 
Dysphagia and Breathing Difficulties [see Warnings and Precautions (5.6)] 
x 
Pulmonary Effects of BOTOX in Patients with Compromised Respiratory Status Treated for Spasticity or for Detrusor 
Overactivity associated with a Neurologic Condition [see Warnings and Precautions (5.7)] 
x 
Corneal Exposure and Ulceration in Patients Treated with BOTOX for Blepharospasm [see Warnings and Precautions (5.8)] 
x 
Retrobulbar Hemorrhages in Patients Treated with BOTOX for Strabismus [see Warnings and Precautions (5.9)] 
x 
Bronchitis and Upper Respiratory Tract Infections in Patients Treated for Spasticity [see Warnings and Precautions (5.10)] 
x 
Autonomic Dysreflexia in Patients Treated for Detrusor Overactivity associated with a Neurologic Condition [see Warnings 
and Precautions (5.11)] 
x 
Urinary Tract Infections in Patients with Overactive Bladder [see Warnings and Precautions (5.12)] 
x 
Urinary Retention in Patients Treated for Bladder Dysfunction [see Warnings and Precautions (5.13)] 
 
6.1 
Clinical Trials Experience  
Because clinical trials are conducted under widely varying conditions, the adverse reaction rates observed in the clinical trials of a 
drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical 
practice. 
 
BOTOX and BOTOX Cosmetic contain the same active ingredient in the same formulation, but with different labeled Indications and 
Usage. Therefore, adverse reactions observed with the use of BOTOX Cosmetic also have the potential to be observed with the use of 
BOTOX. 
 
In general, adverse reactions occur within the first week following injection of BOTOX and, while generally transient, may have a 
duration of several months or longer. Localized pain, infection, inflammation, tenderness, swelling, erythema, and/or 
bleeding/bruising may be associated with the injection. Symptoms associated with flu-like symptoms (e.g., nausea, fever, myalgia) 
have been reported after treatment. Needle-related pain and/or anxiety may result in vasovagal responses (including syncope, 
hypotension), which may require appropriate medical therapy. 
 
 
Local weakness of the injected muscle(s) represents the expected pharmacological action of botulinum toxin. However, weakness of 
nearby muscles may also occur due to spread of toxin [see Warnings and Precautions (5.2)]. 
 
Overactive Bladder 
Table 11 presents the most frequently reported adverse reactions in double-blind, placebo-controlled clinical trials for overactive 
bladder occurring within 12 weeks of the first BOTOX treatment.  
 
Table 11: Adverse Reactions Reported by ≥2% of BOTOX treated Patients and More Often than in Placebo-treated Patients 
Within the First 12 Weeks after Intradetrusor Injection, in Double-blind, Placebo-controlled Clinical Trials in Patients with 
OAB 
 
 
Adverse Reactions 
BOTOX 
100 Units 
(N=552) 
Placebo 
(N=542) 
Urinary tract infection 
Dysuria  
Urinary retention 
Bacteriuria 
Residual urine volume* 
99 (18%) 
50 (9%) 
31 (6%) 
24 (4%) 
17 (3%) 
30 (6%) 
36 (7%) 
2 (0%) 
11 (2%) 
1 (0%) 
Page 53 of 92

 
 
*Elevated PVR not requiring catheterization. Catheterization was required for PVR >350 mL regardless of symptoms, and for PVR 
>200 mL to <350 mL with symptoms (e.g., voiding difficulty).  
 
A higher incidence of urinary tract infection was observed in patients with diabetes mellitus treated with BOTOX 100 Units and 
placebo than in patients without diabetes, as shown in Table 12.  
 
Table 12: Proportion of Patients Experiencing Urinary Tract Infection following an Injection in Double-blind,  
Placebo-controlled Clinical Trials in OAB according to history of Diabetes Mellitus 
 
Patients with Diabetes 
Patients without Diabetes 
BOTOX 100 Units 
(N=81) 
Placebo 
(N=69) 
BOTOX 100 Units 
(N=526) 
Placebo 
(N=516) 
Urinary tract infection  
(UTI) 
25 (31%) 
8 (12%) 
135 (26%) 
51 (10%) 
 
The incidence of UTI increased in patients who experienced a maximum post-void residual (PVR) urine volume >200 mL following 
BOTOX injection compared to those with a maximum PVR <200 mL following BOTOX injection, 44% versus 23%, respectively. 
No change was observed in the overall safety profile with repeat dosing during an open-label, uncontrolled extension trial. 
 
Detrusor Overactivity associated with a Neurologic Condition 
Table 13 presents the most frequently reported adverse reactions in the two Phase 3 double-blind, placebo-controlled studies (NDO-1 
and NDO-2) within 12 weeks of injection for patients with detrusor overactivity associated with a neurologic condition treated with 
BOTOX 200 Units.  
 
Table 13: Adverse Reactions Reported by >2% of BOTOX treated Patients and More Frequent than in Placebo-treated 
Patients Within the First 12 Weeks after Intradetrusor Injection in Double-blind, Placebo-controlled Clinical Trials (NDO-1 
and NDO-2) 
 
 
Adverse Reactions   
BOTOX 200 Units 
(N=262) 
Placebo 
(N=272) 
Urinary tract infection 
Urinary retention   
Hematuria 
64 (24%) 
45 (17%) 
10 (4%) 
47 (17%) 
8 (3%) 
8 (3%) 
 
The following adverse reactions with BOTOX 200 Units were reported at any time following initial injection and prior to re-injection 
or study exit (median duration of exposure was 44 weeks): urinary tract infections (49%), urinary retention (17%), constipation (4%), 
muscular weakness (4%), dysuria (4%), fall (3%), gait disturbance (3%), and muscle spasm (2%). 
 
In the Multiple Sclerosis (MS) patients enrolled in the double-blind, placebo-controlled trials, the MS exacerbation annualized rate 
(i.e., number of MS exacerbation events per patient-year) was 0.23 for BOTOX and 0.20 for placebo. 
 
No change was observed in the overall safety profile with repeat dosing.  
 
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.  
 
Table 14: Adverse Reactions Reported by >2% of BOTOX treated Patients and More Frequent than in Placebo-treated Patients 
Within the First 12 Weeks after Intradetrusor Injection (NDO-3) 
 
 
Adverse Reactions 
BOTOX 
100 Unit 
(N=66) 
Placebo 
(N=78) 
     Urinary tract infection 
     Bacteriuria 
     Urinary retention 
     Dysuria 
     Residual urine volume* 
17 (26%) 
6 (9%) 
10 (15%) 
3 (5%) 
11 (17%) 
5 (6%) 
4 (5%) 
1 (1%) 
1 (1%) 
1 (1%) 
* Elevated PVR  not requiring catheterization. Catheterization was required for PVR >350 mL regardless of symptoms, and for PVR 
>200 mL to <350 mL with symptoms (e.g., voiding difficulty). 
Page 54 of 92

 
 
 
The following adverse events with BOTOX 100 Units were reported at any time following initial injection and prior to re-injection or 
study exit (median duration of exposure was 51 weeks): urinary tract infections (39%), bacteriuria (18%), urinary retention (17%), 
residual urine volume* (17%), dysuria (9%), and hematuria (5%). 
 
No difference in the MS exacerbation annualized rate (i.e., number of MS exacerbating events per patient-year) was observed (BOTOX 
=0, placebo =0.07). 
 
Chronic Migraine 
In double-blind, placebo-controlled chronic migraine efficacy trials (Study 1 and Study 2), the discontinuation rate was 12% in the 
BOTOX treated group and 10% in the placebo-treated group. Discontinuations due to an adverse event were 4% in the BOTOX group 
and 1% in the placebo group. The most frequent adverse events leading to discontinuation in the BOTOX group were neck pain, 
headache, worsening migraine, muscular weakness and eyelid ptosis. 
 
The most frequently reported adverse reactions following injection of BOTOX for chronic migraine appear in Table 15. 
 
Table 15: Adverse Reactions Reported by >2% of BOTOX treated Patients and More Frequent than in Placebo-treated 
Patients in Two Chronic Migraine Double-blind, Placebo-controlled Clinical Trials 
 
 
Adverse Reactions by System Organ Class 
BOTOX 
155 Units-195 Units 
(N=687) 
Placebo  
(N=692) 
Nervous system disorders 
   Headache 
   Migraine 
   Facial paresis 
 
32 (5%) 
26 (4%) 
15 (2%) 
 
22 (3%) 
18 (3%) 
0 (0%) 
Eye disorders 
   Eyelid ptosis 
 
25 (4%) 
 
2 (<1%) 
Infections and Infestations 
   Bronchitis    
 
17 (3%) 
 
11 (2%) 
Musculoskeletal and connective tissue disorders 
   Neck pain 
   Musculoskeletal stiffness 
   Muscular weakness 
   Myalgia 
   Musculoskeletal pain 
   Muscle spasms    
 
60 (9%) 
25 (4%) 
24 (4%) 
21 (3%) 
18 (3%) 
13 (2%) 
 
19 (3%) 
6 (1%) 
2 (<1%) 
6 (1%) 
10 (1%) 
6 (1%) 
General disorders and administration site 
conditions 
   Injection site pain 
 
 
23 (3%) 
 
 
14 (2%) 
Vascular Disorders 
   Hypertension 
 
11 (2%) 
 
7 (1%) 
 
Other adverse reactions that occurred more frequently in the BOTOX group compared to the placebo group at a frequency less than 
1% and potentially BOTOX related include: vertigo, dry eye, eyelid edema, dysphagia, eye infection, and jaw pain. Severe worsening 
of migraine requiring hospitalization occurred in approximately 1% of BOTOX treated patients in Study 1 and Study 2, usually within 
the first week after treatment, compared to 0.3% of placebo-treated patients. 
 
Page 55 of 92

 
 
Upper Limb Spasticity 
The most frequently reported adverse reactions following injection of BOTOX for adult upper limb spasticity appear in Table 16. 
 
Table 16: Adverse Reactions Reported by ≥2% of BOTOX treated Patients and More Frequent than in Placebo-treated 
Patients in Adult Upper Limb Spasticity Double-blind, Placebo-controlled Clinical Trials 
 
 
Adverse  Reactions by 
System Organ Class 
BOTOX  
251 Units-      
360 Units 
(N=115) 
BOTOX  
150 Units-      
250 Units 
(N=188) 
BOTOX   
<150 Units 
(N=54) 
Placebo 
(N=182) 
 
Gastrointestinal disorder 
    Nausea 
 
3 (3%) 
 
3 (2%) 
 
1 (2%) 
 
1 (1%) 
General disorders and 
administration site conditions 
    Fatigue 
 
 
4 (3%) 
 
 
4 (2%) 
 
 
1 (2%) 
 
 
0  
Infections and infestations 
   Bronchitis 
 
4 (3%) 
 
4 (2%) 
 
0  
 
2 (1%) 
Musculoskeletal and 
connective tissue disorders 
   Pain in extremity 
Muscular weakness 
 
 
7 (6%) 
0  
 
 
10 (5%) 
7 (4%) 
 
 
5 (9%) 
1 (2%) 
 
 
8 (4%) 
2 (1%) 
 
Twenty two adult patients, enrolled in double-blind placebo controlled studies, received 400 Units or higher of BOTOX for treatment 
of upper limb spasticity. In addition, 44 adults received 400 Units of BOTOX or higher for four consecutive treatments over 
approximately one year for treatment of upper limb spasticity. The type and frequency of adverse reactions observed in patients 
treated with 400 Units of BOTOX were similar to those reported in patients treated for upper limb spasticity with 360 Units of 
BOTOX. 
 
Lower Limb Spasticity 
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. 
 
Table 17: Adverse Reactions Reported by >2% of BOTOX treated Patients and More Frequent than in Placebo-treated 
Patients in Adult Lower Limb Spasticity Double-blind, Placebo-controlled Clinical Trial (Study 6) 
Adverse Reactions 
BOTOX  
(N=231) 
Placebo 
 (N=233) 
Musculoskeletal and connective 
tissue disorders 
Arthralgia 
Back pain 
Myalgia 
8 (3%) 
6 (3%) 
4 (2%) 
2 (1%) 
4 (2%) 
3 (1%) 
Infections and infestations 
Upper respiratory tract infection 
4 (2%) 
2 (1%) 
General disorders and 
administration site conditions 
Injection site pain 
5 (2%) 
2 (1%) 
 
Cervical Dystonia 
In cervical dystonia patients evaluated for safety in double-blind and open-label studies following injection of BOTOX, the most 
frequently reported adverse reactions were dysphagia (19%), upper respiratory infection (12%), neck pain (11%), and headache 
(11%). 
 
Other events reported in 2-10% of patients in any one study in decreasing order of incidence include: increased cough, flu syndrome, 
back pain, rhinitis, dizziness, hypertonia, soreness at injection site, asthenia, oral dryness, speech disorder, fever, nausea, and 
drowsiness. Stiffness, numbness, diplopia, ptosis, and dyspnea have been reported. 
 
Dysphagia and symptomatic general weakness may be attributable to an extension of the pharmacology of BOTOX resulting from the 
spread of the toxin outside the injected muscles [see Warnings and Precautions (5.2, 5.6)]. 
 
Page 56 of 92

 
 
The most common severe adverse reaction associated with the use of BOTOX injection in patients with cervical dystonia is dysphagia 
with about 20% of these cases also reporting dyspnea [see Warnings and Precautions (5.2, 5.6)]. Most dysphagia is reported as mild 
or moderate in severity. However, it may be associated with more severe signs and symptoms [see Warnings and Precautions (5.6)]. 
 
Additionally, reports in the literature include a case of a female patient who developed brachial plexopathy two days after injection of 
120 Units of BOTOX for the treatment of cervical dystonia, and reports of dysphonia in patients who have been treated for cervical 
dystonia. 
 
Primary Axillary Hyperhidrosis 
The most frequently reported adverse reactions (3-10% of adult patients) following injection of BOTOX in double-blind studies 
included injection site pain and hemorrhage, non-axillary sweating, infection, pharyngitis, flu syndrome, headache, fever, neck or back 
pain, pruritus, and anxiety. 
 
The data reflect 346 patients exposed to BOTOX 50 Units and 110 patients exposed to BOTOX 75 Units in each axilla. 
 
