What is the evidence for using lidocaine IV infusion for trigeminal neuralgia? Are there significant side effects that require monitoring in a hospital setting?

Comment by InpharmD Researcher

Though limited, current evidence assessing intravenous (IV) lidocaine in trigeminal neuralgia suggests it can provide meaningful short-term pain relief, particularly in patients who have not responded to standard therapies. Across retrospective series and a small randomized controlled trial, pain reductions were documented using validated pain scales, with some patients achieving complete resolution and others experiencing partial relief requiring ongoing therapy. Reported side effects were generally mild and transient, including somnolence, peri-oral tingling, dizziness, dysgeusia, headache, and palpitations; no serious cardiorespiratory events were observed, though monitoring during infusion is commonly practiced (e.g., ECG, pulse oximetry, blood pressure measurements). Overall, IV lidocaine appears to be a well-tolerated option for refractory trigeminal neuralgia, but larger, prospective studies are needed to clarify efficacy, optimal dosing, and longer-term safety.

Background

A 2025 retrospective case series (see Table 1) with an accompanying systematic review evaluated the use of IV lidocaine for intractable trigeminal neuralgia (TGN), identifying seven published studies that together included 66 patients and adding 20 additional patients from the authors’ own cohort for a total of 86 treated individuals. Most patients (78, 90.7%) received IV lidocaine for refractory TGN after unsuccessful medical, ablative, or surgical therapy, while eight patients (9.3%) were treated emergently in the emergency department. All included studies used objective pain-assessment tools, such as the numerical rating scale (NRS), visual analogue scale (VAS), verbal rating scale (VRS), or the Barrow Neurological Institute (BNI) pain intensity score, to evaluate treatment response. Reported durations of pain relief ranged from 24 hours to several months. When outcomes were categorized using BNI scores, 29 patients (33.7%) achieved complete pain resolution without the need for further medical therapy (BNI I), one patient (1.1%) had marked improvement with only occasional pain not requiring regular antiepileptic medication (BNI II), 49 patients (57%) experienced meaningful pain relief but continued to require medical therapy (BNI IIIA), and three patients (3.5%) had improved but still bothersome episodic pain manageable with medication (BNI IIIB). In contrast, one patient (1.1%) had persistent uncontrolled pain after infusion (BNI IV), and three patients (3.5%) did not respond at all (BNI V). Recurrence of TGN symptoms occurred in ten patients (11.6%), with a median pain-free duration of 5.5 months (range up to 11.8 months; IQR 10 months). Importantly, no significant adverse effects were reported across the included studies or the case series. [1]

References: [1] Mohamed MW, Irem-Oko F, Sheikh A, Phillips N, Mckinlay J, Anderson I. Lidocaine infusion for the treatment of intractable trigeminal neuralgia: retrospective case series and systematic review. Acta Neurochir (Wien). 2025;167(1):259. Published 2025 Sep 29. doi:10.1007/s00701-025-06672-8
Literature Review

A search of the published medical literature revealed 3 studies investigating the researchable question:

What is the evidence for using lidocaine IV infusion for trigeminal neuralgia? Are there significant side effects that require monitoring in a hospital setting?

Level of evidence

C - Multiple studies with limitations or conflicting results  Read more→


Please see Tables 1-3 for your response.

 

Lidocaine infusion for the treatment of intractable trigeminal neuralgia: retrospective case series and systematic review
Design

Retrospective case series and systematic review

N= 20
Objective To investigate the effectiveness, duration of pain relief, and safety profile of intravenous Lidocaine in managing refractory trigeminal neuralgia
Study Groups

All patients (n= 20)
Inclusion Criteria

Patients diagnosed with TGN, with documented clinical follow-up and outcome data
Exclusion Criteria

Patients under 18, underwent concurrent treatments during the same session, or were lost to follow-up
Methods

Retrospective analysis of 20 patients with TGN who received IV Lidocaine at 1.5 mg/kg over 60 min. 
Duration January 2016 to December 2022
Outcome Measures BNI pain intensity scores, duration of pain relief, and safety profile
Baseline Characteristics   All patients (n= 20)
Gender - Male 9 (45%)
Gender - Female 11 (55%)
Median age 74.5
Age range 41-85
Results   Number of Patients (%)
BNI IIIA (pain controlled with medications) 16 (80%)
BNI II (occasional pain, no medications required) 1 (5%)
No response 3 (15%)
Pain relief >6 months 9 (45%)
Pain relief 3-6 months 5 (25%)
Pain relief <3 months 6 (30%)

