by Eyton J. Shalom, MTOM, L.Ac.

Abstract Trigeminal Neuralgia (TN) is one of the most painful disorders known to humankind. Biomedical treatment is both medical and surgical, each of which has their own attendant iatrogenesis. Acupuncture is effective in treating the branch of the disorder while herbal medicine focuses on pattern discrimination of the root. This article scans the current biomedical treatment, the differential diagnosis in Chinese herbal medicine, and gives a case study placing the herbal medical treatment in the larger world of Chinese Medicine and modern holistic healing.

Trigeminal Neuralgia, also known as Tic Douloureux (French for painful tic) and thereafter referred to in this article by its acronym TN, is described in biomedicine as "a disorder of the sensory nucleus of the trigeminal nerve producing bouts of severe, seconds-long pain in the distribution of one or more divisions, most often the superior mandibular or maxillary." Until recently biomedical tradition asserted that the cause of TN was unknown, and certainly the underlying etiology remains so, but recent surgical advances suggest the cause of pain to be vascular compression of the proximal part of the nerve as it exits the brain stem. This is deduced because in surgical treatment for TN, an offending arteriolic lesion has been identified, and when excised, leads in most cases to at least initial pain relief. There are no pathologic changes in the nerve itself in this disease. Victims are generally older patients (over 40). The pain is often set off by touching a point on the face, or by activities like speaking, chewing or brushing the teeth. Exposure to wind can be devastating, and putting on make-up becomes an activity fraught with danger. Pain is intense and often excruciating, and although each bout is brief, successive bouts and the constant fear of recurrence may incapacitate the patient, even driving some to suicide. With this in mind, we should remember in treatment that chronic sufferers present in an aversive emotional state that is derived from the aggregate of negative perceptions associated with the disease, only one of which is pain. Loss of friends, ability to engage in pleasurable activities, even financial independence combine to create a climate of suffering that can render life very unpleasant.

TN history is most often typical and diagnostic. No clinical or pathologic signs occur with TN, so that finding sensory or neural abnormality or dysfunction as the cause of facial or dental pain rules TN out. Differential diagnosis includes neoplasms, vascular malformations of the brainstem, demyelinating lesions, past-herpetic lesions, RA, Sjogren's syndrome, migraine, and chronic meningitis, each with their own particular sensory, neural or pain presentations that separate them from TN as the cause of trigeminal nerve pain.

Etiological theories are few, with some physicians asserting that the tiny muscles attached to the surface of the offending arteriole slacken with age, thereby allowing the blood vessel to impinge on the nerve root. However, this theory does not explain why this process occurs in some and not others, when externally there does not appear to be a difference in the muscle slackness between the 65 year old with TN and the one without. One factor not discussed in the biomedical literature, but observed in practice, is the occurrence of major stress factors in the lives of TN sufferers. Stress is cited as a major contributing factor in flare-ups, if not in the original onset, by victims of the disorder. This is interesting, and leads me to my own hypotheses for a possible cause of the blood vessel lesion. We know that some muscle fibers shorten as a result of the stress-induced sympathetic response. And we know that acupuncture treatment induces parasympathetic "deactivation" of the fight or flight response, leading to lengthening of muscle fibers. Could it be muscle tightness (stagnation of Qi and blood) then, rather than slackness, that somehow leads the tiny artery into conflict with the nerve?

Biomedical treatment is both medical and surgical. Medical treatment with Carbamazepine (Tegratol) is the conservative first step; if this fails or renders excessive side effects, Dilantin or Baclofen are then substituted or added. Unfortunately, Tegratol is liver and kidney toxic, so blood must be consistently monitored at the risk of permanent damage to those organs. The second two medications are also not without risk. In any case, none of the drug combinations give consistent or sustained effectiveness to all, or even most patients. Those with unsuccessful drug therapy move on to one of the various surgical procedures. These range from microvascular decompression, in which a small pad is placed between the nerve and the blood vessel lesion, Gamma knife surgery in which radiation is used to damage the nerve, and various percutaneous procedures which involve deadening the nerve to kill pain. Unfortunately, each of these procedures has its assets and liabilities.