Blepharospasm 
In a study of blepharospasm patients who received an average dose per eye of 33 Units (injected at 3 to 5 sites) of the currently 
manufactured BOTOX, the most frequently reported  adverse reactions were ptosis (21%), superficial punctate keratitis (6%), and eye 
dryness (6%). 
 
Other events reported in prior clinical studies in decreasing order of incidence include: irritation, tearing, lagophthalmos, photophobia, 
ectropion, keratitis, diplopia, entropion, diffuse skin rash, and local swelling of the eyelid skin lasting for several days following eyelid 
injection.  
 
In two cases of VII nerve disorder, reduced blinking from BOTOX injection of the orbicularis muscle led to serious corneal exposure, 
persistent epithelial defect, corneal ulceration and a case of corneal perforation. Focal facial paralysis, syncope, and exacerbation of 
myasthenia gravis have also been reported after treatment of blepharospasm. 
 
Strabismus 
Extraocular muscles adjacent to the injection site can be affected, causing vertical deviation, especially with higher doses 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. 
 
In a series of 5587 injections, retrobulbar hemorrhage occurred in 0.3% of cases. 
 
6.2           Immunogenicity 
As with all therapeutic proteins, there is a potential for immunogenicity. The detection of antibody formation is highly dependent on 
the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) 
positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample 
collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies to 
onabotulinumtoxinA in the studies described below with the incidence of antibodies in other studies or to other products may be 
misleading.  
 
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. 
 
One patient among the 445 hyperhidrosis patients (0.2%), two patients among the 380 adult upper limb spasticity patients (0.5%) and 
no patients among 406 migraine patients with analyzed specimens developed the presence of neutralizing antibodies. 
 
In overactive bladder patients with analyzed specimens from the two phase 3 studies and the open-label extension study, neutralizing 
antibodies developed in 0 of 954 patients (0.0%) while receiving BOTOX 100 Unit doses and 3 of 260 patients (1.2%) after 
subsequently receiving at least one 150 Unit dose. Response to subsequent BOTOX treatment was not  different following 
seroconversion in these three patients.  
 
In detrusor overactivity associated with neurologic condition patients with analyzed specimens in the drug development program 
(including the open-label extension study), neutralizing antibodies developed in 3 of 300 patients (1.0%) after receiving only BOTOX 
200 Unit doses and 5 of 258 patients (1.9%) after receiving at least one 300 Unit dose. Following development of neutralizing 
Page 57 of 92

 
 
antibodies in these 8 patients, 4 continued to experience clinical benefit, 2 did not experience clinical benefit, and the effect on the 
response to BOTOX in the remaining 2 patients is not known.  
 
The data reflect the patients whose test results were considered positive for neutralizing activity to BOTOX in a mouse protection 
assay or negative based on a screening ELISA assay or mouse protection assay.  
 
Formation of neutralizing antibodies to botulinum toxin type A may reduce the effectiveness of BOTOX treatment by inactivating the 
biological activity of the toxin. The critical factors for neutralizing antibody formation have not been well characterized. The results 
from some studies suggest that BOTOX injections at more frequent intervals or at higher doses may lead to greater incidence of 
antibody formation. The potential for antibody formation may be minimized by injecting with the lowest effective dose given at the 
longest feasible intervals between injections. 
 
6.3  
Post-Marketing Experience 
The following adverse reactions have been identified during post-approval use of BOTOX. Because these reactions are reported 
voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal 
relationship to drug exposure. These reactions include: abdominal pain; alopecia, including madarosis; anorexia; brachial plexopathy; 
denervation/muscle atrophy; diarrhea; hyperhidrosis; hypoacusis; hypoaesthesia; malaise; paresthesia; peripheral neuropathy; 
radiculopathy; erythema multiforme, dermatitis psoriasiform, and psoriasiform eruption; strabismus; tinnitus; and visual disturbances. 
 
There have been spontaneous reports of death, sometimes associated with dysphagia, pneumonia, and/or other significant debility or 
anaphylaxis, after treatment with botulinum toxin [see Warnings and Precautions (5.4, 5.6)]. 
 
There have also been reports of adverse events involving the cardiovascular system, including arrhythmia and myocardial infarction, 
some with fatal outcomes. Some of these patients had risk factors including cardiovascular disease. The exact relationship of these 
events to the botulinum toxin injection has not been established. 
 
New onset or recurrent seizures have also been reported, typically in patients who are predisposed to experiencing these events. The 
exact relationship of these events to the botulinum toxin injection has not been established.   
 
7  
DRUG INTERACTIONS 
 
7.1 
Aminoglycosides and Other Agents Interfering with Neuromuscular Transmission 
Co-administration of BOTOX and aminoglycosides or other agents interfering with neuromuscular transmission (e.g., curare-like 
compounds) should only be performed with caution as the effect of the toxin may be potentiated. 
 
7.2 
Anticholinergic Drugs 
Use of anticholinergic drugs after administration of BOTOX may potentiate systemic anticholinergic effects. 
 
7.3 
Other Botulinum Neurotoxin Products 
The effect of administering different botulinum neurotoxin products at the same time or within several months of each other is 
unknown. Excessive neuromuscular weakness may be exacerbated by administration of another botulinum toxin prior to the resolution 
of the effects of a previously administered botulinum toxin.  
 
7.4 
Muscle Relaxants 
Excessive weakness may also be exaggerated by administration of a muscle relaxant before or after administration of BOTOX.   
 
8 
USE IN SPECIFIC POPULATIONS 
 
8.1  
Pregnancy 
Risk Summary  
There are no studies or adequate data from postmarketing surveillance on the developmental risk associated with use of BOTOX in 
pregnant women. In animal studies, administration of BOTOX during pregnancy resulted in adverse effects on fetal growth (decreased 
fetal weight and skeletal ossification) at clinically relevant doses, which were associated with maternal toxicity [see Data)]. 
 
In the U.S. general population, the estimated background risk of major birth defects and miscarriages in clinically recognized 
pregnancies is 2-4% and 15-20%, respectively.  The background risk of major birth defects and miscarriage for the indicated 
populations is unknown. 
 
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Data  
Animal Data 
When BOTOX (4, 8, or 16 Units/kg) was administered intramuscularly to pregnant mice or rats two times during the period of 
organogenesis (on gestation days 5 and 13), reductions in fetal body weight and decreased fetal skeletal ossification were observed at 
the two highest doses. The no-effect dose for developmental toxicity in these studies (4 Units/kg) is approximately equal to the human 
dose of 400 Units, on a body weight basis (Units/kg). 
 
When BOTOX was administered intramuscularly to pregnant rats (0.125, 0.25, 0.5, 1, 4, or 8 Units/kg) or rabbits (0.063, 0.125, 0.25, 
or 0.5 Units/kg) daily during the period of organogenesis (total of 12 doses in rats, 13 doses in rabbits), reduced fetal body weights and 
decreased fetal skeletal ossification were observed at the two highest doses in rats and at the highest dose in rabbits. These doses were 
also associated with significant maternal toxicity, including abortions, early deliveries, and maternal death. The developmental no-
effect doses in these studies of 1 Unit/kg in rats and 0.25 Units/kg in rabbits are less than the human dose of 400 Units, based on 
Units/kg. 
 
When pregnant rats received single intramuscular injections (1, 4, or 16 Units/kg) at three different periods of development (prior to 
implantation, implantation, or organogenesis), no adverse effects on fetal development were observed. The developmental no-effect 
level for a single maternal dose in rats (16 Units/kg) is approximately 2 times the human dose of 400 Units, based on Units/kg. 
 
8.2  
Lactation 
Risk Summary 
There are no data on the presence of BOTOX in human or animal milk, the effects on the breastfed infant, or the effects on milk 
production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for 
BOTOX and any potential adverse effects on the breastfed infant from BOTOX or from the underlying maternal conditions. 
 
8.4           Pediatric Use 
Bladder Dysfunction 
Safety and effectiveness in patients below the age of 18 years have not been established. 
 
Prophylaxis of Headaches in Chronic Migraine 
Safety and effectiveness in patients below the age of 18 years have not been established.  
 
Spasticity 
Safety and effectiveness in patients below the age of 18 years have not been established. 
 
Axillary Hyperhidrosis 
Safety and effectiveness in patients below the age of 18 years have not been established. 
 
Cervical Dystonia 
Safety and effectiveness in pediatric patients below the age of 16 years have not been established. 
 
Blepharospasm and Strabismus  
Safety and effectiveness in pediatric patients below the age of 12 years have not been established. 
 
 
8.5   
Geriatric Use 
Of the 2145 patients in placebo-controlled clinical studies of BOTOX for the treatment of spasticity, 33.5% were 65 or older, and 
7.7% were 75 years of age or older. No overall differences in safety were observed between elderly patients and younger patients.  
 
In clinical studies of BOTOX across other indications, no overall differences in safety were observed between elderly patients and 
younger patients, with the exception of Overactive Bladder (see below). Other reported clinical experience has not identified 
differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled 
out.  
 
Overactive Bladder 
Of 1242 overactive bladder patients in placebo-controlled clinical studies of BOTOX, 41.4% were 65 years of age or older, and 14.7% 
were 75 years of age or older. Adverse reactions of UTI and urinary retention were more common in patients 65 years of age or older 
in both placebo and BOTOX groups compared to younger patients (see Table 18). Otherwise, there were no overall differences in the 
safety profile following BOTOX treatment between patients aged 65 years and older compared to younger patients in these studies. 
 
Page 59 of 92

 
 
Table 18: Incidence of Urinary Tract Infection and Urinary Retention according to Age Group during First Placebo-
controlled Treatment, Placebo-controlled Clinical Trials in Patients with OAB 
 
<65 Years 
65 to 74 Years 
≥75 Years 
 
 
Adverse Reactions  
BOTOX 
100 Units 
(N=344) 
Placebo 
(N=348) 
BOTOX 
100 Units 
(N=169) 
Placebo 
(N=151) 
BOTOX 
100 Units 
(N=94) 
Placebo 
(N=86) 
Urinary tract infection 
73 (21%) 
23 (7%) 
51 (30%) 
20 (13%) 
36 (38%) 
16 (19%) 
Urinary retention 
21 (6%) 
2 (0.6%) 
14 (8%) 
0 (0%) 
8 (9%) 
1 (1%) 
 
Observed effectiveness was comparable between these age groups in placebo-controlled clinical studies. 
10     
OVERDOSAGE 
Excessive doses of BOTOX (onabotulinumtoxinA) for injection may be expected to produce neuromuscular weakness with a variety 
of symptoms.  
 
 
Symptoms of overdose are likely not to be present immediately following injection. Should accidental injection or oral ingestion occur 
or overdose be suspected, the person should be medically supervised for several weeks for signs and symptoms of systemic muscular 
weakness which could be local, or distant from the site of injection [see Boxed Warning and Warnings and Precautions (5.2, 5.6)]. 
These patients should be considered for further medical evaluation and appropriate medical therapy immediately instituted, which may 
include hospitalization. 
 
If the musculature of the oropharynx and esophagus are affected, aspiration may occur which may lead to development of aspiration 
pneumonia. If the respiratory muscles become paralyzed or sufficiently weakened, intubation and assisted respiration may be 
necessary until recovery takes place. Supportive care could involve the need for a tracheostomy and/or prolonged mechanical 
ventilation, in addition to other general supportive care. 
 
In the event of overdose, antitoxin raised against botulinum toxin is available from the Centers for Disease Control and Prevention 
(CDC) in Atlanta, GA. However, the antitoxin will not reverse any botulinum toxin-induced effects already apparent by the time of 
antitoxin administration. In the event of suspected or actual cases of botulinum toxin poisoning, please contact your local or state 
Health Department to process a request for antitoxin through the CDC. If you do not receive a response within 30 minutes, please 
contact the CDC directly at 1-770-488-7100. More information can be obtained at 
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5232a8.htm. 
 
11 
DESCRIPTION 
BOTOX (onabotulinumtoxinA) for injection is a sterile, vacuum-dried purified botulinum toxin type A, produced from fermentation 
of Hall strain Clostridium botulinum type A, and intended for intramuscular, intradetrusor and intradermal use. It is purified from the 
culture solution by dialysis and a series of acid precipitations to a complex consisting of the neurotoxin, and several accessory 
proteins. The complex is dissolved in sterile sodium chloride solution containing Albumin Human and is sterile filtered (0.2 microns) 
prior to filling and vacuum-drying. 
 
The primary release procedure for BOTOX uses a cell-based potency assay to determine the potency relative to a reference standard. 
The assay is specific to Allergan’s products BOTOX and BOTOX Cosmetic. One Unit of BOTOX corresponds to the calculated 
median intraperitoneal lethal dose (LD50) in mice. Due to specific details of this assay such as the vehicle, dilution scheme, and 
laboratory protocols, Units of biological activity of BOTOX cannot be compared to nor converted into Units of any other botulinum 
toxin or any toxin assessed with any other specific assay method. The specific activity of BOTOX is approximately 20 
Units/nanogram of neurotoxin protein complex. 
 
Each vial of BOTOX contains either 100 Units of Clostridium botulinum type A neurotoxin complex, 0.5 mg of Albumin Human, and 
0.9 mg of sodium chloride; or 200 Units of Clostridium botulinum type A neurotoxin complex, 1 mg of Albumin Human, and 1.8 mg 
of sodium chloride in a sterile, vacuum-dried form without a preservative. 
 
12 
CLINICAL PHARMACOLOGY 
 
12.1   
Mechanism of Action 
BOTOX blocks neuromuscular transmission by binding to acceptor sites on motor or autonomic 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 activity. 
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.  
 
Page 60 of 92

 
 
When injected intradermally, BOTOX produces temporary chemical denervation of the sweat gland resulting in local reduction in 
sweating. 
 
Following intradetrusor injection, BOTOX affects the efferent pathways of detrusor activity via inhibition of acetylcholine release.  
 
12.3  
Pharmacokinetics 
Using currently available analytical technology, it is not possible to detect BOTOX in the peripheral blood following intramuscular 
injection at the recommended doses. 
 
13 
NONCLINICAL TOXICOLOGY 
 
13.1  
Carcinogenesis, Mutagenesis, Impairment of Fertility 
Carcinogenesis 
Long term studies in animals have not been performed to evaluate the carcinogenic potential of BOTOX.  
 
Mutagenesis 
BOTOX was negative in a battery of in vitro (microbial reverse mutation assay, mammalian cell mutation assay, and chromosomal 
aberration assay) and in vivo (micronucleus assay) genetic toxicology assays. 
 
