Facial+Pain+(Trigeminal+Neuralgia)


 * [[image:trigeminal_neuralgia.png width="221" height="174" align="right"]]Facial pain** refers specifically to spasmodic penetrating pain of the cheek and temple. This pain is of sudden onset and is characteristically paroxysmal, radiating and quite severe

Facial pain is more common during middle age, and more prevalent among women. The pain persists for only several seconds or minutes before spontaneous remission, w/ no other symptoms between bouts. Usually one side of the face is affected, commonly the upper or lower jaw. Cases of facial pain are often prolonged, recurrent, and unresponsive to treatment


 * Trigeminal neuralgia (TN)**, also called tic douloureux, is a chronic pain condition that affects the sensory nucleus of the trigeminal - or 5th - cranial nerve.

Trigeminal neuralgia is more common in people over 40 years of age The male-to-female ratio is 2: 3 Secondary depression is common in severe, chronic cases

Etiology
-Most cases (85%) are idiopathic; these are termed “classic trigeminal neuralgia.” -An abnormal vascular course of the superior cerebellar artery is often cited as the cause. -Aneurysms, tumors, chronic meningeal inflammation, or other lesions may irritate trigeminal nerve roots along the pons causing symptomatic trigeminal neuralgia. -Uncommonly, an area of demyelination from multiple sclerosis may be the precipitant. Lesions of the entry zone of the trigeminal roots within the pons may cause a similar pain syndrome. -Infrequently, adjacent dental fillings composed of dissimilar metals may trigger attacks, and an atypical case has been reported following tongue piercing.

Trigeminal Neuralgia Symptoms
Pain is brief and paroxysmal, but it may occur in volleys of multiple attacks. Pain is stabbing or shock-like and is typically severe. One or more branches of the trigeminal nerve (usually maxillary or mandibular) are involved. Pain is unilateral (rarely bilateral). Duration of pain is typically from a few seconds to 1-2 minutes. Pain may occur several times a day; patients typically experience no pain between episodes. Light touch or vibration is the most provocative. Activities such as shaving, face washing, or chewing often trigger an episode. Stimuli as mild as a light breeze may provoke pain in some patients. Pain provokes brief muscle spasm of the facial muscles, thus producing the tic.
 * Nature of pain:**
 * Distribution of pain:**
 * Pain triggers:**

Trigeminal Neuralgia Diagnosis
Diagnosis is generally based on the patient’s medical history and description of symptoms, a physical exam, and a thorough neurological examination by a physician. Contrast MRI is often conducted to exclude a mass lesion or vascular compression on the nerve roots.

Trigeminal Neuralgia Differential Diagnosis
-Multiple sclerosis: development of trigeminal neuralgia in the young suggest the possibility of MS -TMD Other Problems to Be Considered: -Atypical facial pain -Glossopharyngeal neuralgia -Compression of trigeminal roots from tumors or aberrant vessels -Dental problems

Trigeminal Neuralgia Biomedical Treatment
-Carbamazepine: tx of choice; anti-convulsant; side-effects -Other anticonvulsants: oxcarbazepine, topiramate, clonazepam, phenytoin, lamotrigin, and valproic acid. -Gabapentin or baclofen can be used as a second drug to treat TN and may be given in combination with other anticonvulsants. -Tricyclic antidepressants: amitriptyline or nortriptyline are used to treat pain described as constant, burning, or aching. -Rhizotomy: a procedure in which select nerve fibers are destroyed to block pain; causes some degree of permanent sensory loss and facial numbness; several forms available to treat TN -Microvascular decompression: the most invasive of all surgeries for TN, but it also offers the lowest probability that pain will return. -Neurectomy: involves cutting part of the nerve; may be performed during microvascular decompression if no vessel is found to be pressing on the trigeminal nerve. Neurectomies may also be performed by cutting branches of the trigeminal nerve in the face. When done during microvascular decompression, a neurectomy will cause permanent numbness in the area of the face that is supplied by the nerve or nerve branch that is cut. However, when the operation is performed in the face, the nerve may grow back and in time sensation may return. Some degree of facial numbness is expected after most of these procedures, and TN might return despite the procedure’s initial success. Depending on the procedure, other surgical risks include hearing loss, balance problems, infection, and stroke.
 * Medications:**
 * Neurosurgical procedures:**
 * TN Surgery risks:**

Trigeminal Neuralgia TCM Disease Categorization
Miàn Tòng: “face pain” Biān Tóu Tòng: “side head pain” Tóu Tòng : “headache” Tóu Fēng: “head wind” Jué Nì Tóu Tòng: “reverse flow headache”

Trigeminal Neuralgia Etiology and Pathogenesis
Facial pain is most often the result of wind-cold evil entering the facial portion of the Yangming channel, hindering the movement of Qi and Blood and causes obstruction of the channels, leading to pain. The second cause is Liver & Stomach fire flaring upward, giving rise to facial pain. This usually results from the transformation of stagnant Liver Qi to fire, coupled w/ food stagnation as a consequence of overindulgent eating.

