What are your preferred second-line medications for trigeminal neuralgia?

My FIRST-LINE medication for trigeminal neuralgia is botulinum toxin. I write about its application in face pain, including trigeminal neuralgia, in Chapter 16 of my book, HEADACHES: Why You Have Them - What You Can Do About Them.

My first line is oxcarbazepine or carbamazepine. The second line is gabapentin. Then, in no particular order, baclofen and lamotrigine. Other options to try: pimozide, tizanidine, phenytoin, valproic acid. If 1 agent does not provide good control, I refer to a surgeon as we try a 2nd agent.

Unclear to me why Botox would work.

I have had patients with refractory headaches that neurologists have used Botox with success for tension/migraines. But for trigeminal neuralgia, I’ve seen gabapentin used.

Also need to work up if HSV could be involved.

I’ve used valacyclovir along with gabapentin for relief and control in one patie...