Impairment of Fertility 
In fertility studies of BOTOX (4, 8, or 16 Units/kg) in which either male or female rats were injected intramuscularly prior to mating 
and on the day of mating (3 doses, 2 weeks apart for males: 2 doses, 2 weeks apart for females) to untreated animals, reduced fertility 
was observed in males at the intermediate and high doses and in females at the high dose. The no-effect doses for reproductive toxicity 
(4 Units/kg in males, 8 Units/kg in females) are approximately equal to the human dose of 400 Units, on a body weight basis 
(Units/kg). 
 
13.2  
Animal Toxicology and/or Pharmacology 
In a study to evaluate inadvertent peribladder administration, bladder stones were observed in 1 of 4 male monkeys that were injected 
with a total of 6.8 Units/kg divided into the prostatic urethra and proximal rectum (single administration). No bladder stones were 
observed in male or female monkeys following injection of up to 36 Units/kg (~12X the highest human bladder dose) directly to the 
bladder as either single or 4 repeat dose injections or in female rats for single injections up to 100 Units/kg (~33X the highest human 
bladder dose [200 Units], based on Units/kg). 
 
14 
CLINICAL STUDIES 
 
14.1  
Overactive Bladder (OAB) 
Two double-blind, placebo-controlled, randomized, multi-center, 24-week clinical studies were conducted in patients with OAB with 
symptoms of urge urinary incontinence, urgency, and frequency (Studies OAB-1 and OAB-2). Patients needed to have at least 3 
urinary urgency incontinence episodes and at least 24 micturitions in 3 days to enter the studies. A total of 1105 patients, whose 
symptoms had not been adequately managed with anticholinergic therapy (inadequate response or intolerable side effects), were 
randomized to receive either 100 Units of BOTOX (n=557), or placebo (n=548).  Patients received 20 injections of study drug (5 units 
of BOTOX or placebo) spaced approximately 1 cm apart into the detrusor muscle. 
 
In both studies, significant improvements compared to placebo in the primary efficacy variable of change from baseline in daily 
frequency of urinary incontinence episodes were observed for BOTOX 100 Units at the primary time point of week 12. Significant 
improvements compared to placebo were also observed for the secondary efficacy variables of daily frequency of micturition episodes 
and volume voided per micturition. These primary and secondary variables are shown in Tables 19 and 20, and Figures 5 and 6. 
 
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Table 19: Baseline and Change from Baseline in Urinary Incontinence Episode Frequency, Micturition Episode Frequency 
and Volume Voided Per Micturition, Study OAB-1   
 
BOTOX 
100 Units 
(N=278) 
 
Placebo 
(N=272) 
 
Treatment 
Difference 
 
p-value 
 
Daily Frequency of Urinary Incontinence 
Episodesa 
 
 
 
 
Mean Baseline 
5.5 
5.1 
 
 
Mean Change* at Week 2 
-2.6 
-1.0 
-1.6 
 
Mean Change* at Week 6 
-2.8 
-1.0 
-1.8 
 
Mean Change* at Week 12** 
-2.5 
-0.9 
-1.6 
(-2.1, -1.2) 
<0.001 
Daily Frequency of Micturition Episodesb 
 
 
 
 
Mean Baseline 
12.0 
11.2 
 
 
Mean Change† at Week 12** 
-1.9 
-0.9 
-1.0 
(-1.5, -0.6) 
<0.001 
Volume Voided per Micturitionb (mL) 
 
 
 
 
Mean Baseline 
156 
161 
 
 
Mean Change† at Week 12** 
38  
8 
30 
(17, 43) 
<0.001 
* Least squares (LS) mean change, treatment difference and p-value are based on an ANCOVA model with baseline value as covariate and treatment 
group and investigator as factors. Last observation carried forward (LOCF) values were used to analyze the primary efficacy variable. 
† LS mean change, treatment difference and p-value are based on an ANCOVA model with baseline value as covariate and stratification factor, treatment 
group and investigator as factors. 
** Primary timepoint 
a Primary variable 
b Secondary variable 
 
Table 20: Baseline and Change from Baseline in Urinary Incontinence Episode Frequency, Micturition Episode Frequency 
and Volume Voided Per Micturition, Study OAB-2  
 
 
BOTOX 
100 Units 
(N=275) 
 
Placebo 
(N=269) 
 
Treatment 
Difference 
 
p-value 
 
Daily Frequency of Urinary Incontinence 
Episodesa 
 
 
 
 
Mean Baseline 
5.5 
5.7 
 
 
Mean Change* at Week 2 
-2.7 
-1.1 
-1.6 
 
Mean Change* at Week 6 
-3.1 
-1.3 
-1.8 
 
Mean Change* at Week 12** 
-3.0 
-1.1 
-1.9 
(-2.5, -1.4) 
<0.001 
Daily Frequency of Micturition Episodesb 
 
 
 
 
Mean Baseline 
12.0 
11.8 
 
 
Mean Change† at Week 12** 
-2.3 
-0.6 
-1.7 
(-2.2, -1.3) 
<0.001 
Volume Voided per Micturitionb (mL) 
 
 
 
 
Mean Baseline 
144 
153  
 
 
Mean Change† at Week 12** 
40  
10  
31 
(20, 41) 
<0.001 
 * LS mean change, treatment difference and p-value are based on an ANCOVA model with baseline value as covariate and treatment group and 
investigator as factors. LOCF values were used to analyze the primary efficacy variable.  
† LS mean change, treatment difference and p-value are based on an ANCOVA model with baseline value as covariate and stratification factor, 
treatment group and investigator as factors. 
** Primary timepoint 
a Primary variable 
b Secondary variable 
 
Page 62 of 92

 
 
Figure 5: Mean Change from Baseline in Daily Frequency of Urinary Incontinence Episodes following intradetrusor injection 
in Study OAB-1 
 
 
Figure 6: Mean Change from Baseline in Daily Frequency of Urinary Incontinence Episodes following intradetrusor injection 
in Study OAB-2 
 
 
The median duration of response in Study OAB-1 and OAB-2, based on patient qualification for re-treatment, was 19-24 weeks for the 
BOTOX 100 Unit dose group compared to 13 weeks for placebo. To qualify for re-treatment, at least 12 weeks must have passed since 
the prior treatment, post-void residual urine volume must have been less than 200 mL and patients must have reported at least 2 
urinary incontinence episodes over 3 days.      
 
14.2 
Detrusor Overactivity associated with a Neurologic Condition 
Two double-blind, placebo-controlled, randomized, multi-center clinical studies were conducted in patients with urinary incontinence 
due to detrusor overactivity associated with a neurologic condition who were either spontaneously voiding or using catheterization 
(Studies NDO-1 and NDO-2). A total of 691 spinal cord injury (T1 or below) or multiple sclerosis patients, who had an inadequate 
response to or were intolerant of at least one anticholinergic medication, were enrolled. These patients were randomized to receive 
either 200 Units of BOTOX (n=227), 300 Units of BOTOX (n=223), or placebo (n=241).  
 
In both studies, significant improvements compared to placebo in the primary efficacy variable of change from baseline in weekly 
frequency of incontinence episodes were observed for BOTOX (200 Units) at the primary efficacy time point at week 6. Increases in 
maximum cystometric capacity and reductions in maximum detrusor pressure during the first involuntary detrusor contraction were 
also observed. These primary and secondary endpoints are shown in Tables 21 and 22, and Figures 7 and 8.  
 
No additional benefit of BOTOX 300 Units over 200 Units was demonstrated. 
 
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Table 21: Baseline and Change from Baseline in Weekly Urinary Incontinence Episode Frequency, Maximum Cystometric 
Capacity and Maximum Detrusor Pressure during First Involuntary Detrusor Contraction (cmH2O) Study NDO-1  
 
 
BOTOX    
200 Units 
Placebo 
Treatment 
Difference* 
p-value* 
Weekly Frequency of Urinary Incontinence 
Episodesa 
N 
Mean Baseline 
Mean Change* at Week 2 
Mean Change* at Week 6** 
 
Mean Change* at Week 12 
 
 
134 
32.3 
-15.3 
-19.9 
 
-19.8 
 
 
146 
28.3 
-10.0 
-10.6 
 
-8.8 
 
 
 
 
-5.3 
-9.2 
(-13.1, -5.3) 
-11.0 
 
 
 
 
─ 
p<0.001 
 
─ 
Maximum Cystometric Capacityb (mL) 
N 
Mean Baseline 
 
Mean Change* at Week 6** 
 
123 
253.8 
135.9 
 
129 
259.1 
12.1 
 
 
 
123.9 
(89.1, 158.7) 
 
 
 
p<0.001 
Maximum Detrusor Pressure during First 
Involuntary Detrusor Contractionb (cmH2O) 
N 
Mean Baseline 
 
Mean Change* at Week 6** 
 
 
41 
63.1 
-28.1 
 
 
103 
57.4 
-3.7 
 
 
 
 
-24.4 
 
 
 
 
─ 
* LS mean change, treatment difference and p-value are based on an analysis using an ANCOVA model with baseline weekly endpoint as covariate 
and treatment group, etiology at study entry (spinal cord injury or multiple sclerosis), concurrent anticholinergic therapy at screening, and 
investigator as factors. LOCF values were used to analyze the primary efficacy variable. 
** Primary timepoint 
a Primary endpoint 
b Secondary endpoint 
 
Table 22: Baseline and Change from Baseline in Weekly Urinary Incontinence Episode Frequency, Maximum Cystometric 
Capacity and Maximum Detrusor Pressure during First Involuntary Detrusor Contraction (cmH2O) in Study NDO-2  
 
 
BOTOX    
200 Units 
Placebo 
 
Treatment 
Difference* 
p-value* 
Weekly Frequency of Urinary Incontinence 
Episodesa 
N 
Mean Baseline 
Mean Change* at Week 2 
Mean Change* at Week 6** 
 
Mean Change* at Week 12 
 
 
91 
32.7 
-18.0 
-19.6 
 
-19.6 
 
 
91 
36.8 
-7.9 
-10.8 
 
-10.7 
 
 
 
 
-10.1 
-8.8  
(-14.5, -3.0) 
-8.9 
 
 
 
 
─ 
p=0.003 
 
─ 
Maximum Cystometric Capacityb (mL) 
N 
Mean Baseline 
Mean Change* at Week 6** 
 
88 
239.6 
150.8 
 
85 
253.8 
2.8 
 
 
 
148.0 
(101.8, 194.2) 
 
 
 
p<0.001 
Maximum Detrusor Pressure during First 
Involuntary Detrusor Contractionb (cmH2O) 
N 
Mean Baseline 
Mean Change* at Week 6** 
 
 
29 
65.6 
-28.7 
 
 
68 
43.7 
2.1 
 
 
 
 
-30.7 
 
 
 
 
─ 
* LS mean change, treatment difference and p-value are based on an analysis using an ANCOVA model with baseline weekly endpoint as covariate 
and treatment group, etiology at study entry (spinal cord injury or multiple sclerosis), concurrent anticholinergic therapy at screening, and 
investigator as factors. LOCF values were used to analyze the primary efficacy variable.  
** Primary timepoint 
a Primary endpoint  
b Secondary endpoint  
 
Page 64 of 92

 
 
Figure 7: Mean Change from Baseline in Weekly Frequency of Urinary Incontinence Episodes During Treatment Cycle 1 in 
Study NDO-1    
 
 
Figure 8: Mean Change from Baseline in Weekly Frequency of Urinary Incontinence Episodes During Treatment Cycle 1 in 
Study NDO-2 
 
 
The median duration of response in study NDO-1 and NDO-2, based on patient qualification for re-treatment was 295-337 days (42-
48 weeks) for the 200 Units dose group compared to 96-127 days (13-18 weeks) for placebo. Re-treatment was based on loss of effect 
on incontinence episode frequency (50% of effect in Study NDO-1; 70% of effect in Study NDO-2).   
 
A placebo-controlled, double-blind randomized post-approval 52 week study (Study NDO-3) was conducted in MS patients with urinary 
incontinence due to neurogenic detrusor overactivity who were not adequately managed with at least one anticholinergic agent and not 
catheterizing at baseline. These patients were randomized to receive either 100 Units of BOTOX (n=66) or placebo (n=78).   
 
Significant improvements compared to placebo in the primary efficacy variable of change from baseline in  daily frequency of 
incontinence episodes were observed for BOTOX® (100 Units) at the primary efficacy time point at week 6. Increases in maximum 
cystometric capacity and reductions in maximum detrusor pressure during the first involuntary detrusor contraction were also 
observed.  These primary and secondary endpoints are shown in Table 23. 
 
 
Page 65 of 92

 
 
Table 23: Baseline and Change from Baseline in Daily Urinary Incontinence Episode Frequency, Maximum Cystometric 
Capacity and Maximum Detrusor Pressure during First Involuntary Detrusor Contraction (cmH2O) in Study NDO-3 
 
 
BOTOX    
100 Units 
Placebo 
 
Treatment 
Difference* 
p-value* 
Daily Frequency of Urinary Incontinence 
Episodesa 
N 
Mean Baseline 
Mean Change* at Week 2 
Mean Change* at Week 6** 
 
Mean Change* at Week 12 
 
 
66 
4.2 
-2.9 
-3.4 
 
-2.7 
 
 
78 
4.3 
-1.2 
-1.1 
 
-1.0 
 
 
 
 
-1.7 
-2.3 
(-3.0, -1.7) 
-1.8 
 
 
 
 
─ 
p<0.001 
 
─ 
Maximum Cystometric Capacityb (mL) 
N 
Mean Baseline 
Mean Change* at Week 6** 
 
62 
248.9 
134.4 
 
72 
245.5 
3.5 
 
 
 
130.9 
(94.8, 167.0) 
 
 
 
p<0.001 
Maximum Detrusor Pressure during First 
Involuntary Detrusor Contractionb (cmH2O) 
N 
Mean Baseline 
Mean Change* at Week 6** 
 
 
25 
42.4  
-19.2 
 
 
51 
39.0 
2.7 
 
 
 
 
-21.9 
(-37.5, -6.3) 
 
 
 
 
 
* LS mean change, treatment difference and p-value are based on an analysis using an ANCOVA model with baseline daily endpoint as covariate and 
treatment group and propensity score stratification as factors. LOCF values were used to analyze the primary efficacy variable.  
** Primary timepoint 
a Primary endpoint  
b Secondary endpoint  
 
The median duration of response in study NDO-3, based on patient qualification for re-treatment was 362 days (52 weeks) for the 
BOTOX 100 Units dose group compared to 88 days (13 weeks) for placebo.  To qualify for re-treatment, at least 12 weeks must have 
passed since the prior treatment, post-void residual urine volume must have been less than 200 mL and patients must have reported at 
least 2 urinary incontinence episodes over 3 days with no more than 1 incontinence-free day. 
 