Gamma knife (radiation) surgery is the most recent shining star, with a similar effectiveness rate (relief of pain) as the percutaneous procedures, but with a decreased rate of paresthesia side effect due to its more exact and finer degree of nerve damage. Proponents of percutaneous procedures argue that radiation surgery has not been around long enough to study its long-term effectiveness, nor to observe the long term effects of the radiation on the trigeminal nerve itself. Microvascular decompression gives fairly long pain relief, (up to ten years in some cases) with repeat surgery necessitated later. It is, however, a major surgery involving a site adjacent to the brain stem, as well as removal of a significant portion of skull behind the ear. Like all the surgical modalities, it has only a partial pain relief record. All the percutaneous procedures operate on the principle of gross deadening of the nerve to relieve pain, substituting in its stead numbness and dysesthesia (tingling, crawling, or burning sensations). Many patients find this very frustrating and also receive pain relief for as little as a year. They must become "multiple-procedure patients" who find that after two or three times "these procedures don't seem to work as well as they used to." Many, if not most, of these patients still require some kind of drug therapy even after surgery. It is interesting to note that there have not been extensive comparative studies to determine which surgical procedure is the most effective, and at meetings of the American Association of Neurological Surgeons, debate centers upon which procedure is most effective based on interpretations of small studies of individual procedures. One of these, radiation therapy with the Linac linear accelerator, has not been studied at all to determine if it is effective in treating the pain of TN. Against this backdrop, it would seem common sense for the western medical establishments to test the effectiveness of acupuncture and Chinese herbal drug therapy for the relief of TN pain and suffering.

Chinese medical descriptions of Trigeminal Neuralgia fall under the traditional disease categories of facial pain mian tong, head Wind tou feng, and side head Wind pian tou feng, which include biomedical-defined diseases different than TN as well. While acupuncture treatment of TN is directed at spreading the Qi through the channels in the affected area, a branch treatment, herbal therapy is based on pattern discrimination. These include: Wind Heat harnassing above, Wind Cold assailing above, Liver and Stomach Fire flaming upward, Yin Vacuity Stomach Heat, Phlegm Fire attacking above, and Static Blood obstructing internally. Differentiation is as follows:

The above formula, with its strong animal medicinals, is recommended for anyone with a long disease course without a marked vacuity or repletion, heat or cold. There is a very similar formula being called San Cha Fang that is being used at Zhe Jiang Jiao Jiang Hospital by Dr. Huang Dong Du consisting of Chuan Xiong, Dang Gui, Tao Ren, Chi Shao, Bai Shao, Bai Zhu, Gou Teng, Quan Xie, Wu Gong, Di Long.

What these pattern discriminations demonstrate is that the branch (biao) of facial pain exists in the root (ben) of a particular pattern unique to the individual patient at a specific point in time. While acupuncture treatment of the branch remains primarily the same for each patient depending on the location of pain, herbal prescription focuses on the root that the branch grows from. Of course, while each of the above textbook patterns is represented as distinct, actual cases will often contain elements or two or three of the above patterns in one human being. Fore example, a Liver Fire case may include elements of Blood stagnation and Phlegm Fire. Or the Liver Fire case may present with additional disharmonies not included under the above differentiation, such as Liver Fire with damp depression and Spleen vacuity. Successful long-term treatment requires resolving the pattern of disharmony seen in the individual patient in all its facets.

All but one of the above patterns are pure repletion. This means that in treating TN, even if the patient is elderly or apparently weak, if the pattern identification is correct, and the pattern is definitely of a replete nature, then we must expel the evil pathogenic factor, whether internal or external, whether Wind, Cold, Heat, Fire, Phlegm, or Blood (stasis). We may also supplement Upright Zheng Qi, but only after clearing the evil. In practice, supplementation is generally of the Yin and Blood, which aids in the decongesting of the Liver Zang and in restoring the balance of Yang with Yin. We may at some point have to supplement Qi, so as to aid the Spleen's transformation of dampness which can be an underlying etiological factor.

Case Study
Sally D., female, age 60, overweight, presents with frequent electrical pain down the right side of her face, across her upper lip, and into her upper teeth, corresponding to the second or maxillary branch of the trigeminal nerve. Discomfort increases markedly with exposure to wind, touching her nose, brushing teeth, or touch her face to her cat's fur. Her tongue is swollen and reddish purple with a red tip, thick purple veins on the underside, a greasy yellow coat from the rear of the tongue to the center, the edges peeled and swollen. Her pulse is tight/jim mai, large, and slippery. She is under the care of a neurologist and is taking Tegratol, 1200 mg/day.

