Dear Patients and Friends:
February 14 was the first day of the Chinese New Year. This year is the year of the tiger. In Chinese tradition, the year of the tiger will usually make you look forward to the bright future and bring you an exciting fortune. Therefore, we wish you a Happy Chinese New Year of Tiger!
This month’s case discussion is about Trigeminal Neuralgia, which is common to middle and elderly aged people. We hope you may learn something from this case discussion.
Happy Chinese New Year!!!
Jun Xu, M.D. and Hong Su, C.M.D.
News Letter, Vol. 2 (2), February, 2010, © Copyright
Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.
Rehabilitation Medicine and Acupuncture Center
1171 East Putnam Avenue, Building 1, 2nd Floor
Greenwich, CT 06878
Tel: (203) 637-7720
Sharon, a 65-year-old woman who suffered from a toothache on the right side of her mouth for a month, finally consulted her dentist who found two loose teeth in the back, right side of the mouth. The patient loves sweets, which may have caused the problem, but the pain was so severe that she was unable to sleep. The pain occurred proximally and started when Sharon tried to brush his teeth; the pain was so severe that she could not bear to touch the teeth or the right side of her face and jaw. Even air currents could trigger the pain. She had difficulty eating, talking, and brushing her teeth. The shooting pain felt like electrical shocks and burning, and, at times, was unbearable. It attacked the right side of the jaw and face and lasted for hours. The patient intentionally tried not to use the right side of teeth in order to avoid triggering an episode of pain. Finally, the dentist decided to pull out the two lower teeth. At this point, the patient felt immediate swelling on the right side of her face and, after a week, the pain became worse. The doctor also prescribed narcotics to ease the pain. There was no improvement after the tooth extraction and the patient still could not touch the right side of his face.
Upon examining him, I discovered that although the pain did not extend to the right side of her eye, the right cheek and jaw were tender and the pain was described as intolerable by the patient. She felt it was incapacitating her to the extent that she was losing normal function and had dropped ten pounds. She also experienced fatigue and was unable to sleep.
Sharon is suffering from trigeminal neuralgia. The trigeminal nerve carries sensation from the face to the brain. Many studies indicate that when the superior cerebellar artery compresses this nerve, the nerves protecting the myelin sheath are injured, causing erratic and hyperactive function of the nerve. This can lead to pain at the slightest stimulation of any area served by the nerve, as well hindering of the nerve’s ability to shut down pain signals when the stimulation ends. The trigeminal nerve is the fifth cranial nerve, which registers sensory data such as pressure and temperature and measures pain originating from the face above the jaw line. The trigeminal nerve has three branches, one going to the eye, the second to the mouth, and the third to the jaw. In Sharon’s case, two of these three trigeminal branches (mouth and jaw) were affected. This condition is usually found in males and females at the ratio of 2:3, and most trigeminal neuralgia cases are idiopathic and typically occur in the sixth decade of life, although they may occur at any age. The symptomatic or secondary trigeminal neuralgia may occur in younger patients.
The patient’s history is the most important factor in the diagnosis of trigeminal nerve neuralgia. The nature of the pain may be brief and proximal, but it may also occur in multiple attacks and may be stabbing or shock-like or extremely severe. It is usually distributed in one or more branches of the trigeminal nerve and is usually maxillary or mandibular and unilateral. This pain typically lasts from a few seconds to one to two minutes and will typically occur for a few months each year.
Treatment with Western Medicine:
- Medications. The most typical medications prescribed by doctors and dentists are anticonvulsants such as carbamazepine, oxcababazepine, phyntoin or gabapentin. Generally, these are the most effective for pain relief, and can be adjuncted with muscle relaxants such as baclofen. Some opiates can also be effective such as OxyContin or Duragesic in patch form, for decreasing pain in the jaw and face, as well as low doses of antidepressants such as amitriptyline.
- Surgery. Surgery may relieve pressure on the nerve or selectively truncate the nerve by disrupting the pain signals from getting through to the brain. It is usually 90% successful if done by an experienced surgeon. The most specific kind of surgery is microvascular decompression.
- Stereotactic radiation therapy. A surgeon uses a gamma knife or linear accelerator (a form of radiation therapy) such as the Novalis Cyberknife. The therapy penetrates the skin and targets the selective nerve root and disrupts the pain signal transmissions.
Treatment with Traditional Chinese Medicine:
According to Traditional Chinese Medicine, the stomach meridian is distributed around the eye, the jaw, and the teeth. Therefore, if the stomach meridian is blocked, the external wind and heat will be mutually mixed, and the wind flame will invade the stomach meridian and cause severe pain along the meridian (i.e. along the face, teeth, and eye).
The main treatment for trigeminal neuralgia is to soothe the stomach meridian by redistributing the wind, dissipating the heat and improving the energy flow in the area. The acupuncture points along the face, eye, and teeth must be carefully selected. The three branches of the meridian should be treated separately:
1. Ophthalmic nerve branch. This is the top branch of the trigeminal nerve. Acupuncture points include the EX-HN4 Yu Yao, GB 1 Tong Zi Liao, SJ 23 Si Zu Kong, EX-HN5 Tai Yang and UB1 Jing Ming. The needles should be inserted in 0.3 to 0.5 inches deep. The patient should feel a stimulation similar to an electric shock. Continue to twist the needles three to five times, and then put the needles on the electrical stimulating machine for 30 minutes.
2. Maxillary nerve branch. Use the St 2 Si Bai and St 1 Chen Qi points and the manipulation described above.
3. Mandibular nerve branch. Use the St 7 Xia Guan, Ren24 Cheng Jiang and St 4 Di Chang points and the manipulation described above.
In addition, choose some body points such as GB40 Qiu Xu, Li v 5 Li Gou, LI 4 He Gu, Lu 7 Lie Que, etc. in order to adjust the energy of the entire body.
Stimulating these above acupuncture points can improve the energy flow and decrease the pain sensation signals that the trigeminal nerve sends to the brain. The acupuncturist must ensure that the patient feels an electrical shock sensation from the needles. This treatment allows the energy to go to the trigeminal nerve to improve the energy flow and decrease the pain.
Sharon was treated with a combination of Treatments # 2 and # 3 plus electrical stimulation of the acupuncture needles three times a week for three weeks. After the first visit, she felt better and reported getting a good night’s sleep for the first time in six weeks. After four weeks of treatment, the pain had subsided by 80%; thus, the treatments were decreased to once a month; after six months on this schedule, the patient told me he felt no more pain.
In my experience, the treatment of this illness has two facets. First, there must be a clear diagnosis. In Sharon’s case, the dentist was wrong in the evaluation of the condition, and pulled two teeth unnecessarily. It is also necessary to combine western medicine with TCM in this case, and to treat all three of the nerve branches, if necessary. If the treatment is done properly, the patient’s pain should subside and he/she should be able to function normally in day-to-day life.
Tips for acupuncturists:
- You should combine the local points with the distal points for your treatment.
- Electrical stimulation is very important.
- Do not use moza in these kinds of cases.
Tips for patients:
- Seek for medical attention as early as possible.
- An ice-cold massage at the above points might decrease the pain.