 
14.3 
Chronic Migraine 
BOTOX was evaluated in two randomized, multi-center, 24-week, 2 injection cycle, placebo-controlled double-blind studies. Study 1 
and Study 2 included chronic migraine adults who were not using any concurrent headache prophylaxis, and during a 28-day baseline 
period had >15 headache days lasting 4 hours or more, with >50% being migraine/probable migraine. In both studies, patients were 
randomized to receive placebo or 155 Units to 195 Units BOTOX injections every 12 weeks for the 2-cycle, double-blind phase. 
Patients were allowed to use acute headache treatments during the study. BOTOX treatment demonstrated statistically significant and 
clinically meaningful improvements from baseline compared to placebo for key efficacy variables (see Table 24). 
 
Table 24: Week 24 Key Efficacy Variables for Study 1 and Study 2 
 
 
Efficacy per 28 days 
Study 1 
Study 2 
BOTOX 
(N=341) 
Placebo 
(N=338) 
BOTOX 
(N=347) 
Placebo 
(N=358) 
Change from baseline in frequency of 
headache days 
-7.8* 
-6.4 
-9.2* 
-6.9 
Change from baseline in total cumulative 
hours of headache on headache days 
-107* 
-70 
-134* 
-95 
* Significantly different from placebo (p<0.05)  
 
Patients treated with BOTOX had a significantly greater mean decrease from baseline in the frequency of headache days at most 
timepoints from Week 4 to Week 24 in Study 1 (Figure 9), and all timepoints from Week 4 to Week 24 in Study 2 (Figure 10), 
compared to placebo-treated patients. 
 
 
 
Page 66 of 92

 
 
Figure 9: Mean Change from Baseline in Number of Headache Days for Study 1 
 
Figure 10: Mean Change from Baseline in Number of Headache Days for Study 2 
 
 
14.4 
Spasticity 
Upper Limb Spasticity 
The efficacy of BOTOX for the treatment of upper limb spasticity was evaluated in three randomized, multi-center, double-blind, 
placebo-controlled studies (Studies 1, 2, and 3). Two additional randomized, multi-center, double-blind, placebo-controlled studies for 
upper limb spasticity in adults also included the evaluation of the efficacy of BOTOX for the treatment of thumb spasticity (Studies 4 
and 5).   
 
Study 1 included 126 patients (64 BOTOX and 62 placebo) with upper limb spasticity (Ashworth score of at least 3 for wrist flexor 
tone and at least 2 for finger flexor tone) who were at least 6 months post-stroke. BOTOX (a total dose of 200 Units to 240 Units) and 
placebo were injected intramuscularly (IM) into the flexor digitorum profundus, flexor digitorum sublimis, flexor carpi radialis, flexor 
carpi ulnaris, and if necessary into the adductor pollicis and flexor pollicis longus (see Table 25). Use of an EMG/nerve stimulator was 
recommended to assist in proper muscle localization for injection. Patients were followed for 12 weeks. 
 
Page 67 of 92

 
 
Table 25: Study Medication Dose and Injection Sites in Study 1 
 
Muscles Injected 
Volume  
(mL) 
BOTOX  
(Units) 
Number of 
Injection Sites 
Wrist     
Flexor Carpi Radialis 
 
1 
 
50 
 
1 
Flexor Carpi Ulnaris 
1 
50 
1 
Finger  
Flexor Digitorum 
Profundus 
 
1 
 
50 
1 
Flexor Digitorum Sublimis 
1 
50 
1 
Thumb    
Adductor Pollicisa 
 
0.4 
 
20 
 
1 
Flexor Pollicis Longusa 
0.4 
20 
1 
a injected only if spasticity is present in this muscle 
 
The primary efficacy variable was wrist flexors muscle tone at week 6, as measured by the Ashworth score. The Ashworth Scale is a 
5-point scale with grades of 0 [no increase in muscle tone] to 4 [limb rigid in flexion or extension]. It is a clinical measure of the force 
required to move an extremity around a joint, with a reduction in score clinically representing a reduction in the force needed to move 
a joint (i.e., improvement in spasticity).  
 
Key secondary endpoints included Physician Global Assessment, finger flexors muscle tone, and thumb flexors tone at Week 6. The 
Physician Global Assessment evaluated the response to treatment in terms of how the patient was doing in his/her life using a scale 
from -4 = very marked worsening to +4 = very marked improvement. Study 1 results on the primary endpoint and the key secondary 
endpoints are shown in Table 26.  
 
Table 26: Primary and Key Secondary Endpoints by Muscle Group at Week 6 in Study 1  
 
BOTOX  
(N=64) 
Placebo 
(N=62) 
Median Change from Baseline in Wrist 
Flexor Muscle Tone on the Ashworth Scale†a 
 
-2.0* 
 
0.0 
Median Change from Baseline in Finger 
Flexor Muscle Tone on the Ashworth Scale††b 
 
-1.0* 
 
0.0 
Median Change from Baseline in Thumb 
Flexor Muscle Tone on the Ashworth Scale††c 
 
-1.0 
 
-1.0 
Median Physician Global Assessment of 
Response to Treatment†† 
 
2.0* 
 
0.0 
 †  Primary endpoint at Week 6 
†† Secondary endpoints at Week 6 
* Significantly different from placebo (p<0.05)  
a BOTOX injected into both the flexor carpi radialis and ulnaris muscles 
b BOTOX injected into the flexor digitorum profundus and flexor digitorum sublimis muscles 
c BOTOX injected into the adductor pollicis and flexor pollicis longus muscles 
    
Study 2 compared 3 doses of BOTOX with placebo and included 91 patients [BOTOX 360 Units (N=21), BOTOX 180 Units (N=23), 
BOTOX 90 Units (N=21), and placebo (N=26)] with upper limb spasticity (expanded Ashworth score of at least 2 for elbow flexor 
tone and at least 3 for wrist flexor tone) who were at least 6 weeks post-stroke. BOTOX and placebo were injected with EMG 
guidance into the flexor digitorum profundus, flexor digitorum sublimis, flexor carpi radialis, flexor carpi ulnaris, and biceps brachii 
(see Table 27). 
 
Page 68 of 92

 
 
Table 27: Study Medication Dose and Injection Sites in Study 2 and Study 3 
 
Total Dose 
 
 
Muscles Injected  
BOTOX  
low dose  
(90 Units) 
BOTOX  
mid dose  
(180 Units) 
BOTOX 
 high dose 
(360 Units) 
Volume    
(mL)      
per site 
Injection  
Sites 
(n) 
Wrist 
Flexor Carpi 
Ulnaris 
 
10 Units 
 
20 Units 
 
40 Units 
 
0.4 
 
1 
Flexor Carpi 
Radialis 
15 Units 
30 Units 
60 Units 
0.6 
1 
Finger 
Flexor Digitorum 
Profundus 
 
 
7.5 Units 
 
 
15 Units 
 
 
30 Units 
 
 
0.3 
 
 
1 
Flexor Digitorum 
Sublimis 
 
7.5 Units 
 
15 Units 
 
30 Units 
 
0.3 
 
1 
Elbow 
Biceps Brachii 
 
50 Units 
 
100 Units 
 
200 Units 
 
0.5  
 
4 
 
The primary efficacy variable in Study 2 was the wrist flexor tone at Week 6 as measured by the expanded Ashworth Scale. The 
expanded Ashworth Scale uses the same scoring system as the Ashworth Scale, but allows for half-point increments. 
 
Key secondary endpoints in Study 2 included Physician Global Assessment, finger flexors muscle tone, and elbow flexors muscle tone 
at Week 6. Study 2 results on the primary endpoint and the key secondary endpoints at Week 6 are shown in Table 28.  
 
 
Table 28: Primary and Key Secondary Endpoints by Muscle Group and BOTOX Dose at Week 6 in Study 2 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
† Primary endpoint at Week 6 
†† Secondary endpoints at Week 6 
* Significantly different from placebo (p<0.05) 
a p=0.053 
b Total dose of BOTOX injected into both the flexor carpi radialis and ulnaris muscles 
c Total dose of BOTOX injected into the flexor digitorum profundus and flexor digitorum sublimis muscles 
d Dose of BOTOX injected into biceps brachii muscle 
 
Study 3 compared 3 doses of BOTOX with placebo and enrolled 88 patients [BOTOX 360 Units (N=23), BOTOX 180 Units (N=23), 
BOTOX 90 Units (N=23), and placebo (N=19)] with upper limb spasticity (expanded Ashworth score of at least 2 for elbow flexor 
tone and at least 3 for wrist flexor tone and/or finger flexor tone) who were at least 6 weeks post-stroke. BOTOX and placebo were 
injected with EMG guidance into the flexor digitorum profundus, flexor digitorum sublimis, flexor carpi radialis, flexor carpi ulnaris, 
and biceps brachii (see Table 27). 
 
The primary efficacy variable in Study 3 was wrist and elbow flexor tone as measured by the expanded Ashworth score. A key 
secondary endpoint was assessment of finger flexors muscle tone. Study 3 results on the primary endpoint at Week 4 are shown in 
Table 29. 
 
 
BOTOX  
low dose 
(90 Units) 
(N=21) 
BOTOX  
mid dose 
(180 Units) 
(N=23) 
BOTOX  
high dose 
(360 Units) 
(N=21) 
Placebo 
(N=26) 
Median Change from Baseline in Wrist 
Flexor Muscle Tone on the Ashworth Scale†b 
 
-1.5* 
 
-1.0* 
 
-1.5* 
 
-1.0 
Median Change from Baseline in Finger 
Flexor Muscle Tone on the Ashworth Scale††c 
 
-0.5 
 
-0.5 
 
-1.0 
 
-0.5 
Median Change from Baseline in Elbow 
Flexor Muscle Tone on the Ashworth Scale††d 
 
-0.5 
 
-1.0* 
 
-0.5a 
 
-0.5 
Median Physician Global Assessment of 
Response to Treatment 
 
1.0* 
 
1.0* 
 
1.0* 
 
0.0 
Page 69 of 92

 
 
 
 
Table 29: Primary and Key Secondary Endpoints by Muscle Group and BOTOX Dose at Week 4 in Study 3 
 
 
 
 
 
 
 
 
 
 
 
†  Primary endpoint at Week 4 
†† Secondary endpoints at Week 4 
* Significantly different from placebo (p<0.05)  
b Total dose of BOTOX injected into both the flexor carpi radialis and ulnaris muscles 
c Total dose of BOTOX injected into the flexor digitorum profundus and flexor digitorum sublimis muscles 
d Dose of BOTOX injected into biceps brachii muscle  
 
Study 4 included 170 patients (87 BOTOX and 83 placebo) with upper limb spasticity who were at least 6 months post-stroke.  In 
Study 4, patients received 20 Units of BOTOX into the adductor pollicis and flexor pollicis longus (total BOTOX dose =40 Units in 
thumb muscles) or placebo (see Table 30). Study 5 included 109 patients with upper limb spasticity who were at least 6 months post-
stroke. In Study 5, patients received 15 Units (low dose) or 20 Units (high dose) of BOTOX into the adductor pollicis and flexor 
pollicis longus under EMG guidance (total BOTOX low dose =30 Units, total BOTOX high dose =40 Units), or placebo (see Table 
30). The duration of follow-up in Study 4 and Study 5 was 12 weeks.   
 
Table 30: Study Medication Dose and Injection Sites in Studies 4 and 5  
  Muscles 
Injected 
Study 4 
Study 5 
Number of 
Injection Sites 
for Studies 4 
and 5 
BOTOX 
(Units) 
Volume     
 (mL) 
BOTOX 
low dose 
(Units) 
BOTOX 
high dose 
(Units) 
Volume     
low dose 
(mL) 
Volume    
high dose 
(mL) 
Thumb    
Adductor Pollicis 
 
20 
 
0.4 
 
15 
 
20 
 
0.3 
 
0.4 
 
1 
Flexor Pollicis 
Longus 
20 
0.4 
15 
20 
0.3 
0.4 
1 
 
The results of Study 4 for the change from Baseline to Week 6 in thumb flexor tone measured by modified Ashworth Scale (MAS) 
and overall treatment response by Physician Global Assessment at week 6 are presented in Table 31. The MAS uses a similar scoring 
system as the Ashworth Scale. 
 
Table 31: Efficacy Endpoints for Thumb Flexors at Week 6 in Study 4  
 
BOTOX   
(N=66) 
Placebo  
(N=57) 
Median Change from Baseline in Thumb Flexor 
Muscle Tone on the modified Ashworth Scale††a 
 
-1.0* 
 
0.0 
Median Physician Global Assessment of 
Response to Treatment†† 
 
2.0* 
 
0.0 
†† Secondary endpoints at Week 6 
* Significantly different from placebo (p<0.001)  
a BOTOX injected into the adductor pollicis and flexor pollicis longus muscles 
 
In Study 5, the results of the change from Baseline to Week 6 in thumb flexor tone measured by modified Ashworth Scale and Clinical 
Global Impression (CGI) of functional assessment scale assessed by the physician using an 11-point Numeric Rating Scale [-5 worst 
possible function to +5 best possible function]) are presented in Table 32.   
 