History
Pain began one year ago immediately after the patient's mother died. The mother had been mentally ill and in a locked facility. Patient reports visiting her mother shortly before her death and being cursed "you will have tremendous pain and nothing will really cure you." Patient herself has a history of mental-emotional instability, and has been on psychiatric disability in the past. She has a history of mild alcoholism and a diet high in sugar and greasy foods. She has had migraines and nosebleeds with emotional upset since childhood. The day before the onset of pain, she had been driving in her car thinking about her mother, feeling enraged, and had a major nose bleed, bilaterally, so profuse she had to stop the car. The next day she received what she described as 2,000 volts of electricity in her face for a brief second. She sought medical treatment after one week and was put on the Tegratol with limited results.

She avoids touching her face for any reason. While she "hates being cold" she reports no symptom aggravation with cold weather or beverages. Her appetite and digestion are unremarkable, BMs regular and problem-free. Sleep is good. She admits to being hot tempered and says "I picture my temper as a fireball," though most of the time she claims to repress it. She is very frustrated with her life; has frustration with her job, her family, and her husband. She is very angry with her doctors and feels they do not listen to her.

This is an interesting case in which the quality of the branch symptom; electrical facial pain, the patient's emotional state; agitated and angry, and the nosebleeds fit neatly into the Liver Fire Flaming Upward root pattern. Here anger is both part of the root patter, and a major underlying path-mechanism leading to the root. Anger causes impaired free coursing of Qi, which in turn leads to binding depression of Liver Qi, which in turn transforms into Liver Fire or severe emotional disturbance that can directly lead to upflaming Liver Fire.

Chapter 39 of the Su Wen states: " When there is anger the Qi goes into countercurrent. If it is intense, there is vomiting of blood..." According to Elizabeth Rochat de la Vallee, the character for anger, Nu, shows a heart underneath a female slave underneath the hand of a master. This gives the sense of suppressed rage that this particular patient carries with her and which is as much anger as the violent bursting out type that she experiences from time to time and which is a symptom of Liver Fire. This patient is frustrated with her job, her doctors, her mother, her husband, her daughter, her coworkers, her boss. No one listens to her and that is frustrating, too.

Her tongue clearly shows stasis of blood, with large purple veins on the underside and an overall reddish purple color. The Nei Jing states, "If blood has a surplus, anger will occur..." Yan De-Xin, a proponent of blood stasis as an important etiological factor in geriatric disease states that "imbalance in Qi and Blood can lead to essence spirit (psychological) disease." He quotes Wang Qing-ren's view that "blood stasis renders it impossible for the cerebral Qi to connect with viscera and bowel Qi, thus causing essence spirit disease." He goes on to say: "Excess of the seven emotions leads to confusion and chaos in organic function. Therefore, if the seven emotions cause damage, Qi depression enduring for many days will necessarily cause blood depression."

While Sally D.'s pain pattern most neatly fits the Liver Fire diagnosis, clearly her overall pattern does contain Blood stasis and that has to be addressed along with the dampness manifested in her body type (overweight) and her tongue body and coat (swollen and greasy). Clear the filth and stagnation to open the flow of Qi from up to down and from depth to surface.

Diagnosis
Liver Fire flaming upward, Blood stasis, dampness with Spleen not transforming fluids.

Treatment Principle
Clear and Drain Liver Fire, Subdue Liver Wind, Spread Liver Qi, Invigorate Blood, Dispel Blood Stasis, Relieve Pain, Dry Dampness, Improve Spleen, Transport Fx.

Prescription
One of the arts of Chinese herbal medicine is combining ready-made formulas to treat complicated patterns of disharmony. Even when using water-based polypharmacy or "raw herbs" the challenge is to connect real human beings with textbook patterns one hardly ever encounters in said humans as presented in the texts. In this case, the patient's specific pain pattern, nose bleeding, emotional state, as well as elements of tongue and pulse fit the Liver Fire pattern even though she does not have the rest of the textbook heat symptoms like red eyes and face, bitter taste, dry throat, reddish urine, or constipation. As she was not amenable to cooking herbs, K'an brand liquid extracts were used starting with Long Dan Xie Gan Tang to reduce Liver Fire and Damp Heat, modified by combining with Purge Internal Wind, a combination that further pacifies the Liver, Quells fire, descends Yang, extinguishes internal wind, clears heat, and benefits the Yin. Acupuncture treatment was also undertaken to spread the Qi in the affected channels, clear Yang and calm the Shen.

