Botulinum Toxin Therapy for Trigeminal Neuralgia

An effective, modern and safe treatment for severe facial pain.
Dr Lidiia Prakhova – neurologist, specialist in botulinum toxin therapy, neuropathic pain and demyelinating diseases.

Trigeminal neuralgia (TN) is one of the most painful conditions in neurology. Patients often describe the attacks as sharp, “electric shock–like” pain in the face, triggered by talking, chewing, tooth brushing, washing the face or even light wind.

The pain usually appears only on one side of the face and can involve the jaw, lips, cheeks, teeth or the area around the eye and forehead. Attacks may occur many times per day and severely affect quality of life.

Standard medications such as carbamazepine and oxcarbazepine can be very helpful, but in some patients they lose effectiveness over time or cause significant side effects such as dizziness, drowsiness or blood test abnormalities.

For these patients, botulinum toxin type A (Botox®, Dysport®, Xeomin®) becomes an important, evidence-based next step.

For more information about facial pain and related conditions, see: Cranial neuralgias and facial pain – overview »

What is trigeminal neuralgia?

The trigeminal nerve provides sensation to the face. When it becomes pathologically hyperexcitable – for example due to vascular compression, demyelinating disease (such as multiple sclerosis) or other types of damage – short but extremely intense bursts of pain occur.

The pain is most often felt:

• in the cheek, lip or chin;
• around the teeth and lower jaw;
• around the eye, forehead or temple;
• strictly on one side of the face.

Because the attacks are brief but very intense and can be triggered by everyday activities, many patients become anxious, avoid eating or speaking and significantly change their lifestyle.

Why can botulinum toxin help in trigeminal neuralgia?

Botulinum toxin type A is a minimally invasive, local treatment that blocks abnormal nerve signalling in the painful area. Clinical trials and meta-analyses have shown that it can:

• significantly reduce pain intensity;
• decrease the number of daily attacks;
• improve quality of life and sleep;
• have a favourable safety profile;
• allow some patients to reduce the dose of oral medications.

The European Academy of Neurology considers botulinum toxin a second-line treatment option for trigeminal neuralgia when first-line medications are insufficient or poorly tolerated.

Botulinum toxin has also shown benefit in multiple sclerosis–related trigeminal neuralgia, where treatment may be particularly challenging.

Who may benefit from botulinum toxin therapy?

This treatment is especially suitable for patients who:

• have frequent TN attacks despite adequate medical therapy;
• cannot tolerate carbamazepine or oxcarbazepine;
• have trigeminal neuralgia associated with multiple sclerosis or other demyelinating disease;
• wish to postpone or avoid invasive surgical procedures if possible;
• prefer a local, minimally invasive and safe treatment option with a predictable effect.

How is the procedure performed?

Treatment is always personalised and based on the patient’s unique pain pattern.

During the consultation, Dr Prakhova:

1. assesses which branch of the trigeminal nerve is affected (V1, V2 or V3);
2. maps the exact area where the “electric shock” pain originates;
3. marks precise injection points along the painful distribution;
4. performs microinjections of botulinum toxin into the skin and subcutaneous tissues with a very fine needle;
5. uses ultrasound or EMG guidance when needed for maximum precision.

The procedure usually takes 10–20 minutes. It does not require general anaesthesia or hospitalisation, and patients can return to their usual activities on the same day.

First improvements are commonly noticed within 5–7 days, with peak effect around 10–14 days. The typical duration of benefit is about 3–4 months, after which the injections can be repeated.

Safety and possible side effects

When performed by an experienced neurologist, botulinum toxin therapy for trigeminal neuralgia has a very favourable safety profile.

Most side effects, if they appear, are mild and temporary:

• small bruises at injection sites;
• slight, short-lived facial asymmetry;
• mild chewing muscle weakness (if the lower branch V3 is treated).

Serious complications are extremely rare. Before the procedure, Dr Prakhova discusses the potential risks and expected benefits with each patient.

Advantages of treatment with Dr Lidiia Prakhova

• over 30 years of experience in neurology and neuroimmunology;
• special expertise in multiple sclerosis and other demyelinating CNS diseases;
• extensive practice with botulinum toxin in dystonia, spasticity, chronic migraine and pain syndromes;
• high precision thanks to ultrasound and EMG guidance when indicated;
• a patient-centred approach and careful follow-up after the procedure.

Other areas of expertise include: botulinum toxin therapy for dystonia and modern treatment options for migraine »

Consultation and appointments

Botulinum toxin therapy for trigeminal neuralgia is performed by Dr Lidiia Prakhova at Shamir Medical Center (Assaf Harofeh) in Israel.

Phone:
08-977-97-75 / 08-977-91-45

Email:
neuro@shamir.gov.il
089779758@shamir.gov.il

Selected references

1. Hu X, Xia Y, Li J, et al. Efficacy and Safety of Botulinum Toxin Type A in the Treatment of Trigeminal Neuralgia. Clin J Pain. 2024;40(6):383–392. doi:10.1097/AJP.0000000000001207
2. Tereshko Y, Bello S, Lettieri C, et al. Botulinum Toxin Type A for Trigeminal Neuralgia: A Comprehensive Literature Review. Toxins. 2024;16(11):500. doi:10.3390/toxins16110500
3. Tereshko Y, Valente M, Belgrado E, et al. The Therapeutic Effect of Botulinum Toxin Type A on Trigeminal Neuralgia: Type 1 vs Type 2. Toxins. 2023;15(11):654. doi:10.3390/toxins15110654
4. Wu CJ, Lian YJ, Zheng YK, et al. Botulinum Toxin Type A for the Treatment of Trigeminal Neuralgia: Randomized, Double-Blind, Placebo-Controlled Trial. Cephalalgia. 2012;32(6):443–450. doi:10.1177/0333102412441721
5. Morra ME, Elgebaly A, Elmaraezy A, et al. Therapeutic Efficacy and Safety of Botulinum Toxin A Therapy in Trigeminal Neuralgia: Meta-Analysis. J Headache Pain. 2016;17:63. doi:10.1186/s10194-016-0651-8
6. Bendtsen L, Zakrzewska JM, Heinskou TB, et al. Advances in Diagnosis and Management of Trigeminal Neuralgia. Lancet Neurol. 2020;19:784–796. doi:10.1016/S1474-4422(20)30233-7
7. Asan F, Gündüz A, Tütüncü M, et al. Treatment of Multiple Sclerosis–Related Trigeminal Neuralgia With OnabotulinumtoxinA. Headache. 2022;62:1322–1328. doi:10.1111/head.14414
8. Tangney T, Heydari ES, Sheldon BL, et al. Botulinum Toxin as an Effective Treatment for Trigeminal Neuralgia in Surgical Practices. Stereotact Funct Neurosurg. 2022;100:314–320. doi:10.1159/000526053
9. Xu YY, Guo CW, Chen HJ, et al. Efficacy of Single vs Multiple Botulinum Toxin Type A Injections for Trigeminal Neuralgia. Front Neurol. 2025;16:1570447. doi:10.3389/fneur.2025.1570447
10. Türk Börü Ü, Duman A, Bölük C, et al. Botulinum Toxin A in Trigeminal Neuralgia: 6-Month Follow-Up. Medicine. 2017;96(39):e8133. doi:10.1097/MD.0000000000008133