BNI=  Barrow Neurological Institute 
Adverse Events

No treatment-related significant adverse events
Study Author Conclusions

Lidocaine infusion therapy for refractory worsening trigeminal neuralgia is safe and improves pain control when combined with ongoing medical therapy.
Critique The study's retrospective nature and small sample size limit its generalizability. However, it provides valuable insights into the potential of IV Lidocaine as a safe and effective treatment for refractory TGN, especially when other treatments have failed. The systematic review adds context but highlights the need for more robust, controlled studies.
References:
[1] Mohamed MW, Irem-Oko F, Sheikh A, Phillips N, Mckinlay J, Anderson I. Lidocaine infusion for the treatment of intractable trigeminal neuralgia: retrospective case series and systematic review. Acta Neurochir (Wien). 2025;167(1):259. Published 2025 Sep 29. doi:10.1007/s00701-025-06672-8

 

A single infusion of intravenous lidocaine for primary headaches and trigeminal neuralgia: a retrospective analysis
Design

Retrospective, single-center analysis

N= 15
Objective To report on the experience of using a single one-hour IV lidocaine infusion in an outpatient day-case setting for the management of refractory primary headache disorders with facial pain and trigeminal neuralgia
Study Groups

Trigeminal autonomic cephalalgias (n= 9)

Chronic migraine (n= 3) T

rigeminal neuralgia (n= 3)
Inclusion Criteria Patients with medically refractory headache with facial pain and trigeminal neuralgia treated with IV lidocaine between March 2018 and July 2022
Exclusion Criteria History of significant cardiac disease, arrhythmia, seizures, and previous allergic reactions to lidocaine
Methods

Retrospective analysis on patients treated with IV lidocaine 5 mg/kg in 60 mL saline over 1 hour, followed by a 30-minute observation period. Patients were considered responders if they reported a reduction in pain intensity and/or headache frequency of 50% or greater
Duration March 2018 to July 2022
Outcome Measures reduction in headache/facial pain intensity of at least 50% 
Baseline Characteristics   All patients (n= 15)
Average age at first infusion, years 50 (range 24-73)
Average duration of condition, years 14.9
Co-existing conditions - chronic migraine and fibromyalgia 5 patients
Results  

Immediate responders (> 50% pain relief)

 Average duration of benefit, weeks
SUNCT/SUNA 4 (67%) 11.2
Chronic facial migraine 3 (100%) 9
Trigeminal Neuralgia 3 (100%) 10.7
CCH 2 (100%) 5
HC 0 (0%) 0

SUNCT, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing; SUNA, short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms; CCH, chronic cluster headache; HC, hemicrania continua
Adverse Events

Six out of 15 patients reported mild and self-limiting side effects (40%). Common side effects included peri-oral tingling, light-headedness, dull headache, limb numbness, transitory dysgeusia, palpitations, and tiredness.
Study Author Conclusions

A single infusion of IV lidocaine might be an effective and safe transitional treatment in refractory headache conditions with facial pain and trigeminal neuralgia. The sustained effect of repeated treatment cycles in some patients may suggest a role as long-term preventive therapy in some patients.
Critique

The study's retrospective design and small sample size limit the generalizability of the findings. However, the study provides valuable insights into the potential of a single infusion of IV lidocaine as a cost-effective and well-tolerated treatment option for refractory headache conditions. Prospective randomized-control trials are needed to establish greater quality evidence.
References:
[1] Mullins CF, Fuccaro M, Pang D, Min L, Andreou AP, Lambru G. A single infusion of intravenous lidocaine for primary headaches and trigeminal neuralgia: a retrospective analysis. Front Neurol. 2023;14:1202426. Published 2023 Aug 10. doi:10.3389/fneur.2023.1202426

 

The Effect of Intravenous Lidocaine on Trigeminal Neuralgia: A Randomized Double Blind Placebo Controlled Trial
Design

Randomized double blind placebo controlled crossover study

N= 20
Objective To investigate in a prospective way the effect of lidocaine in patients with trigeminal neuralgia
Study Groups

Lidocaine (n= 20)

