The evidence for noncosmetic uses of botulinum toxin Botulinum toxin has been studied for a variety of uses beyond the cosmetic. Here's what you need to know about which uses are worth considering for your patient. M ention the word "botulinum toxin" and one's mind is likely to go to the big business of cosmetic procedures. Among the 15.7 minimally invasive cosmetic procedures performed in 2017, botulinum toxin type A (BoNT-A) made up the largest share, with 7.23 million procedures. 1 However, botulinum toxin-which was first recognized for the ability to paralyze muscles through decreased release of acetylcholine-also has many pain-related and noncosmetic uses; some are approved by the US Food and Drug Administration (FDA) and others are off-label (see TABLE 1 2-31). This review provides an evidence-based look at these uses, from those that have good evidence to support them-including chronic migraine and overactive bladder-to those that have limited (or no) evidence to support them-such as chronic pelvic pain and cluster headache. But before we get into the evidence behind specific uses for botulinum toxin, let's review the available options and the potential risks they pose. Many options Although botulinum toxin is produced by Clostridium botulinum, the synthetic process to produce pharmaceuticals is patented and branded. BoNT-A is 1 of 7 recognized serotypes derived from C botulinum; some examples of BoNT-A include onabotulinumtoxinA, abobotulinumtoxinA, and incobotu-linumtoxinA. Clinically, the differences are minor, but they do allow for use of other brands if a patient becomes intolerant to the selected therapy. Treatment doses and costs for each brand vary. ❚ Training. Primary care providers can obtain didactic training from pharmaceutical companies as well as skills training through workshops on botulinum toxin. Credentialed providers can perform some procedures in the primary care setting (TABLE 2). ❚ Adverse effects also vary depending on the formulation and the sites injected. Patients generally tolerate the procedure Blake Busey, DO, FAAFP;