 
BOTOX  
low dose 
(90 Units) 
(N=23) 
BOTOX   
mid dose 
(180 Units) 
(N=21) 
BOTOX  
high dose 
(360 Units) 
(N=22) 
Placebo 
(N=19) 
 
 
Median Change from Baseline in Wrist 
Flexor Muscle Tone on the Ashworth Scale†b 
 
-1.0 
 
-1.0 
 
-1.5* 
 
-0.5 
Median Change from Baseline in Finger 
Flexor Muscle Tone on the Ashworth Scale††c 
 
-1.0 
 
-1.0 
 
-1.0* 
 
-0.5 
Median Change from Baseline in Elbow 
Flexor Muscle Tone on the Ashworth Scale†d 
 
-0.5 
 
-0.5 
 
-1.0* 
 
-0.5 
Page 70 of 92

 
 
Table 32: Efficacy Endpoints for Thumb Flexors at Week 6 in Study 5  
 
BOTOX 
low dose 
(30 Units) 
(N=14) 
Placebo 
low dose 
(N=9) 
BOTOX 
high dose 
(40 Units)  
(N=43) 
Placebo 
high dose 
(N=23) 
Median Change from Baseline in Thumb Flexor 
Muscle Tone on the modified Ashworth Scale†††a 
 
-1.0 
 
-1.0 
 
-0.5* 
 
0.0 
Median Change from Baseline in Clinical 
Global Impression Score by Physician †† 
 
1.0 
 
0.0 
 
2.0* 
 
0.0 
†† Secondary endpoint at Week 6 
††† Other endpoint at Week 6 
* Significantly different from placebo (p<0.010)  
a BOTOX injected into the adductor pollicis and flexor pollicis longus muscles 
 
Lower Limb Spasticity  
The efficacy and safety of BOTOX for the treatment of lower limb spasticity was evaluated in Study 6, a randomized, multi-center, 
double-blind, placebo-controlled study. Study 6  included 468 post-stroke patients (233 BOTOX and 235 placebo) with ankle 
spasticity (modified Ashworth Scale ankle score of at least 3) who were at least 3 months post-stroke. A total dose of 300 Units of 
BOTOX or placebo were injected intramuscularly and divided between the gastrocnemius, soleus, and tibialis posterior, with optional 
injection into the flexor hallucis longus, flexor digitorum longus, flexor digitorum brevis, extensor hallucis, and rectus femoris (see 
Table 33) with up to an additional 100 Units (400 Units total dose). The use of electromyographic guidance or nerve stimulation was 
required to assist in proper muscle localization for injections. Patients were followed for 12 weeks.  
 
Table 33: Study Medication Dose and Injection Sites in Study 6  
Muscles Injected 
BOTOX 
(Units) 
Number of 
Injection Sites 
Mandatory Ankle Muscles 
Gastrocnemius (medial head) 
75 
3 
Gastrocnemius (lateral head) 
75 
3 
Soleus 
75 
3 
Tibialis Posterior 
75 
3 
Optional Muscles 
Flexor Hallucis Longus 
50 
2 
Flexor Digitorum Longus 
50 
2 
Flexor Digitorum Brevis 
25 
1 
Extensor Hallucis 
25 
1 
Rectus Femoris 
100 
4 
 
The co-primary endpoints were the average of the change from baseline in modified Ashworth Scale (MAS) ankle score at Week 4 
and Week 6, and the average of the Physician Global Assessment of Response (CGI) at Week 4 and Week 6. The CGI evaluated the 
response to treatment in terms of how the patient was doing in his/her life using a 9-point scale from -4=very marked worsening to 
+4=very marked improvement).   
 
Statistically significant between-group differences for BOTOX over placebo were demonstrated for the co-primary efficacy measures 
of MAS and CGI (see Table 34). 
 
Page 71 of 92

 
 
Table 34: Co-Primary Efficacy Endpoints Results in Study 6 (Intent-to-treat Population) 
 
BOTOX 
300 to 400 Units 
(N=233) 
Placebo 
 
(N=235) 
Mean Change from Baseline in Ankle Plantar 
Flexors on the modified Ashworth Scale 
 
 
Week 4 and 6 Average 
-0.8* 
-0.6 
Mean Clinical Global Impression Score by 
Investigator 
 
 
Week 4 and 6 Average 
0.9* 
0.7 
* Significantly different from placebo (p<0.05) 
 
Compared to placebo, significant improvements in MAS change from baseline for ankle plantar flexors (see Figure 11) and CGI (see 
Figure 12) were observed at Week 2, Week 4, and Week 6 for patients treated with BOTOX. 
 
Figure 11: Modified Ashworth Scale Ankle Score for Study 6 – Mean Change from Baseline by Visit 
 
 
Figure 12: Clinical Global Impression by Physician for Study 6 – Mean Scores by Visit 
 
 
14.5 
Cervical Dystonia 
A randomized, multi-center, double-blind, placebo-controlled study of the treatment of cervical dystonia was conducted. This study 
enrolled adult patients with cervical dystonia and a history of having received BOTOX in an open label manner with perceived good 
response and tolerable side effects. Patients were excluded if they had previously received surgical or other denervation treatment for 
their symptoms or had a known history of neuromuscular disorder. Subjects participated in an open label enrichment period where 
they received their previously employed dose of BOTOX. Only patients who were again perceived as showing a response were 
advanced to the randomized evaluation period. The muscles in which the blinded study agent injections were to be administered were 
determined on an individual patient basis. 
 
There were 214 subjects evaluated for the open label period, of which 170 progressed into the randomized, blinded treatment period 
(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 
Page 72 of 92

 
 
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 allots 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. 
 
Table 35: Efficacy Outcomes of the Phase 3 Cervical Dystonia Study (Group Means) 
 
Placebo 
(N=82) 
BOTOX        
(N=88) 
95% CI on 
Difference 
Baseline CDSS 
9.3 
9.2 
 
Change in CDSS  
at Week 6 
-0.3 
-1.3 
(-2.3, 0.3)[a,b] 
% Patients with Any 
Improvement on 
Physician Global 
Assessment 
31% 
51% 
(5%, 34%)[a] 
Pain Intensity Baseline 
1.8 
1.8 
 
Change in Pain Intensity 
at Week 6 
-0.1 
-0.4 
(-0.7, -0.2)[c] 
Pain Frequency Baseline 
1.9 
1.8 
 
Change in Pain 
Frequency at Week 6 
-0.0 
-0.3 
(-0.5, -0.0)[c] 
[a] Confidence intervals are constructed from the analysis of covariance table with treatment and investigational site as main effects, 
and baseline CDSS as a covariate. 
[b] These values represent the prospectively planned method for missing data imputation and statistical test. Sensitivity analyses 
indicated that the 95% confidence interval excluded the value of no difference between groups and the p-value was less than 0.05. 
These analyses included several alternative missing data imputation methods and non-parametric statistical tests. 
[c] Confidence intervals are based on the t-distribution.  
 
Exploratory analyses of this study suggested that the majority of patients who had shown a beneficial response by week 6 had returned 
to their baseline status by 3 months after treatment. Exploratory analyses of subsets by patient sex and age suggest that both sexes 
receive benefit, although female patients may receive somewhat greater amounts than male patients. There is a consistent treatment-
associated effect between subsets greater than and less than age 65. There were too few non-Caucasian patients enrolled to draw any 
conclusions regarding relative efficacy in racial subsets. 
 
In this study the median total BOTOX dose in patients randomized to receive BOTOX (N=88) was 236 Units, with 25th to 75th 
percentile ranges of 198 Units to 300 Units. Of these 88 patients, most received injections to 3 or 4 muscles; 38 received injections to 
3 muscles, 28 to 4 muscles, 5 to 5 muscles, and 5 to 2 muscles. The dose was divided amongst the affected muscles in quantities 
shown in Table 36. The total dose and muscles selected were tailored to meet individual patient needs. 
 
Table 36: Number of Patients Treated per Muscle and Fraction of Total Dose Injected into Involved Muscles 
 
 
Muscle 
Number of 
Patients Treated 
in this Muscle  
(N=88) 
 
Mean % Dose 
per Muscle  
 
Mid-Range of % 
Dose per Muscle* 
Splenius capitis/cervicis 
83 
38 
25-50 
Sternocleidomastoid 
77 
25 
17-31 
Levator scapulae 
52 
20 
16-25 
Trapezius 
49 
29 
18-33 
Semispinalis 
16 
21 
13-25 
Scalene 
15 
15 
6-21 
Longissimus 
8 
29 
17-41 
* The mid-range of dose is calculated as the 25th to 75th percentiles. 
 
Page 73 of 92

 
 
There were several randomized studies conducted prior to the double-blind, placebo-controlled study, which were supportive but not 
adequately designed to assess or quantitatively estimate the efficacy of BOTOX. 
 
14.6 
Primary Axillary Hyperhidrosis 
The efficacy and safety of BOTOX for the treatment of primary axillary hyperhidrosis were evaluated in two randomized, multi-
center, double-blind, placebo-controlled studies. Study 1 included adult patients with persistent primary axillary hyperhidrosis who 
scored 3 or 4 on a Hyperhidrosis Disease Severity Scale (HDSS) and who produced at least 50 mg of sweat in each axilla at rest over 5 
minutes. HDSS is a 4-point scale with 1 = “underarm sweating is never noticeable and never interferes with my daily activities”; to 4 
= “underarm sweating is intolerable and always interferes with my daily activities”. A total of 322 patients were randomized in a 1:1:1 
ratio to treatment in both axillae with either 50 Units of BOTOX, 75 Units of BOTOX, or placebo. Patients were evaluated at 4-week 
intervals. Patients who responded to the first injection were re-injected when they reported a re-increase in HDSS score to 3 or 4 and 
produced at least 50 mg sweat in each axilla by gravimetric measurement, but no sooner than 8 weeks after the initial injection.  
 
Study responders were defined as patients who showed at least a 2-grade improvement from baseline value on the HDSS 4 weeks after 
both of the first two treatment sessions or had a sustained response after their first treatment session and did not receive re-treatment 
during the study. Spontaneous resting axillary sweat production was assessed by weighing a filter paper held in the axilla over a period 
of 5 minutes (gravimetric measurement). Sweat production responders were those patients who demonstrated a reduction in axillary 
sweating from baseline of at least 50% at week 4. 
 
In the three study groups the percentage of patients with baseline HDSS score of 3 ranged from 50% to 54% and from 46% to 50% for 
a score of 4. The median amount of sweat production (averaged for each axilla) was 102 mg, 123 mg, and 114 mg for the placebo, 50 
Units and 75 Units groups respectively. 
 
The percentage of responders based on at least a 2-grade decrease from baseline in HDSS or based on a >50% decrease from baseline 
in axillary sweat production was greater in both BOTOX groups than in the placebo group (p<0.001), but was not significantly 
different between the two BOTOX doses (see Table 37). 
 
Duration of response was calculated as the number of days between injection and the date of the first visit at which patients returned to 
3 or 4 on the HDSS scale. The median duration of response following the first treatment in BOTOX treated patients with either dose 
was 201 days. Among those who received a second BOTOX injection, the median duration of response was similar to that observed 
after the first treatment. 
 
In study 2, 320 adults with bilateral axillary primary hyperhidrosis were randomized to receive either 50 Units of BOTOX (n=242) or 
placebo (n=78). Treatment responders were defined as subjects showing at least a 50% reduction from baseline in axillary sweating 
measured by gravimetric measurement at 4 weeks. At week 4 post-injection, the percentages of responders were 91% (219/242) in the 
BOTOX group and 36% (28/78) in the placebo group, p<0.001. The difference in percentage of responders between BOTOX and 
placebo was 55% (95% CI=43.3, 65.9). 
 
Table 37: Study 1 - Study Outcomes 
 
 
Treatment Response 
BOTOX 
50 Units 
(N=104) 
BOTOX 
75 Units 
(N=110) 
Placebo  
(N=108) 
BOTOX 
50-placebo  
(95% CI) 
BOTOX 
75-placebo 
(95% CI) 
HDSS Score change >2 
(n)a 
55% (57) 
49% (54) 
6% (6) 
 
49.3% 
(38.8, 59.7) 
43% 
(33.2, 53.8) 
>50% decrease in 
axillary sweat 
production % (n) 
81% (84) 
86% (94) 
41% (44) 
40% 
(28.1, 52.0) 
45% 
(33.3, 56.1) 
a Patients who showed at least a 2-grade improvement from baseline value on the HDSS 4 weeks after both of the first two treatment 
sessions or had a sustained response after their first treatment session and did not receive re-treatment during the study. 
 
14.7 
Blepharospasm 
Botulinum toxin has been investigated for use in patients with blepharospasm in several studies. In an open label, historically 
controlled study, 27 patients with essential blepharospasm were injected with 2 Units of BOTOX at each of six sites on each side. 
Twenty-five of the 27 patients treated with botulinum toxin reported improvement within 48 hours. One patient was controlled with a 
higher dosage at 13 weeks post initial injection and one patient reported mild improvement but remained functionally impaired. 
 
In another study, 12 patients with blepharospasm were evaluated in a double-blind, placebo-controlled study. Patients receiving 
botulinum toxin (n=8) improved compared with the placebo group (n=4). The effects of the treatment lasted a mean of 12 weeks.  
 
Page 74 of 92

 
 
One thousand six hundred eighty-four patients with blepharospasm who were evaluated in an open label trial showed clinical 
improvement as evaluated by measured eyelid force and clinically observed intensity of lid spasm, lasting an average of 12 weeks 
prior to the need for re-treatment. 
 
14.8 
Strabismus 
Six hundred seventy-seven patients with strabismus treated with one or more injections of BOTOX were evaluated in an open label 
trial. Fifty-five percent of these patients improved to an alignment of 10 prism diopters or less when evaluated six months or more 
following injection.   
 
16 
HOW SUPPLIED/STORAGE AND HANDLING 
BOTOX is supplied in a single-use vial in the following sizes: 
100 Units      NDC 0023-1145-01 
200 Units      NDC 0023-3921-02 
 
Vials of BOTOX have a holographic film on the vial label that contains the name “Allergan” within horizontal lines of rainbow color. 
In order to see the hologram, rotate the vial back and forth between your fingers under a desk lamp or fluorescent light source. (Note: 
the holographic film on the label is absent in the date/lot area.) If you do not see the lines of rainbow color or the name “Allergan”, do 
not use the product and contact Allergan for additional information at 1-800-890-4345 from 7:00 AM to 3:00 PM Pacific Time. 
 
Storage 
Unopened vials of BOTOX should be stored in a refrigerator (2° to 8°C) for up to 36 months. Do not use after the expiration date on 
the vial. Administer BOTOX within 24 hours of reconstitution; during this period reconstituted BOTOX should be stored in a 
refrigerator (2° to 8°C). Reconstituted BOTOX should be clear, colorless, and free of particulate matter. 
 
17 
PATIENT COUNSELING INFORMATION 
Advise the patient to read the FDA-approved patient labeling (Medication Guide). 
 
Swallowing, Speaking or Breathing Difficulties, or Other Unusual Symptoms  
Advise patients to inform their doctor or pharmacist if they develop any unusual symptoms (including difficulty with swallowing, 
speaking, or breathing), or if any existing symptom worsens [see Boxed Warning and Warnings and Precautions (5.2, 5.6)]. 
 