-Exogenous Pathogens: Wind-Cold or Wind-Heat pathogens invade the Yang channels of the hand or feet and attack the facial region. They may combine with Phlegm and obstruct the channels and collaterals causing Qi stagnation and Blood stasis that results in pain -Diet: excessive intake of spicy, greasy, or sweet foods leads to Heat accumulation in the Stomach and Large Intestine. This Heat transforms into Fire which then flares up along the Yang Ming channels of the face causing toothache. Also, excessive intake of greasy, sweet foods may, over time, result in Phlegm accumulation which can combine with exogenous pathogens to obstruct the channels and collaterals of the face. -Emotional Stress: frustration, anger, irritability causes Liver Qi stagnation that transforms into Liver Fire which flares up along the Shaoyang channel in the face causing facial pain.
 * Repletion:**

-Poor diet: improper food choices over time weaken the Spleen/Stomach resulting in decreased production of Qi and Blood. This causes lack of nourishment to the face with Qi stagnation and Blood stasis from vacuity. Aging, excessive sexual activity, chronic disease: these can weaken the Kidney Yin resulting in upward flaring of vacuity Fire causing facial pain.
 * Vacuity:**

External Wind-Cold
LI-4, ST-7, TW-5, GB-20 Auxillary Points: supraorbital pain: + Yu Yao, BL-2, GB-14, Tai Yang Supramaxillary pain: + ST-2, SI-18, GB-3, LI-20 mandibular pain: + Jia Cheng Jiang, St-6, ST-5, TW-17 include ashi points modifications: +Quan Xie (6g), Wu Gong (6g), Tian Nan Xing (6g) Reinforce warming the channels & dispersing cold: + Gui Zhi (9g.), Gao Ben (9g.)
 * Clinical manifestations:** sudden attacks of facial pain, often occuring w/ local muscular spasms, aggravation of pain byexposure to cold and alleviation by exposure to heat, runny nose w/ clear thin mucus, excessive salivation
 * Tongue:** Thin White coat, thick greasy coat w/ phlegm
 * Pulse:** Floating, Tight
 * Treatment Method:** Dispel Wind, dissipate cold, relieve pain
 * Acupuncture Treatment:** Needle w/ draining technique, add moxa
 * Herbal Treatment:** Chuan Xiong Cha Tiao San

Wind-Heat Invasion (with Phlegm Obstruction)
Chuan Xiong Cha Tiao San + Bai Jiang Can (Stiff Silkworm) 6g Ju Hua (Chrysanthemum flower) 12g If Wind-Heat and pain is severe: + Shi Gao (15g)
 * Clinical Manifestations:** recurrent episodes of severe, unilateral facial pain that is aggravated by heat and relieved by cold; a red facial complexion, red eyes; sweating during episodes of pain
 * Additional Symptoms:** theoretically chills and fever, thirst, dark urine; dizziness, chest oppression, numbness of the limbs with Phlegm
 * Tongue:** red with thin, yellow coat; greasy, yellow coat with Phlegm
 * Pulse:** theoretically floating and rapid; usually wiry; slippery and wiry with Phlegm
 * Treatment Method:** Expel Wind, clear Heat, (resolve Phlegm), open the channels and collaterals, stop pain
 * Herbal Treatment:** Ju Hua Cha Tiao San
 * Modifications:**

Liver and Stomach Fire
LI-4, ST-7, LR-2, ST-44 Auxillary Points: Kidney vacuity w/ effulgent fire: + KI-3, SP-6 supraorbital pain: + Yu Yao, BL-2, GB-14, Tai Yang Supramaxillary pain: + ST-2, SI-18, GB-3, LI-2 mandibular pain: + Jia Cheng Jiang, St-6, ST-5, TW-17 include ashi points modifications: Drain Liver and Stomach Fire: + Tian Ma (9g.), Gou Teng (9g.), Huang Qin (9g.), Shan Zhi Zi (9g.), Bai Jiang Can (9g.), Quan Xie (4.5g.) Yin vacuity w/ effulgent fire: + Sheng Di Huang (12g.), Zhi Mu (9g.), Gou Qi Zi (9g.), Niu Xi (9g.) Chronic cases to dispel stasis, free connections, relieve pain: + Tao Ren (9g.), Hong Hua (9g.), Chi Shao Yao (9g.)
 * Clinical manifestations:** sudden attacks of facial pain, burning sensation at site of pain, irritability, bloodshot eyes, tearing of the eyes, thirst, constipation in some cases
 * Tongue:** Red w/ Yellow coating
 * Pulse:** Rapid, Wiry, Forceful
 * Treatment Method:** Clear Liver and Stomach Fire, relieve pain
 * Acupuncture Treatment:** Needle w/ draining technique
 * Herbal Treatment:** Xiong Zhi Shi Gao Tang

