Baclofen Dosing for Hemifacial Spasm
Baclofen is not a first-line treatment for hemifacial spasm, and there is no established standard dosing regimen from major guidelines; however, based on limited research evidence, doses ranging from 30-90 mg daily in divided doses have been used, though botulinum toxin injection remains the evidence-based treatment of choice.
Current Standard of Care
Botulinum toxin injection is the established first-line treatment for hemifacial spasm, not oral medications like baclofen 1. The research literature shows that botulinum toxin type A is both effective and safe for long-term management of HFS, with the majority of patients maintaining treatment for over 10 years without primary or secondary resistance 1.
Baclofen Dosing When Used for HFS
When baclofen has been attempted for hemifacial spasm in research settings:
- Typical dose range: 30-90 mg daily, divided into multiple doses 2
- Alternative approach: Some studies report doses as low as 5-10 mg three times daily (15-30 mg total daily) based on general baclofen dosing principles 3
- The medication is typically started at low doses and titrated upward to minimize side effects 4
Important Caveats
- Limited efficacy: Only 6 patients total were reported in one small case series showing response to baclofen for HFS 2
- Stress-related cases: The limited positive responses to baclofen appeared to occur primarily in stress-related hemifacial spasm cases 2
- Side effects: Memory loss and other cognitive effects can occur, requiring additional medications or dose reduction 2
- Sedation risk: Oral baclofen commonly causes sedation, drowsiness, dizziness, mental confusion, and somnolence, with adverse effects typically appearing at doses >60 mg/day 5
Alternative Medication: Gabapentin
Gabapentin has shown more promising results than baclofen in small studies:
- Dose range: 900-1,600 mg daily 6
- Advantages: Rapid improvement with better side effect profile compared to baclofen 6
- Evidence quality: Still limited to small case series (5 patients) 6
Why Baclofen Is Not Recommended
The stroke rehabilitation guidelines mention baclofen only for spasticity (velocity-dependent muscle hyperactivity), not for hemifacial spasm, which is a different pathophysiology involving neurovascular compression of the facial nerve 4. Intrathecal baclofen is reserved for severe spasticity unresponsive to other treatments, not for focal movement disorders like HFS 4, 5, 7.
Recommended Treatment Algorithm
- First-line: Botulinum toxin injection into affected facial muscles 1
- Definitive treatment: Microvascular decompression surgery for appropriate surgical candidates 6
- Medical alternatives (if botulinum toxin fails or is refused): Consider gabapentin 900-1,600 mg daily over baclofen 6
- Baclofen trial (last resort): If attempted, start 15-30 mg daily in divided doses, titrate slowly to maximum 60-90 mg daily, monitoring closely for sedation and cognitive effects 2, 5