Ability to Operate Machinery or Vehicles 
Advise patients that if loss of strength, muscle weakness, blurred vision, dizziness, or drooping eyelids occur, they should avoid 
driving a car or engaging in other potentially hazardous activities. 
 
Voiding Symptoms after Bladder Injections 
After bladder injections for urinary incontinence, advise patients to contact their physician if they experience difficulties in voiding or 
burning sensation upon voiding.  
 
Manufactured by:Allergan Pharmaceuticals Ireland a subsidiary of: Allergan, Inc.  2525 Dupont Dr. Irvine, CA 92612 
© 2017 Allergan. All rights reserved. 
All trademarks are the property of their respective owners.    
Patented. www.allergan.com/patents  
Irvine, CA 92612   
 
 
 
Page 75 of 92

 
 
 
MEDICATION GUIDE 
BOTOX®  
BOTOX® Cosmetic  
(Boe-tox) 
(onabotulinumtoxinA) 
for Injection 
What is the most important information I should know about BOTOX and BOTOX Cosmetic? 
BOTOX and BOTOX Cosmetic may cause serious side effects that can be life threatening, 
including: 
x 
Problems breathing or swallowing 
x 
Spread of toxin effects 
These problems can happen hours, days, to weeks after an injection of BOTOX or BOTOX 
Cosmetic. Call your doctor or get medical help right away if you have any of these problems after 
treatment with BOTOX or BOTOX Cosmetic: 
x 
Problems swallowing, speaking, or breathing. These problems can happen hours, days, to 
weeks after an injection of BOTOX or BOTOX Cosmetic usually because the muscles that you 
use to breathe and swallow can become weak after the injection. Death can happen as a 
complication if you have severe problems with swallowing or breathing after treatment with BOTOX or 
BOTOX Cosmetic.  
o 
People with certain breathing problems may need to use muscles in their neck to help them 
breathe. These people may be at greater risk for serious breathing problems with BOTOX or 
BOTOX Cosmetic.   
o 
Swallowing problems may last for several months. People who cannot swallow well may need a 
feeding tube to receive food and water. If swallowing problems are severe, food or liquids may go 
into your lungs. People who already have swallowing or breathing problems before receiving 
BOTOX or BOTOX Cosmetic have the highest risk of getting these problems. 
x 
Spread of toxin effects. In some cases, the effect of botulinum toxin may affect areas of the body 
away from the injection site and cause symptoms of a serious condition called botulism. The 
symptoms of botulism include:   
o 
loss of strength and muscle weakness all over the body 
o 
double vision, blurred vision and drooping eyelids 
o 
hoarseness or change or loss of voice (dysphonia) 
o 
trouble saying words clearly (dysarthria) 
o 
loss of bladder control 
o 
trouble breathing 
o 
trouble swallowing 
These symptoms can happen hours, days, to weeks after you receive an injection of BOTOX or BOTOX 
Cosmetic. 
These problems could make it unsafe for you to drive a car or do other dangerous activities. See "What 
should I avoid while receiving BOTOX or BOTOX Cosmetic?" 
There has not been a confirmed serious case of spread of toxin effect away from the injection site when 
BOTOX has been used at the recommended dose to treat chronic migraine, severe underarm sweating, 
blepharospasm, or strabismus, or when BOTOX Cosmetic has been used at the recommended dose to 
treat frown lines, crow’s feet lines, and/or forehead lines. 
Page 76 of 92

 
 
What are BOTOX and BOTOX Cosmetic? 
BOTOX is a prescription medicine that is injected into muscles and used: 
x 
to treat overactive bladder symptoms such as a strong need to urinate with leaking or wetting 
accidents (urge urinary incontinence), a strong need to urinate right away (urgency), and urinating 
often (frequency) in adults when another type of medicine (anticholinergic) does not work well enough 
or cannot be taken. 
x 
to treat leakage of urine (incontinence) in adults with overactive bladder due to neurologic disease 
when another type of medicine (anticholinergic) does not work well enough or cannot be taken. 
x 
to prevent headaches in adults with chronic migraine who have 15 or more days each month with 
headache lasting 4 or more hours each day. 
x 
to treat increased muscle stiffness in elbow, wrist, and finger muscles in adults with upper limb 
spasticity. 
x 
to treat increased muscle stiffness in ankle and toe muscles in adults with lower limb spasticity. 
x 
to treat the abnormal head position and neck pain that happens with cervical dystonia (CD) in adults.  
x 
to treat certain types of eye muscle problems (strabismus) or abnormal spasm of the eyelids 
(blepharospasm) in people 12 years and older. 
BOTOX is also injected into the skin to treat the symptoms of severe underarm sweating (severe primary 
axillary hyperhidrosis) when medicines used on the skin (topical) do not work well enough.  
BOTOX Cosmetic is a prescription medicine for adults that is injected into muscles and used for a short 
period of time (temporary) to improve the look of: 
x 
moderate to severe frown lines between the eyebrows (glabellar lines)  
x 
moderate to severe crow’s feet lines 
x 
moderate to severe forehead lines 
You may receive treatment for frown lines, crow’s feet lines, and forehead lines at the same time. 
It is not known whether BOTOX is safe or effective in people younger than: 
x 
18 years of age for treatment of urinary incontinence  
x 
18 years of age for treatment of chronic migraine 
x 
18 years of age for treatment of spasticity 
x 
16 years of age for treatment of cervical dystonia 
x 
18 years of age for treatment of hyperhidrosis 
x 
12 years of age for treatment of strabismus or blepharospasm 
BOTOX Cosmetic is not recommended for use in children younger than 18 years of age.   
It is not known whether BOTOX and BOTOX Cosmetic are safe or effective to prevent headaches in 
people with migraine who have 14 or fewer headache days each month (episodic migraine). 
It is not known whether BOTOX and BOTOX Cosmetic are safe or effective for other types of muscle 
spasms or for severe sweating anywhere other than your armpits. 
It is not known if BOTOX Cosmetic is safe and effective for use more than 1 time every 3 months.   
 
Who should not receive BOTOX or BOTOX Cosmetic? 
Do not receive BOTOX or BOTOX Cosmetic if you: 
x 
are allergic to any of the ingredients in BOTOX or BOTOX Cosmetic. See the end of this Medication 
Guide for a list of ingredients in BOTOX and BOTOX Cosmetic.  
x 
had an allergic reaction to any other botulinum toxin product such as Myobloc®, Dysport®, or Xeomin® 
x 
have a skin infection at the planned injection site  
x 
are being treated for urinary incontinence and have a urinary tract infection (UTI)  
x 
are being treated for urinary incontinence and find that you cannot empty your bladder on your own 
(only applies to people who are not routinely catheterizing) 
What should I tell my doctor before receiving BOTOX or BOTOX Cosmetic? 
Tell your doctor about all your medical conditions, including if you: 
x 
have a disease that affects your muscles and nerves (such as amyotrophic lateral sclerosis [ALS or 
Lou Gehrig's disease], myasthenia gravis or Lambert-Eaton syndrome). See "What is the most 
important information I should know about BOTOX and BOTOX Cosmetic?" 
Page 77 of 92

 
 
x 
have allergies to any botulinum toxin product 
x 
had any side effect from any botulinum toxin product in the past 
x 
have or have had a breathing problem, such as asthma or emphysema 
x 
have or have had swallowing problems 
x 
have or have had bleeding problems 
x 
have plans to have surgery  
x 
had surgery on your face 
x 
have weakness of your forehead muscles, such as trouble raising your eyebrows 
x 
have drooping eyelids 
x 
have any other change in the way your face normally looks 
x 
have symptoms of a urinary tract infection (UTI) and are being treated for urinary incontinence. 
Symptoms of a urinary tract infection may include pain or burning with urination, frequent urination, or 
fever.    
x 
have problems emptying your bladder on your own and are being treated for urinary incontinence 
x 
are pregnant or plan to become pregnant. It is not known if BOTOX or BOTOX Cosmetic can harm 
your unborn baby. 
x 
are breastfeeding or plan to breastfeed. It is not known if BOTOX or BOTOX Cosmetic passes into 
breast milk. 
Tell your doctor about all the medicines you take, including prescription and over-the-counter 
medicines, vitamins and herbal supplements. Using BOTOX or BOTOX Cosmetic with certain other 
medicines may cause serious side effects. Do not start any new medicines until you have told your 
doctor that you have received BOTOX or BOTOX Cosmetic in the past. 
Especially tell your doctor if you: 
x 
have received any other botulinum toxin product in the last four months 
x 
have received injections of botulinum toxin, such as Myobloc® (rimabotulinumtoxinB), Dysport® 
(abobotulinumtoxinA), or Xeomin® (incobotulinumtoxinA) in the past. Be sure your doctor knows 
exactly which product you received.  
x 
have recently received an antibiotic by injection  
x 
take muscle relaxants 
x 
take an allergy or cold medicine 
x 
take a sleep medicine 
x 
take anti-platelets (aspirin-like products) and/or anti-coagulants (blood thinners) 
Ask your doctor if you are not sure if your medicine is one that is listed above. 
Know the medicines you take. Keep a list of your medicines with you to show your doctor and pharmacist 
each time you get a new medicine. 
How will I receive BOTOX or BOTOX Cosmetic? 
x 
BOTOX or BOTOX Cosmetic is an injection that your doctor will give you. 
x 
BOTOX is injected into your affected muscles, skin, or bladder. 
x 
BOTOX Cosmetic is injected into your affected muscles. 
x 
Your doctor may change your dose of BOTOX or BOTOX Cosmetic, until you and your doctor find 
the best dose for you.  
x 
Your doctor will tell you how often you will receive your dose of BOTOX or BOTOX Cosmetic 
injections. 
What should I avoid while receiving BOTOX or BOTOX Cosmetic? 
BOTOX and BOTOX Cosmetic may cause loss of strength or general muscle weakness, vision 
problems, or dizziness within hours to weeks of taking BOTOX or BOTOX Cosmetic. If this happens, 
do not drive a car, operate machinery, or do other dangerous activities. See "What is the most 
important information I should know about BOTOX and BOTOX Cosmetic?" 
What are the possible side effects of BOTOX and BOTOX Cosmetic? 
BOTOX and BOTOX Cosmetic can cause serious side effects. See "What is the most important 
information I should know about BOTOX and BOTOX Cosmetic?" 
Other side effects of BOTOX and BOTOX Cosmetic include: 
x 
dry mouth 
Page 78 of 92

 
 
x 
discomfort or pain at the injection site 
x 
tiredness 
x 
headache 
x 
neck pain 
x 
eye problems: double vision, blurred vision, decreased eyesight, drooping eyelids, swelling of your 
eyelids, and dry eyes.  
x 
drooping eyebrows 
x 
urinary tract infection in people being treated for urinary incontinence 
x 
painful urination in people being treated for urinary incontinence 
x 
inability to empty your bladder on your own and are being treated for urinary incontinence. If you have 
difficulty fully emptying your bladder after getting BOTOX, you may need to use disposable self-
catheters to empty your bladder up to a few times each day until your bladder is able to start 
emptying again. 
x 
allergic reactions. Symptoms of an allergic reaction to BOTOX or BOTOX Cosmetic may include: 
itching, rash, red itchy welts, wheezing, asthma symptoms, or dizziness or feeling faint. Tell your 
doctor or get medical help right away if you are wheezing or have asthma symptoms, or if you 
become dizzy or faint. 
Tell your doctor if you have any side effect that bothers you or that does not go away. 
These are not all the possible side effects of BOTOX and BOTOX Cosmetic. For more information, ask 
your doctor or pharmacist. 
Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-
1088.  
General information about BOTOX and BOTOX Cosmetic: 
Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide.   
This Medication Guide summarizes the most important information about BOTOX and BOTOX 
Cosmetic. If you would like more information, talk with your doctor. You can ask your doctor or 
pharmacist for information about BOTOX and BOTOX Cosmetic that is written for healthcare 
professionals.  
What are the ingredients in BOTOX and BOTOX Cosmetic? 
Active ingredient: onabotulinumtoxin A 
Inactive ingredients: human albumin and sodium chloride 
Manufactured by: Allergan Pharmaceuticals Ireland a subsidiary of: Allergan, Inc.  2525 Dupont Dr. Irvine, CA 92612 
2017 Allergan. All rights reserved. All trademarks are the property of their respective owners. 
Patented. See: www.allergan.com/patents 
This Medication Guide has been approved by the U.S. Food and Drug Administration.                                          Revised: 10/2017 
 
72309US21 
72312US21 
72511US17 
 
 
Page 79 of 92

PARTNERS HUMAN RESEARCH COMMITTEE
PROTOCOL SUMMARY
Partners Human Subjects Research Application Form
Filename: Protocol Summary
Version Date:  June 1, 2005
 
1
Answer all questions accurately and completely in order to provide the PHRC with the relevant 
information to assess the risk-benefit ratio for the study.  Do not leave sections blank.
PRINCIPAL/OVERALL INVESTIGATOR
This is a joint research project:
Dr. William Gerald Austen Jr. is the PI at Partners.
Dr. Rami Burstein is the Principal Investigator at BIDMC 
PROTOCOL TITLE
Novel concepts for OnabotulinumtoxinA (Botox) mechanisms of action: role in altering the 
molecular environment in which pain fibers exist
FUNDING
Allergan Inc.
VERSION DATE
11/13/18
SPECIFIC AIMS
Concisely state the objectives of the study and the hypothesis being tested.
To compare Botox-treated and Botox-untreated symptomatic tissues (defined as areas where the 
head hurts and the pain is felt) of chronic migraine (CM) patients using targeted transcriptome and 
genome-wide epigenome analysis.  This aim will test the hypothesis that Botox reverses the 
abnormal expression of inflammatory genes in headache-affected regions and pericranial muscles, 
fascia, and perineurium of nerves supplying them.
BACKGROUND AND SIGNIFICANCE
Provide a brief paragraph summarizing prior experience important for understanding the 
proposed study and procedures. 
The broad objective of this proposal is to understand better how Botox works and determine 
whether it can attenuate inflammation.  Based on our preliminary findings, we expect the proposed 
research to vastly expand the understanding of Botox MOA, both in migraine prophylaxis and 
somatic pain conditions associated with inflammation.  Scientifically, we expect to gain new insight 
into the role played by Botox in environments that surround relevant peripheral nociceptors – 
potentially by attenuating local expression of pro-inflammatory molecules (mRNA) and their post-
transcriptional regulators (non-coding RNA).  In the context of migraine, such tissues include the 
calvarial periosteum, galea aponeurotica, pericranial muscles and fascia surrounding extracranial 
nerves (e.g., occipital, supraorbital, auriculotemporal nerves).  In the context of other somatic 
Page 80 of 92