Progress
After five days, the tongue color and coat were more normal, while the tip retained redness with a white creamy coat in the rear. The veins and swelling were unchanged. Patient was able to scratch her face, brush her teeth, and bury her face in her cat's fur without pain. Her pain was down from a ten to a five.

After ten days, the pain was down to a two with the tongue unchanged. Patient began lowering Tegratol to 100/mg per week with her doctor's cooperation. Xui Fu Zhu Yu Tang was now combined with Purge Internal Wind to treat the blood stasis, unblock the luo mai/connecting vessels, and continue spreading Liver Qi and reducing Wind. To this the simple patent formula from China, Ping Wei San was added to address the damp turbidity and the lack of fluid transport.

Chinese Herbal Medicine exists in no less of a vacuum than its biomedical counterpart drug therapy. If we just treat with herbs or acupuncture, ignoring the spiritual and emotional realities of the patient bore us, we are not doing that much differently than those biomedical physicians who, for example, prescribe pain killers for tension headache without addressing the issue of tension reactivity in the headache patient. As one of the underlying pathomechanisms behind the root pattern of disharmony of this patient was frustration and anger due to not being listed to. I tried to create an environment conducive to her Qi spreading and Heat clearing by simply listening, and sharing her discomfort. As Peter Deadman points out, compassion means "to feel with." We also discussed the effects of long term unresolved conflicts and anger on her particular condition and on wellness in general. The potential benefits of counseling, therapy, anger management, assertiveness training, and ultimately, some kind of meditative physical or mental practice was discussed, with a view towards engaging the patient in her own healing process.

And, as Chinese Medicine is Wholistic, and does emphasize diet, exercise, massage, etc., along with acupuncture and drug therapy, we discussed the effects of excessive sugar, coffee, alcohol, and fried food on someone with a Liver damp-heat, Spleen-damp, Blood stagnation pattern, and the patient agreed to keep a diet diary and begin paying attention to the effects of food and substances on her specific condition and general state of well-being. She was given specific suggestions for a dietary plan that would help resolve the root pattern. While all this "non-herbal, non-acupuncture" therapy takes precious time, it is an investment that takes the patient beyond medicine to the origins of their suffering. "The beginning is the end and the end is the beginning."

Places in which what Grossinger calls "spiritual" medicine [as opposed to pharmaceutical (herbs, drugs, foods) and mechanical (chiropractic, surgery, acupuncture)] is still practiced, including parts of modern China, would certainly take seriously, even if not literally, the psycho-emotional-spiritual effects of the mother's curse on this patient. Treatment here could, depending on the patient's belief system and the local culture, range from shamanistic practices, conventional offerings, to ancestors and/or spirit forces, prayer, confession, and even modern talking or insight therapies.

After 30 days, this patient was pain free and had lowered her Tegratol dose by 200 mg. She had discontinued her martini and fried food lunches and was eating more vegetables at the workplace cafeteria. She had an appointment for counseling. Her tongue color was less dusky and the coating closer to normal. After 120 days, the patient remained pain free and had continued lowering the Tegratol by 200 mgs. per month so that she was now down to 400 mg. She had completed a short course of counseling and reported better communication with her husband and less frustration at the workplace. Her facial pain was so much better that she underwent "permanent" eyebrow and lip coloring, a kind of tattoo-like process that is painful even to the non-TN sufferer. Her tongue was pink-red with a thin white coat. Pulse was still slippery but less constrained. Herbal therapy continued for a total of one year with the patient leveling her Tegratol off at 200 mg/day.

One and a half years later, the patient returned to herbal therapy after being off herbs for six months. Subsequent to some very stressful events involving illness in the family and discomfort at the workplace, there had been some resumption of pain to the tune of five or six electrical jolts per day. The patient again went back on Long Dan Xie Gan Tang/Purge Internal Wind with immediate results. Pain disappeared after one week, and patient now stays on Chinese herbal therapy based on her particular signs and symptoms. Her lifestyle modifications have been significant, but not comprehensive. One might hope that if she were to wholeheartedly embrace a more effective stress coping mechanism, such as Tai Ji or meditation, perhaps she could ultimately reduce her dependence on herbal drugs as well as the biomedical ones.