Kidney Yin Vacuity with the Vacuity Fire
Herbal Treatment:Zhi Bai Di Huang Wan (Anemarrhena, Phellodendron, and Rehmannia Pill)
 * Clinical Manifestations:** recurrent episodes of chronic, unilateral, mild to severe burning facial pain that is worse in the afternoon or nighttime
 * Additional Symptoms:** soreness and weakness in the low back and knees, hot flashes, dry throat, first, night sweating, insomnia, dizziness, tinnitus
 * Tongue**: red with little coat
 * Pulse:** thin and rapid
 * Treatment Methods:** Supplement the Kidneys, nourish Yin, clear vacuity Fire, stop pain

Phlegm Obstruction with Blood Stasis

 * Note: In this is not a common stand alone pattern, but rather one that complicates other patterns.
 * Clinical Manifestations:** recurrent episodes of severe, unilateral, sharp facial pain accompanied by heaviness or lack of sensation on the skin; pain may be worse at night; facial complexion appears dark or sooty
 * Additional Symptoms:** possible vomiting during episodes of pain
 * Tongue:** pale, purplish tongue with white, greasy coat
 * Pulse:** wiry or slippery
 * Treatment Methods:** Quicken the Blood, resolve Phlegm, open the channels and collaterals, stop pain
 * Herbal Treatment:** Ban Xia Bai Zhu Tian Ma Tang (Pinellia, Atractylodes, Gastrodia Decoction)

Acupuncture Treatment:
1st branch: BL-2, Yu Yao, TB-23, GB-I4, ST-8, Tai Yang; TB-3, LI-4 2nd branch: LI-20, ST-2, ST-3, ST-7, SI-18, LI-19, TB-20; LI-4 3rd branch: ST-5, ST-6, ST-7, TB-I7, CV-24, Jia Cheng Jiang; ST-44, LI-4 In addition to the patient’s description, one may palpate the following points to determine which branch the trigeminal nerve is affected: Pain when pressing BL-2 = 1st branch Pain when pressing ST-2 = 2nd branch Pain when pressing ST-5 = 3rd branch
 * Basic points:**
 * Use 2-3 points per treatment and alternate points.

Wind-Cold (with Phlegm): GB-20, TW-5, (ST-40, ST-36) Wind-Fire (with Phlegm): TB-5, GB-20, LI-1, TB-1, SI-1, LI-11, ST-44, ST-40 LV Fire: TW-2, LV-2, GB-43, LV-8 ST Fire: ST-44, LI-11, LI-2 Phlegm Obstruction + Blood Stasis: ST-36, ST-40, SP-10, BL-17 KI & ST Yin vacuity with vacuity Fire: KI-2, KI-3, KI-6, ST-44, BL-21, BL-23
 * Modification based on the pattern:**

Alternate Therapeutic Methods
Method: needle to elicit strong sensation & retain needles for 20-30 minutes. Alternatively embed therapy can be used.
 * Auricular Acupuncture:** Cheek, Maxilla, Mandibula, forehead, Shen Men
 * Electroacupuncture:** Many Chinese acupuncturists use this for all patterns of this disease.

Herbs for Facial Pain
Shi Gao(Gypsum) Chuan Xiong (Ligusticum root)-acrid, warm; LV, GB, PC Bai Zhi(Angelica root)-acrid, warm; LU, ST, SP Xi Xin (Asarum herb)-acrid, warm; LU, KI Tian Ma (Gastrodia rhizome)-sweet, neutral; LV Quan Xie (Scorpion)-acrid, neutral, toxic; LV Wu Gong (Centipede)-acrid, warm, toxic; LV Bai Fu Zi (Typhonium rhizome)-acrid, sweet, warm, toxic; SP, ST Bai Jiang Can (Stiff Silkworm)-salty, acrid, neutral; LV, LU Di Long (Earthworm)-salty, cold; LV, SP, BL,LU Bing Pian (Borneol)-acrid, bitter, cool; HT, SP, LU Gao Ben (Ligusticum rhizome)-acrid, warm; BL, GV Man Jing Zi (Vitex fruit)-acrid, bitter, cool; BL, LV, ST San Qi (Notoginseng root)-sweet, bitter, warm; LV, ST Yan Hu Suo (Corydalis rhizome)-acrid, bitter, warm; HT, LV, SP

Many Chinese formulas for treatment of pain from trigeminal neuralgia call for the use of She Xiang (Musk), which is very expensive and difficult to obtain. Bing Pian (Borneol) and Xi Xin (Asarum herb and root) are considered acceptable, although less potent, substitutes.