Partners Human Subjects Research Application Form
Filename: Protocol Summary
Version Date:  June 1, 2005
 
2
pains, such tissues include muscles, fascia, and the perineurium.  The potential impacts of the 
proposed research is that if successful, it will broaden the clinical use of Botox.  Equally important, 
it will define a novel framework for conceptualizing about Botox MOA and consequently, why and 
how it may be used to treat other pains and possibly conditions associated with abnormal 
inflammatory and immune responses. 
The goals of the proposed research will be achieved by studying tissues commonly discarded 
during nerve decompression surgeries performed to alleviate neck and head pain in chronic 
migraineurs.  These goals were formulated on the basis of two sets of preliminary clinical findings.  
The first showed that gene transcripts (mRNA) that promote immune and inflammatory responses 
are significantly upregulated in calvarial periosteum of CM patients (as compared to control 
subjects) and that gene transcripts (mRNA) that reduce immune and inflammatory responses are 
significantly down-regulated in calvarial periosteum of CM patients (as compared to control 
subjects).
In more detail, there is new evidence of extracranial origins of migraine headache. Clinically, 
there is data that describes an imploding headache (extracranial) versus exploding headache 
(intracranial) [1]. There is evidence that expression of proinflammatory genes (eg, CCL8, TLR2) 
in the calvarial periosteum is significantly increased in CM patients, whereas expression of 
genes that suppress inflammation and immune cell differentiation (eg, IL10RA, CSF1R) is 
decreased. It is well known that anti- inflammatory drugs improve migraine attacks. It has further 
been shown that extracranial administration of OnabotulinumtoxinA is effective in reducing the 
number of migraine days per month in patients who testified to having ‘imploding’, but not in 
those who testified to having ‘exploding’ headache [2]. The identification of extracranial 
pathophysiologies in chronic migraine patients whose headaches are most commonly perceived 
as imploding, and the finding that imploding migraine patients are those who benefit most from 
prophylactic treatment with OnabotulinumtoxinA [1], gave rise to a theory that Botox may help 
patients with imploding headache due to anti- inflammatory properties. 
1. Jakubowski M, McAllister PJ, Bajwa ZH, Ward TN, Smith P, Burstein R (2006) Exploding vs. 
imploding headache in migraine prophylaxis with Botulinum Toxin A. Pain 125 (3):286-295. 
doi:10.1016/j.pain.2006.09.012
2. Burstein R, Dodick D, Silberstein S (2009) Migraine prophylaxis with botulinum toxin A is 
associated with perception of headache. Toxicon 54 (5):624-627. 
doi:10.1016/j.toxicon.2009.01.009
RESEARCH DESIGN AND METHODS
Briefly describe study design and anticipated enrollment, i.e., number of subjects to be enrolled 
by researchers study-wide and by Partners researchers.  Provide a brief summary of the 
eligibility criteria (for example, age range, gender, medical condition).  Include any local site 
restrictions, for example, “Enrollment at Partners will be limited to adults although the sponsor’s 
protocol is open to both children and adults.”
Patients diagnosed with chronic migraine (fulfill criteria for CM as defined in the ICHD-3 beta), 
especially those complaining about chronic muscle tenderness, are routinely considered good 
candidate to benefit from a surgery in which trapped nerves are decompressed.  In routine 
clinical care, such patients are referred to Dr. Perry to determine whether or not they fit to 
undergo the nerve decompression procedure.   Of great importance to the evaluation of the 
proposed study is the fact that the decision on whether or not to operate is unrelated to and 
independent of any academic study.  Those deemed good candidate for the surgery would be 
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Partners Human Subjects Research Application Form
Filename: Protocol Summary
Version Date:  June 1, 2005
 
3
presented with an option to hear about the study from Dr. Austen, the plastic surgeon 
responsible for their well-being during the surgery and the one handling the discarded tissues.  
Those interested in hearing about the study will be presented with all the necessary details 
required by the IRB and then given the option to sign (or not to sign).  
Accordingly, up to 50 65 chronic migraine patients will be recruited to the study (if they are 
found fit to undergo the surgery) by Dr. Austen, a certified plastic surgeon with enormous 
experience in performing these procedures.  
Inclusion Criteria:
•
Age 18-65 years
•
Diagnosis of Chronic Migraine consistent with International Classification of 
Headache Disorders (ICHD-III) criteria, with a history of bilateral headache pain and 
chronic tenderness in neck muscles
•
Patient is capable and willing to provide informed consent
•
Female subjects of child bearing potential must have a negative pregnancy test at 
enrollment and agree to remain abstinent or use acceptable methods of birth control 
(i.e., hormonal contraceptives, inrauterindevce, diaphragm with spermicide, cervidal 
cap or spong, condoms or partner has had a vasectomy) for three months following 
injections of Botox
•
Patients referred by their primary Neurologist to the study surgeon and who are 
determined to be candidates for surgical decompression of extracranial sensory 
nerves.
•
Patient agrees to abstain from protocol-specific excluded medications (see Appendix 
A) beginning 14 days prior to the decompression surgery.
Exclusion Criteria:
•
Patient has hypersensitivity reactions or other intolerance to Botox
•
Patient is pregnant or trying to become pregnant with the timeframe of the study.
Infection at proposed injection sites 
Those who agree to participate in the study, will be asked to fill out a 15min headache 
questionnaire that contains questions about their headaches. Subjects will also be asked to 
complete a headache diary 3 months prior to botox injections. 
The headache diary will be filled out every day for 3 months prospectively prior to botox 
injection. Subjects will indicate whether they had migraines that day (check date box), what 
severity the migraines were (on a scale of 0-10), what the duration was (hours), what the 
location was, which other symptoms they experienced, which medications they took, how often 
they went to the ED, saw doctors or missed work and how much the total cost was. The total 
time spent every day filling out the diary should not exceed 5min.
Study subjects will be injected with Botox on one side of the back of the head. The FDA-
approved injection paradigm includes 7 muscles (Frontalis, Corugator, Procerus, Occipitalis, 
temporalis, Trapezius, and the Cervical Paraspinal muscle group), 31 sites and 155 units 
divided as follows: Frontalis – 4 sites, 5 units in each; Corrugator – 2 sites, 5 units in each; 
Procerus – 1 site, 5 units; Occipitalis – 6 sites, 5 units at each; Temporalis – 8 sites, 5 units in 
each; Trapezius – 6 sites, 5 units at each; Cervical Paraspinal – 4 sites, 5 units in each. 
Of these muscles, sites and doses, patients will be injected (from a 100 Unit vial of OnabotulinumtoxinA 
reconstituted per product manufacturer label instructions) as follows:
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Filename: Protocol Summary
Version Date:  June 1, 2005
 
4
(A)
2 sites in the Occipitalis muscle (5 units each)
(B)
4 sites in the Cervical Paraspinal muscle group (5 units each)
(C)
2 sites in the Trapezius muscle (5 units each)
These injections will be given into one side only.  This deviates from the standard of care, as 
Botox is usually injected on both sides if pain is experienced on both sides. The selection will be 
random based on subject number. Odd numbers will be injected on the right and even numbers 
on the left. 
Because the standard surgical procedure involves removal of equal amount of corresponding 
tissues from both sides of the head, an opportunity is created here to analyze identical Botox-
treated and Botox-untreated tissues.  Importantly, all analyzed tissues are discarded as a part of 
the surgery and none is collected for the sake of the study.
Note that one of the standard clinical criteria that these patients must fulfill in order to qualify for 
the surgical decompression procedure (which is unrelated to the study) is to demonstrate that 
they have failed at least 3 attempts to treat their chronic migraine with (not necessarily Botox).  
Thus, all those who qualify for the study would have been treated with Botox at least twice 
before as per the FDA approved protocol.
Thirty days later, patients will undergo a study-unrelated nerve decompression surgery.  This 
procedure involves the removal of different tissues surrounding trapped branches of the 
occipital nerve.  These tissues include muscles, fascia, and periosteum (discarded tissue).  The 
amount of tissue removed at each area is many folds larger than the amount of tissue needed 
for sampling (less than the size of 1 grain of rice.
There will be two visits:
Screening visit: Patients will be screened for eligibility. This will be performed during the regular 
clinical assessment for surgery. The study visit will take 30min. The subject will be asked to 
complete a 15 min questionnaire and will be asked to fill out a 3m headache diary which may 
take up to 5min a day.
Preoperative visit: will be injected with Botulinum Toxin. This will take 30 minutes.
There will be further routine clinical visits postoperatively (one week, 3 months and 12 months). 
However, these visits are not related to the study but are part of regular follow up. No study 
materials for this study will be collected as part of this visit. 
Analysis to be Done at BIDMC
(A) Tissue processing, RNA isolation, genetic processing and mRNA counting will occur in 
Dr. Burstein’s lab at Beth Israel Deaconess Medical Center, Harvard Medical School.
Bioinformatics and biostatistics analyses will be conducted at Dr. Bhasin’s lab at Beth Israel 
Deaconess Medical Center, Harvard Medical School.
Briefly describe study procedures.  Include any local site restrictions, for example, “Subjects 
enrolled at Partners will not participate in the pharmacokinetic portion of the study.”  Describe 
study endpoints.
Subjects enrolled at partners will participate in all portions of the study.
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Version Date:  June 1, 2005
 
