Two Case Reports: Acupuncture Treatment for Trigeminal Neuralgia

The trigeminal nerve is the 5th cranial nerve and it carries sensation from the face to the brain. Trigeminal neuralgia is a chronic pain disorder that affects the trigeminal nerve and produces intense facial pain along one or more of the three branches of this nerve. Pain may be triggered by eating, brushing of the teeth, touching trigger points on the face during everyday activities such as washing the face or applying make-up or even air drafts, which increase the discomfort of those suffering from this disorder. For trigeminal neuralgia the Western Medicine suggests treatment with medications, surgery and stereotactic radiation therapy. According to Traditional Chinese Medicine (TCM), trigeminal neuralgia usually occurs when there is blockage in the stomach meridian and the main treatment for trigeminal neuralgia is acupuncture. In this article are shown two patients, males, both 66 years old, diagnosed with trigeminal neuralgia. Acupuncture treatments were made in our clinic for TCM and acupuncture with fire needle on a trigger i.e. Ashi points. One of the patients needed only one treatment, the other needed six treatments.


Introduction
The trigeminal nerve is the 5th cranial nerve (one of the largest nerves in the head), which travels directly from the brain to the face and it is responsible for the sensations in the face.
[1] Trigeminal neuralgia, also called tic douloureux (due to the fact that facial muscle spasms often accompany the pain), is a neuropathic pain syndrome that affects the trigeminal nerve. [2] It usually appears after exposure to the external factor Wind and is more often seen in women than in men and more often in older and middle aged people. It usually affect 4-5 people in 100 000. Pain in the optical branch is rare and it is more often in the mandibular and maxillary branches. It is characterized and usually starts as very sharp, electric shock like unilateral excruciating, paroxysmal and stabbing facial pain. The pain can range from short duration (only a few seconds) to pain that lasts for days or weeks and can be triggered by many ways and activities. The patient may feel pain in follow areas on the face: the jaw, teeth, gums, cheek and lips. The condition can be worsened by some daily activities as chewing, speaking, smiling, teeth brushing, exposure to cold air, intake of hot or cold fluids. [3][4][5][6] The trigeminal nerve has 3 branches, one going to the eye, the second to the mouth, and the third to the jaw. According to TCM, they come out around the taiyang area of the face and from the TCM perspective, trigeminal neuralgia has multifactorial etiology: 1. Exterior -Wind-Cold Invasion 2. Interior -LV/ST Fire 3. Interior -Yin Deficiency w/empty fire rising. When it is caused by wind-cold invasion the patient will be expressing following symptoms: acute onset, severe pain for a few seconds to a few minutes several times/day, vomiting, nausea, severe chills, fever, cough, headache, body ache, joint ache,. Exterior signs: runny nose, tearing. Тongue exam: thin white. Pulse exam: tight, floating. When it is caused by Liver/Stomach (LV/ST) Fire the patient will be expressing: Severe pain w/irritability. Internal heat signs: thirst, constipation, indigestion, heartburns, vomiting, acid reflux, dry mouth, anxiety, depression. Tongue exam: yellow, dry coat. Pulse exam: wiry. When it is caused by Yin Deficiency w/empty heat rising, the patient will be expressing: Pain but more insidious, gradual, comes and goes, mallar flush, soreness in lumbar area. Tongue exam: Red w/no coat. Pulse exam: Thin, fast. [4] [7] [8] Most commonly it is caused by an attack of exterior pathogenic factors, especially of Wind and Heat, which block and obstruct the free flow of Qi (energy) and blood circulation. From the Western Medicine point of view, trigeminal neuralgia is caused by some impairment of the normal function of the associated nerve. Physical nerve damage and stress -can trigger the beginning of the painful attacks. Nerve damage may result in weakness, sensory loss or other neurologic dysfunction. The Western Medicine suggests treatment with medications, surgery and stereotactic radiation therapy. [9] [10] According to Traditional Chinese Medicine, the main treatment for trigeminal neuralgia is acupuncture.

Material and Methods
In this article are shown two case reports, two patients, males, both 66 years old, suffering from trigeminal neuralgia. The pain in the patients lasted for hours and it was so severe that they were unable to sleep. One of them consulted his dentist and the dentist decided to pull out the two lower teeth. There was no improvement after the tooth extraction. The patient felt swelling on the left side of his face and the pain at this point became worse. In this case, one of the three trigeminal branches was affected (the third branche that is going to the jaw). One of the patients needed only one treatment, the other needed six treatments. They were treated with fire needle acupuncture on the trigger points (most painful points found on palpation in the treated area) with duration of the treatments 3-5 minutes. Treatments were made indoor on room temperature Acupuncture treatments were done in a clinic for TCM and acupuncture in Skopje, by a doctor specialist in acupuncture.

