Ultrasound-Identified Trigger-Point and Ultrasound-Guided IncobotulinumtoxinA (Xeomin®) Injection for Refractory V2–V3 Trigeminal Neuralgia: A Case Report

Trigeminal neuralgia (TN) can be refractory to systemic anticonvulsants. Targeted botulinum toxin type A (BoNT-A) injections are an emerging local therapy. Ultrasound (US) may help identify subclinical peripheral trigger points that are not evident on palpation. We report a case of a 50-year-old male with longstanding left-sided V2-V3 TN who experienced rapid and durable pain relief after US-identified trigger-point mapping, followed by combined intradermal and US-guided intramuscular injections of incobotulinumtoxinA (Xeomin®). On clinical examination, trigger points were not prominent; however, real-time ultrasonography (Clarius L20) identified subtle focal fasciculations/tremor and hyperdynamic areas consistent with peripheral trigger sites. Treatment comprised intradermal "skin-botox" microinjections along the mandibular/zygomatic line (total 20 U; left 15 U, right 5 U) using 34G × 4 mm needles, and US-guided intramuscular masseter injections (total 50 U; 30G × 25 mm needles; higher proportion to symptomatic left side). Pain improved from VAS 8/10 → 2-3/10 within one week and remained reduced for approximately three to four months. No adverse events were observed. The patient also reported aesthetic improvement of jawline contour. US can detect subclinical trigger-point activity and guide precise BoNT-A delivery. Incorporating US-identified trigger-point mapping and US guidance (Clarius L20) allowed targeted intradermal and intramuscular incobotulinumtoxinA injections that produced durable analgesia and cosmetic benefit in refractory TN. Prospective studies should evaluate standardized US-based protocols.