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For studies involving treatment or diagnosis, provide information about standard of care at 
Partners (e.g., BWH, MGH) and indicate how the study procedures differ from standard care.  
Provide information on available alternative treatments, procedures, or methods of diagnosis.
Since the surgery, itself is unrelated to the proposed study, all patients (those who sign the 
informed consent and those who chose not take part in the study) are booked for the surgery.  
Usual waiting time is 3-6 month.  Those who signed the informed consent will be booked for 
another visit to Dr. Austens clinic 30 days prior to their planned surgery.  In this visit, they will be 
injected with 40 units of Botox in one side of their head/neck as detailed below.
During surgery, calvarial periosteum, pericranial muscles and fascia surrounding nerves that are 
routinely removed and discarded, will be collected by Dr. Austen, stored in in RNAlater Solution, 
Ambion, CA, de-identified, frozen, and shipped overnight to Dr. Burstein’s lab at BIDMC, where 
each sample will be recorded, verified, prepared for processing, and analyzed for targeted 
transcriptome and epigenome involved in inflammatory and immune responses.  
The current standard of care for screening for migraine surgery includes injection of Botox to 
identify nerve triggers. In the occipital region, botox is either injected unilaterally or bilaterally 
depending on where pain occurs. When pain occurs bilaterally, Botox is injected on both sides. 
Subjects included in this study have bilateral occipital pain and would therefore as part of 
routine standard care be injected on both sides. As per this protocol, subjects will only be 
injected on one side. The risks of unilateral injection of botox (in addition to the risk of Botox in 
general outlined by the FDA) include continued pain on the uninjected side and/or injected side 
and one- sided muscle weakness, one- sided bruising, one sided infection on the injected side. . 
More generally, botox injections may cause the formation of anti-botox antibodies, which may 
decrease the effectiveness of botox treatment in other areas.
Subjects will be informed that they have the option to be injected with Botox on the uninjected 
side if any unwanted symptoms are experienced on the uninjected side. The cost of injection on 
the other side will be covered by the study funds.
A separate IRB protocol has already been approved for the use of discarded tissues, therefore 
this is also standard procedure.
Describe how risks to subjects are minimized, for example, by using procedures which are 
consistent with sound research design and which do not unnecessarily expose subjects to risk or 
by using procedures already being performed on the subject for diagnostic or treatment purposes.
All proposed procedures are part of standard care for chronic migraine patients except for 
unilateral injection of Botox for which the risks are explained above.
Describe explicitly the methods for ensuring the safety of subjects.  Provide objective criteria for 
removing a subject from the study, for example, objective criteria for worsening disease/lack of 
improvement and/or unacceptable adverse events.  The inclusion of objective drop criteria is 
especially important in studies designed with placebo control groups.
From the time of informed consent and for 3 months following injection, all self-reported adverse 
events will be reviewed by the study physician at each patient contact (patients are followed 
every 4 weeks after botox injection and one week, one month, three months, one year and after 
that yearly after surgery).  All serious adverse events will be reported to the IRB and designated 
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safety monitor within 24 hours of awareness of the event. All unanticipated problems involving 
risks to subjects or others including adverse events will be presorted to the PHRC in 
accordance with PHRC unanticipated problems including adverse events reporting guidelines.
Patients will not be included in the study if they are deemed poor candidates for surgery 
(screening occurs independent of this study). 
Only subjects who have been selected as a surgical candidate for sensory nerve 
decompression of chronic headache would have their tissue tested. The taking of the periosteal 
sample would add no additional risk to the operation, as we are obtaining tissue discarded 
during surgery.
Botox therapy is currently approved by the FDA for preventive treatment of migraines. Possible 
side effects of Botox therapy include bruising, pain during injection, twitching, itching, and 
numbness.
Overall, we believe the risks of this study are sufficiently low and that the benefits of information 
to be gained and the potential benefit of improved migraine treatment outweigh the risks in this 
study.
Patients can elect to withdraw from the study at any time.
FORESEEABLE RISKS AND DISCOMFORTS
Provide a brief description of any foreseeable risks and discomforts to subjects.  Include those 
related to drugs/devices/procedures being studied and/or administered/performed solely for 
research purposes.  In addition, include psychosocial risks, and risks related to privacy and 
confidentiality.  When applicable, describe risks to a developing fetus or nursing infant.
Only subjects who have been selected as a surgical candidate for sensory nerve 
decompression of chronic headache would have their tissue tested. The taking of the tissue 
samples would add no additional risk to the operation, as we are obtaining tissue discarded 
during surgery.
Botox therapy is currently approved by the FDA for preventive treatment of migraines. 
All the potential risks of Botox injections as issued by the FDA are as follows. As we are only 
injecting the back of the occiput, symptoms occurring around the eyes, the oropharynx or 
generalized symptoms are very unlikely.
A.  General: 
•
There have been rare spontaneous reports of death, sometimes associated with 
dysphagia, pneumonia, and/or other significant debility, after treatment with botulinum 
toxin.  
•
There have also been rare reports of adverse events involving the cardiovascular 
system, including arrhythmia and myocardial infarction, some with fatal outcomes.  
Some of these patients had risk factors including cardiovascular disease. The exact 
relationship of these events to the botulinum toxin injection has not been established.
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•
The following events have been reported since the drug has been marketed and a 
causal relationship to the botulinum toxin injected is unknown: skin rash (including 
erythema multiforme, urticaria and psoriasiform eruption), pruritus, and allergic reaction.  
•
In general, adverse events occur within the first week following injection of BOTOX® 
and while generally transient may have a duration of several months.  Localized pain, 
tenderness and/or bruising may be associated with the injection.  Local weakness of the 
injected muscle(s) represents the expected pharmacological action of botulinum toxin.  
However, weakness of adjacent muscles may also occur due to spread of toxin.
•
Extraocular muscles adjacent to the injection site can be affected, causing ptosis or 
vertical deviation, especially with higher doses of BOTOX.  The incidence rates of these 
adverse effects in 2058 adults who received a total of 3650 injections for horizontal 
strabismus are 15.7% and 16.9%, respectively.
•
The incidence of ptosis was 0.9% after inferior rectus injection and 37.7% after 
superior rectus injection.
B.  Side effects and discomforts associated with study treatment that subjects may 
experience include the following and some of these effects may last as long as 3 to 4 
months:
•
Drooping of the upper lid
•
Swelling of the eyelid
•
Dryness of the eye
•
Irritation/tearing of the eye
•
Difficulty in closing the upper lid
•
Sensitivity to light
•
Double vision
•
Soreness and/or bruising at the injection sites
•
Skin rash
•
Loss of facial wrinkling
•
Localized muscle weakness in the muscles which have been injected
•
Slight weakness in other muscles in the neck
•
Difficulty swallowing
•
Generalized weakness and fatigue
C.  If the subject experiences any illness or discomfort during the study, they should notify 
Dr. Austen.  Dr. Austen will then evaluate the subject to determine if the subject should 
continue in the study.
D.  There may be side effects or discomforts from the study treatment which are not yet 
known.  The subject could have an allergic reaction to BOTOX.  A severe allergic 
reaction could be life-threatening.
E.  Women who are pregnant, nursing a child, or planning a pregnancy during this study 
period may not participate in this study.  The subject must confirm that, to the best of 
their knowledge, they are not now pregnant, and that they do not intend to become 
pregnant during the study.  Prior to entering the study, the subject and the study doctor 
must agree on the method of birth control that they will use during the study.  If the 
subject suspects that they have become pregnant during the study, they must notify the 
study doctor immediately.  The sponsor of the study may need access to the subject’s 
medical records regarding their pregnancy and the outcome of their pregnancy.  In 
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addition, if they are pregnant or become pregnant during the study, there may be a risk 
of miscarriage or fetal malformation.
F. Treatment with BOTOX for the treatment of migraine headaches may result in the 
formation of antibodies that may reduce the effectiveness of subsequent treatments with 
BOTOX for other purposes. 
G. Botox injections are associated with pain from the needle prick with pain from the needle 
prick. A bruise may develop at the site, and there is a small chance the subject might get an 
infection. 
Overall, we believe the risks of this study are sufficiently low and that the benefits of information 
to be gained and the potential benefit of improved migraine treatment outweigh the risks in this 
study.
EXPECTED BENEFITS
Describe both the expected benefits to individual subjects participating in the research and the 
importance of the knowledge that may reasonably be expected to result from the study.  Provide 
a brief, realistic summary of potential benefits to subjects, for example, “It is hoped that the 
treatment will result in a partial reduction in tumor size in at least 25% of the enrolled subjects.”  
Indicate how the results of the study will benefit future patients with the disease/condition being 
studied and/or society, e.g., through increased knowledge of human physiology or behavior, 
improved safety, or technological advances.
It is not possible to predict whether participants will benefit directly from participation in this study.  
However, their participation may help others in the future as a result of knowledge gained from the 
research
It is important to note that the clinical outcome of the procedure is unrelated to the proposed study.  
While improvement (or lack of improvement) in headache days per month after the procedure is 
followed by Dr. Austen, it is outside the scope of the proposed study and as such will not be 
collected or reported.
EQUITABLE SELECTION OF SUBJECTS
The risks and benefits of the research must be fairly distributed among the populations that stand 
to benefit from it.  No group of persons, for example, men, women, pregnant women, children, 
and minorities, should be categorically excluded from the research without a good scientific or 
ethical reason to do so.  Please provide the basis for concluding that the study population is 
representative of the population that stands to potentially benefit from this research.
Currently, migraine surgery is only standard of care for adult patients who have failed multiple 
drugs. Pregnant women are not candidates for surgery due to anesthesia risks and cannot be 
included in this study. Further, Botox is not recommended in pregnancy. Children are not 
candidates for the same reasons. All other adults can be included in the study if they able to 
sign surgical consent and are English speakers. 
When people who do not speak English are excluded from participation in the research, provide 
the scientific rationale for doing so.  Individuals who do not speak English should not be denied 
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participation in research simply because it is inconvenient to translate the consent form in 
different languages and to have an interpreter present.
The headache questionnaire provided has been validated in English speaking populations only. 
For guidance, refer to the following Partners policy:
          Obtaining and Documenting Informed Consent of Subjects who do not Speak English
          http://healthcare.partners.org/phsirb/nonengco.htm
RECRUITMENT PROCEDURES
Explain in detail the specific methodology that will be used to recruit subjects.  Specifically 
address how, when, where and by whom subjects will be identified and approached about 
participation.  Include any specific recruitment methods used to enhance recruitment of women 
and minorities.
Recruitment
Patient screening, recruitment and consent will occur at Dr. Austen’s clinic (MGH plastic surgery 
clinic) during a visit that determines their candidacy to undergo the surgery. As migraine 
prevalence is high in females we do not feel the need to enhance recruitment for women.
Patients are referred to the investigator or schedule an appointment independently for migraine 
surgery routinely. Subjects will be selected from among the patients that are referred to the 
investigator. A research nurse will initially explain participation in the study prior to the visit with 
the investigator. The patient will be given the consent forms and can take us much time as 
needed to consent for the study. The patient can also take the consent form home and call if 
interested. At the scheduled visit with the investigator he will reinforce that participation is 
voluntary and with their patients that participation is voluntary, that they do not have to 
participate, and the decision not to participate will not affect their care, now or in the future. The 
investigator can answer any questions the subject may have.
Subject Protection
Study subjects will not be employees of the study team. 
Provide details of remuneration, when applicable.  Even when subjects may derive medical 
benefit from participation, it is often the case that extra hospital visits, meals at the hospital, 
parking fees or other inconveniences will result in additional out-of-pocket expenses related to 
study participation.  Investigators may wish to consider providing reimbursement for such 
expenses when funding is available
There is no subject remuneration.
For guidance, refer to the following Partners policies:
          Recruitment of Research Subjects 
          http://healthcare.partners.org/phsirb/recruit.htm
          Guidelines for Advertisements for Recruiting Subjects
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          http://healthcare.partners.org/phsirb/advert.htm
          Remuneration for Research Subjects
          http://healthcare.partners.org/phsirb/remun.htm
CONSENT PROCEDURES
Explain in detail how, when, where, and by whom consent is obtained, and the timing of consent 
(i.e., how long subjects will be given to consider participation).  For most studies involving more 
than minimal risk and all studies involving investigational drugs/devices, a licensed physician 
investigator must obtain informed consent.  When subjects are to be enrolled from among the 
investigators’ own patients, describe how the potential for coercion will be avoided.
Speaking with and consenting participants will be conducted by Dr Austen.  Sufficient time will be 
provided for eligible participants to review the consent form and ask any questions. The PI or 
designated co-investigator will provide a full description of the consent form and ensure subjects’ 
understanding of the study before the consent is signed. Subjects will receive the same treatment, 
whether or not they participate in the study.
NOTE: When subjects are unable to give consent due to age (minors) or impaired decision-
making capacity, complete the forms for Research Involving Children as Subjects of Research 
and/or Research Involving Individuals with Impaired Decision-making Capacity, available on 
the New Submissions page on the PHRC website: 
http://healthcare.partners.org/phsirb/newapp.htm#Newapp
For guidance, refer to the following Partners policy:
          Informed Consent of Research Subjects
          http://healthcare.partners.org/phsirb/infcons.htm
DATA AND SAFETY MONITORING
Describe the plan for monitoring the data to ensure the safety of subjects.  The plan should 
include a brief description of (1) the safety and/or efficacy data that will be reviewed; (2) the 
planned frequency of review; and (3) who will be responsible for this review and for determining 
whether the research should be altered or stopped.  Include a brief description of any stopping 
rules for the study, when appropriate.  Depending upon the risk, size and complexity of the 
study, the investigator, an expert group, an independent Data and Safety Monitoring Board 
(DSMB) or others might be assigned primary responsibility for this monitoring activity.       
NOTE: Regardless of data and safety monitoring plans by the sponsor or others, the principal 
investigator is ultimately responsible for protecting the rights, safety, and welfare of subjects 
under his/her care.
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Describe the plan to be followed by the Principal Investigator/study staff for review of adverse 
events experienced by subjects under his/her care, and when applicable, for review of sponsor 
safety reports and DSMB reports.  Describe the plan for reporting adverse events to the sponsor 
and the Partners’ IRB and, when applicable, for submitting sponsor safety reports and DSMB 
reports to the Partners’ IRBs.  When the investigator is also the sponsor of the IND/IDE, include 
the plan for reporting of adverse events to the FDA and, when applicable, to investigators at 
other sites.  
NOTE: In addition to the adverse event reporting requirements of the sponsor, the principal 
investigator must follow the Partners Human Research Committee guidelines for Adverse Event 
Reporting
The principal investigator (Dr. Austen) will be responsible for monitoring outcomes. No 
independent monitoring will occur. The principal investigator (Dr. Austen) will report adverse 
events to the IRB in accordance with the IRB adverse event reporting procedures.  
The information collected during this study will be placed in a research folder, and not added to 
the patient’s medical record unless deliberately requested by the patient. All research folders 
will be filed in locked cabinets, independent of clinical charts or any other medical record in 
electronic format. Any magnetic or electronic information will be saved in password-protected 
computers to which only study staff will have access.
Unanticipated problems involving risks to subjects or others including adverse events will be 
reported to the PHRC in accordance with PHRC unanticipated problems reporting guidelines.
MONITORING AND QUALITY ASSURANCE
Describe the plan to be followed by the principal investigator/study staff to monitor and assure 
the validity and integrity of the data and adherence to the IRB-approved protocol.  Specify who 
will be responsible for monitoring, and the planned frequency of monitoring.  For example, 
specify who will review the accuracy and completeness of case report form entries, source 
documents, and informed consent.  
NOTE: Regardless of monitoring plans by the sponsor or others, the principal investigator is 
ultimately responsible for ensuring that the study is conducted at his/her investigative site in 
accordance with the IRB-approved protocol, and applicable regulations and requirements of the 
IRB.
The principal investigator (Dr. Austen) will be responsible for monitoring outcomes. No 
independent monitoring will occur. The principal investigator (Dr. Austen) will report adverse 
events to the IRB in accordance with the IRB adverse event reporting procedures.  
The principal investigator is responsible for adherence to all IRB rules and guidelines and for the 
accuracy and completeness of all forms, entries, and informed consent. 
For guidance, refer to the following Partners policies:
          Data and Safety Monitoring Plans and Quality Assurance
          http://healthcare.partners.org/phsirb/datasafe.htm
          Adverse Event Reporting Guidelines
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          http://healthcare.partners.org/phsirb/adverse_events.htm
PRIVACY AND CONFIDENTIALITY
Describe methods used to protect the privacy of subjects and maintain confidentiality of data 
collected.  This typically includes such practices as substituting codes for names and/or medical 
record numbers; removing face sheets or other identifiers from completed 
surveys/questionnaires; proper disposal of printed computer data; limited access to study data; 
use of password-protected computer databases; training for research staff on the importance of 
confidentiality of data, and storing research records in a secure location.  
NOTE: Additional measures, such as obtaining a Certificate of Confidentiality, should be 
considered and are strongly encouraged when the research involves the collection of sensitive 
data, such as sexual, criminal or illegal behaviors.
All participants are given a participation number/ code at the time of enrollment. This code is 
kept on all data sheets instead of the patient’s name. Subject information is only accessible by 
Partners authorized investigators and will not be shared with outside entities. The final results 
after statistical analysis will not be shared with any institution. 
All clinical study records will be stored in a secure location in the office of Dr. Austen, as all 
research activities involving patient data will take place at MGH.
SENDING SPECIMENS/DATA TO RESEARCH COLLABORATORS OUTSIDE 
PARTNERS
Specimens or data collected by Partners investigators will be sent to research collaborators 
outside Partners, indicate to whom specimens/data will be sent, what information will be sent, 
and whether the specimens/data will contain identifiers that could be used by the outside 
collaborators to link the specimens/data to individual subjects.
De-identified discarded tissue will be transferred to Dr. Burstein’s lab at Beth Israel Deaconess 
Medical Center for processing and analysis. No personally identifiable data (including name, 
date of birth, age, and gender) will be shared between the clinical site (MGH) and the 
processing site (BIDMC).
Specifically address whether specimens/data will be stored at collaborating sites outside 
Partners for future use not described in the protocol.  Include whether subjects can withdraw 
their specimens/data, and how they would do so.  When appropriate, submit documentation of 
IRB approval from the recipient institution.
Specimens will only be used for this research study. Subjects can withdraw their specimens at 
any time.
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RECEIVING SPECIMENS/DATA FROM RESEARCH COLLABORATORS OUTSIDE 
PARTNERS
When specimens or data collected by research collaborators outside Partners will be sent to 
Partners investigators, indicate from where the specimens/data will be obtained and whether the 
specimens/data will contain identifiers that could be used by Partners investigators to link the 
specimens/data to individual subjects.  When appropriate, submit documentation of IRB 
approval and a copy of the IRB-approved consent form from the institution where the 
specimens/data were collected.
Collaborators will not collect specimens or data 
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