Practice Guidelines

AAN Updates Guidelines on the Uses of Botulinum Neurotoxin


Am Fam Physician. 2017 Feb 1;95(3):198-199.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• OnaBoNT-A and incoBoNT-A are equally effective and should be considered for treatment of blepharospasm, and AboBoNT-A is a possibly effective treatment option.

• All FDA-approved formulations of botulinum neurotoxin are commonly used to treat cervical dystonia, despite differing evidence levels.

• Botulinum neurotoxin is effective in treating upper and lower limb spasticity in adults and improving passive function.

• OnoBoNT-A is safe and effective for increasing the number of headache-free days in patients with chronic migraine.

From the AFP Editors

Botulinum neurotoxin is available in two serotypes, A and B. There are four preparations approved by the U.S. Food and Drug Administration (FDA): onabotulinumtoxinA (onaBoNT-A; Botox), abobotulinumtoxinA (aboBoNT-A; Dysport), incobotulinumtoxinA (incoBoNT-A; Xeomin), and rimabotulinumtoxinB (rimaBoNT-B; Myobloc). There are pharmacologic differences between preparations, such as potency and duration of action, and because of this, each formulation was assessed separately for each indication. Efficacy of botulinum neurotoxin is for symptomatic control; there is no evidence for disease modification. In 2008, the American Academy of Neurology (AAN) published guidelines on the use of botulinum neurotoxin. This summary highlights updates on four indications: blepharospasm, cervical dystonia, spasticity in adults, and headache.



Blepharospasm is a dystonia that can cause disabling eyelid closure. Botulinum neurotoxin was determined to be an effective and safe treatment in the 2008 guideline. Updated recommendations consider botulinum neurotoxin to be the preferred treatment of blepharospasm. OnaBoNT-A and incoBoNT-A are equally effective and should be considered. AboBoNT-A is possibly effective and may be considered as a treatment option. There is insufficient evidence to determine the efficacy of rimaBoNT-B for the treatment of blepharospasm.


Cervical d

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Sumi Sexton, MD, Associate Deputy Editor.

A collection of Practice Guidelines published in AFP is available at



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