Botox for trigeminal neuralgia
Edited by Dr. Meredith Barad
Benefit and risks
When to consider treatment
For selected patients with TN despite medication, botulinum toxin A may reduce attack frequency and pain severity as an add-on treatment. Carbamazepine or oxcarbazepine remain first choices; poor control or tolerability also warrants surgical assessment. The EAN recommendation is weak, based on very low-quality evidence. Bendtsen 2019
Facial BOTOX for TN is off-label in the US. Published studies use different products, doses and injection methods; they do not establish one standard facial map. AbbVie 2023 · Bendtsen 2019
The newer narrative reviews organize different superficial injection approaches, but their proposals do not validate one universal dose, depth or map. Keep the Stanford intradermal regimen separate from subcutaneous, submucosal and intramuscular trial methods. Check trial design and denominators in the original studies before comparing response rates. Tereshko 2024 · Argyriou 2026
Discuss adverse effects
Injection pain, bruising and temporary facial weakness or asymmetry can occur. Shehata 2013
Explain that new swallowing, speech or breathing difficulty requires immediate medical attention because toxin effects can spread beyond the injection area. AbbVie 2023
Keep the treatment question specific
Record paroxysmal attack frequency, severity, background pain, triggers and impact on eating or speaking separately. Reconcile the diagnosis and prior treatment before treating a colored territory as an indication. This superficial protocol is distinct from a deep trigeminal nerve or ganglion intervention. Bendtsen 2019
Reassess
Compare attack frequency, pain severity and daily function with baseline, and ask about facial weakness and other adverse effects. Reassess benefit and tolerability before further treatment. Shehata 2013
Preparation and dose
Before injection
Confirm the affected side and divisions. Do not inject through an infected site or use BOTOX in a patient with hypersensitivity to a botulinum toxin preparation or formulation component. Review neuromuscular disease, swallowing or respiratory problems, interacting drugs and recent toxin exposure. AbbVie 2023
Equipment and preparation
Use onabotulinumtoxinA, sterile preservative-free 0.9% sodium chloride for reconstitution, and an appropriately sized sterile syringe and injection needle. Confirm the facial-injection order’s concentration, volume per site and needle specification before drawing up. BOTOX units are product-specific. AbbVie 2023
Intradermal regimen shown here
2.5 U per site × 10 sites = 25 U per affected division. Two affected divisions total 50 U; three total 75 U. Treat the affected divisions. Stanford University 2026
This regimen specifies intradermal deposition. Published subcutaneous and intramuscular approaches use different methods and doses. Stanford University 2026 · Shehata 2013
Connect the map to the tissue
For each selected site, name the patient side, affected division and intended intradermal plane. A sensory territory is not an individual nerve trajectory, and a surface point is not a measured insertion depth. Keep the injection opening within the intended skin layer; do not substitute a deeper PREEMPT muscle injection or a spinal-needle steering maneuver. Walker 1990 · Stanford University 2026
V1, V2 and V3 are sensory territories, not needle paths. Compare the selected region with the patient’s attacks and triggers. The angle of the mandible is mainly cervical sensory territory; it should not become a V3 site simply because it is near the jaw. Walker 1990
Trigeminal divisions
Follow each colored territory from the front of the face into the temple and cheek. The angle of the jaw and neck lie outside the trigeminal territories. Surface boundaries are approximate and vary between individuals.
For each selected point, distinguish patient side, division, site count and units per site. The shown regimen uses 2.5 U × 10 sites = 25 U per affected division; this is a source-specific regimen, not evidence that every facial map or toxin product is interchangeable. Stanford University 2026