When you hear the word Botox, does the image of an older woman with a tight, expressionless face come to mind? 

Though botox injections are still a popular way to fight the signs of aging, especially among women, their approved medical uses continue to grow.

Most research has shown Botox injections to be safe when given in small doses and when administered by an experienced professional. But since the main ingredient is a poisonous substance – botulinum toxin – there are potential risks. 

What are Botox injections?

Botox was the first drug to use botulinum toxin, which can cause botulism, a rare but serious food poisoning that affects the body’s nervous system.

The injections block signals from nerves that cause muscles to contract. They are most often used to temporarily relax facial muscles that cause wrinkles in the forehead and around the eyes, but they also have many medical uses.

Botox is used to treat neck spasms, excessive sweating, an overactive bladder, lazy eye and to prevent chronic migraines. It also can be used to treat foot pain caused by wearing certain types of shoes such as high heels.

The Cleveland Clinic offers Botox injections for women who experience painful sex because of muscle spasms on their pelvic floor or contractions of the vagina. Some women need the injections every six months while others only need them every couple of years.

A new study suggests Botox injections also may be used to reduce anxiety when injected in four sites beyond the forehead. The recipients reported anxiety significantly less frequently than people who underwent different treatments for the same conditions. 

Overall, the risk of anxiety was lowered by 22-72% among patients who were treated with Botox at certain injection sites: facial muscles for cosmetic use, facial and head muscles for migraines, upper and lower limbs for spasm and spasticity, and neck muscles for torticollis.

The researchers hypothesized that the botulinum toxins may spread to the regions of the central nervous system in control of mood and emotions. Or the reduction in anxiety simply could be the result of the treatment giving the patient relief from a chronic condition.

The researchers cautioned that they only studied a small subset of people and that more research is needed to truly determine if Botox has a direct effect on anxiety.

How safe is Botox?

Botox injections are generally safe when performed by an experienced doctor, experts say. Possible side effects and complications include headache or flu-like symptoms, droopy eyelids or cockeyed eyebrows, a crooked smile or drooling, eye dryness or excessive tearing.

Women who are pregnant or breastfeeding should not use Botox. Neither should anyone who is allergic to cow’s milk protein.

More serious complications include muscle weakness, vision problems, difficulty speaking or swallowing, and loss of bladder control. People are advised to seek immediate medical attention if they experience any of these symptoms. 

One review of Botox users in the United Kingdom found that one in eight reported cardiovascular symptoms that ranged from high blood pressure to heart attack.

And although sudden deaths after Botox injections are rare, they do occur. One 34-year-old woman collapsed at a beauty salon soon after receiving Botox injection. She died soon after at a hospital.

The placement and order of the injections are important in order to avoid side effects, so people are advised to seek a doctor with plenty of experience administering Botox treatments for their specific conditions. 

One major concern with regular Botox injections, whether for cosmetic or medical reasons, is that research on long-term safety is limited.

One 2015 study found that patients who received Botox injections every six months to help treat bladder conditions didn’t have an increased risk of side effects over time.

Another review, however, suggested that adverse side effects are more likely after the 10th or 11th injection.