Placebo (n= 20)
Inclusion Criteria Confirmed diagnosis of TN according to IASP definition; age ≥18 years; VAS score ≥3; DN4 score ≥4; having received recommended medications for TN without therapeutic results; TN duration of at least 12 months; no history of allergy to lidocaine; no history of substance abuse; absence of severe psychiatric diseases; not pregnant; not lactating; absence of severe cardiac, hepatic, and renal disease; willing to provide written informed consent
Exclusion Criteria Not specified
Methods

Each patient completed four sessions held every other day, receiving two lidocaine infusions and two placebo infusions in a randomized, double-blind, crossover design. Active treatment consisted of lidocaine 5 mg/kg in 250 mL of 5% dextrose infused over 1 hour, while placebo was 250 mL of 5% dextrose alone. Randomization was computer-generated, with one investigator preparing solutions and another, blinded to allocation, conducting examinations and administering infusions. Before and after each infusion, the blinded investigator recorded VAS pain scores and assessed mechanical, thermal, and cold allodynia as well as pinprick, heat, and cold hyperalgesia. Throughout the session, patients were continuously monitored with ECG, pulse oximetry, and blood pressure measurements, with vital signs documented every 15 minutes, and any adverse effects (e.g., somnolence, confusion, metallic taste, perioral tingling, visual disturbances, tremor) systematically recorded.
Duration February 2007 to September 2011
Outcome Measures Reduction in intensity of pain, allodynia, and hyperalgesia
Baseline Characteristics   Study Population (n= 20)
Male sex (%) 7 (35%)
Age, years 65.20 ± 15.28
Weight, kg 73.75 ± 16.48
Location of neuralgia - 1st trigeminal branch 2 (10%)
Location of neuralgia - 2nd trigeminal branch 2 (10%)
Location of neuralgia - 3rd trigeminal branch 16 (80%)
DN4 score at baseline 6.25 ± 0.63
Abbreviations: DN4= Douleur Neuropathique 4 Questionnaire
Results   Lidocaine (n= 40) Placebo (n= 40) p-value
VAS score post-treatment  1.46 ± 1.37 3.33 ± 2.02 <0.001
VAS score at 16:00  1.77 ± 1.61 4.08 ± 2.33 <0.001
VAS score at 20:00  2.38 ± 1.73 4.45 ± 2.36 <0.001
VAS score at 24:00  2.33 ± 1.84 4.43 ± 2.15 <0.001
VAS score at 08:00 next morning  2.95 ± 1.88 5.20 ± 2.55 <0.001
VAS reduction % pre-/posttreatment  76.4 ± 23.0 40.1 ± 31.9 <0.001
Reduced mechanical allodynia  31 (77.5%) 20 (50.0%) 0.011
Reduced thermal allodynia  18 (45.0%) 7 (17.5%) 0.008
Reduced cold allodynia  15 (37.5%) 5 (12.5%) 0.010
Reduced pinprick hyperalgesia 26 (65.0%) 14 (35.0%) 0.007
Reduced hot hyperalgesia  22 (55.0%) 7 (17.5%) <0.001
Reduced cold hyperalgesia 20 (50.0%) 11 (27.5%) 0.039
Abbreviations: VAS= visual analogue scale
Adverse Events

No statistically significant changes in systolic BP, diastolic BP, HR, and oxygen saturation. Mild side effects reported more in lidocaine group: somnolence (32.5%), dry mouth (12.5%), dizziness (12.5%), headache (7.5%), feeling flushed (5%), confusion (2.5%), dysarthria (2.5%), tinnitus (2.5%)
Study Author Conclusions

Intravenous lidocaine is superior in reducing pain intensity, allodynia, and hyperalgesia compared to placebo, maintaining therapeutic results for 24 hours. It can be considered as an add-on treatment when first-line medications fail.
Critique

The study's crossover design is a strength, allowing each patient to serve as their own control, which is beneficial given the small sample size. However, the study is limited by its small sample size and the use of a single dose of lidocaine, which may not generalize to different dosages or larger populations. Future studies should explore varying dosages and larger sample sizes to confirm these findings.
References:
[1] Stavropoulou E, Argyra E, Zis P, Vadalouca A, Siafaka I. The Effect of Intravenous Lidocaine on Trigeminal Neuralgia: A Randomized Double Blind Placebo Controlled Trial. ISRN Pain. 2014;2014:853826. Published 2014 Mar 10. doi:10.1155/2014/853826