Results and Discussion
Case 1-Male, 66 years old, diagnosed with trigeminal neuralgia, causing him chronic and very intense facial pain. The patients had pain for two years in the right part of the lower mouth (unilateral), In the area of the temporomandibular joint. He has been using lot of medication like Propolis, Gingival, Oralcept and liquids for rinsing the mouth. The patient has consulted before his dentist, thinking that the pain comes from some teeth and the dentist decided to pull out the two lower teeth. The condition didn't have any improvement after the tooth extraction and the patient started feeling even worse. He felt swelling on the right side of his face and the pain at this point became worse. In this case, one of the three trigeminal branches was affected (the third branche that is going to the jaw). The patient is with high blood pressure (normalizing it with tablets -Enap), insomnia and normal blood sugar, stool, urine and appetite. The patient needed only one treatment to improve the condition. Treatment was made on 23rd November 2016. After the treatment he reported that he had been pain free. The patient was treated with fire needle acupuncture on the trigger i.e. Ashi points, that were found on palpation on the most painful places on the face, in the area around the lower jaw.
Case 2 -Male, 66 years old, diagnosed with trigeminal neuralgia. The pain lasted for year and a half, unilateral in the lower jaw with swelling of the cheeks and stronger pain attacks in the evening. The patient is diabetic, with cervical pondylosis, normal blood pressure, normal appetite and infrequent stool (taking tablets for constipation). The patient was taking lots of different medication like Lanzul for gastritis, Loran for triglycerides, medications for epilepsy, vitamins and Bioxan. The patient has done 6 treatments, on the trigger i.e. Ashi points. The treatments were done every week from 3 rd December 2016 to 7 th February 2017. All treatments were done with fire needle acupuncture on the internal side of the mouth, on the left side of the lower jaw. On the 4 th and 5 th treatment we used also normal (cold) needles in the treatment. On the 3 rd treatment patient said the pain was worse at night, then after the 4 th treatment the pain was reduced and he reported getting a good night's sleep for the first time in one year. Between the 5 th and 6 th (last) visit the patient visited a dentist and have extracted one tooth from the lower jaw. On the last visit he said he was having negligible small pain while chewing, probably caused by the tooth extraction. Patient's condition is good for now, but however we want to make future follow ups in this case, so to be sure the condition is completely improved.
The acupuncture points that were treated in our patients are trigger i.e. Ashi points, that are individual in every patient. We find them on the meridian on the most painful place which are manifested as knots. The needling is performed directly into the Ashi point -the area of pain, with fast movement (in and out) and with no retention. One point is needled 5 times. [11] Acupuncture can effectively treat the nerve pain of trigeminal neuralgia. First step include talking with patient about what he is experiencing: what is the pain like, when symptoms started, what makes his pain better or worse, and about his general health. From an acupuncture perspective pain occurs when there is blockage in the meridians. In these cases there is blockage in the stomach meridian. This meridian is distributed around the eye, the jaw, and the teeth. So if the stomach meridian is blocked the pain is felt in this area. The pain is caused because the external factors like Wind and Heat are mixed, and the wind flame invaded the stomach meridian. [12] [13] Acupuncture is used to correct the pattern of disharmony, to restore the normal balance to the body, thus to relieve the pain and other symptoms. Stimulating acupuncture points the energy flow can be improved (energy flows through the body on very specific pathways called meridians) and decrease the pain sensation signals that the trigeminal nerve sends to the brain.
[8] [14] When treating a Wind Cold caused condition the treatment principle is to remove the cold and relieve the exterior. When treating a Liver caused condition the principle is to clean the stagnation and soothe the Liver. If treating Blood stagnation caused condition, the principle is to invigorate the Blood and remove the stagnation. [4] If there's deficiency or excess in the condition then the principle is to tonify (to strengthen the physiological function) and sedate (to harmonize the hyperactive physiologic function) the organs. [3] A study done for trigeminal neuralgia, compared acupuncture treatment with Carbamazepine (a drug used in the treatment of trigeminal neuralgia) 100mg tablets two times per day with gradually increasing the doses to four times per day. In the acupuncture treatment were used normal needles on the acupuncture points Tai Yang (Supreme Yang), LI7 (Wenliu, Warm Flow), LI4 (Hegu, Joining Valley), ST7 (Xiaguan, Lower Controller), DU20 (Baihui, Hundred Meetings), Yin Tang (Hall of Impression), ST6 (Jiache), Jaw Bone and GB20 (Fengchi, Wind Pool). The results show that acupuncture is clinically more effective and have bigger fully recovering rate (70%, 30 out of 40 patients who fully recovered) than the Carbamazepine (55%, 22 out of 40 patients recovered fully). The acupuncture treatment reached 90% total effective rate and the Carbomazepine 87.50%. Some scientists are suggesting a combination of Carbomazepine and acupuncture treatment for trigeminal neuralgia, but the usage of the drug Carbomazepine has some side effects and can cause some very dangerous allergic reactions, involving toxic epidermal necrolysis and Stevens-Johnson syndrome. [6]