Use of Botulinum Toxin in the Presentation of Refractory and Abnormal Facial Pain: A Case Report

Case Diagnosis: 65 year male with abnormally presenting Trigeminal Neuralgia, treated with Botulinum Toxin injections.

Case Description or Program Description: A 65 year old male who presented with 10 years of intermittent V2 localized right sided nasolabial facial pain, refractory to multiple medications, including Oxcarbazepine, Baclofen, Trileptal, Oxtellar, Amitriptyline, and more, presented to pain clinic for second opinion. Patient reported he occasionally had four-to-five hours of relief from taking Excedrin. The pain is arbitrary and sporadic in onset, but he couldn’t identify any exacerbating triggers. Patient had been working with a neurologist to address these symptoms, but over the past 10 years had no improvement.

Setting: On primary examination, the patient wasn't currently experiencing pain but could point to the specific location of his pain. His facial pain is reminiscent of trigeminal neuralgia in location and type of intermittent “electrical-like” shock he felt. Patient’s cranial nerves were all intact. This case is unique in the location of a single isolated trigeminal nerve branch, lack of associated headache and/or jaw clicking/pain, plus his lack of response to all first-line treatments.

Assessment/Results: Patient returned for 2-week and 6-week follow up, reporting around the 2-week mark he noticed reduced severity and frequency of pain, with significant reduction at the 6 week follow-up. Patients pain reduced in frequency and severity after treatment; with relief peaking around 8 weeks post injections.

Discussion (relevance): This case highlights the importance and sometimes challenge of differentiating presentations of trigeminal neuralgia and decisions for nontraditional treatment options. This case explores secondary and non-pharmacological treatments for trigeminal neuralgia and demonstrates the potential benefit of using other non-traditional treatments.

Conclusions: Botulinum toxin injections along affected branches can help refractory trigeminal neuralgia patients by reducing pain intensity and frequency. Non-traditional treatments should be considered before surgery.