Chief Complaint: Facial Pain
Western diagnosis: Trigeminal Neuralgia
Medical History: Patient is a 50 years old male, well nourished. Physical examination revealed 135/95 blood pressure, otherwise appears to be in good health.
Blood Analysis: within normal range
MRI of the brain: Findings: the internal carotid and basilar arteries, proximal anterior and middle cerebral arteries are normal in caliber, contour and signal intensity. No congenital aneurysm or mass effect.
Impression: Normal examination.
Questioning exam: Patient suffers of severe attacks of facial pain (L) lasting for about 30 to 45 seconds followed by a burning sensation lasting 2 to 3 minutes.
The period of pain free after each attack was of about one hour. Any light touch or movement would trigger the pain at any time.
Pulse exam: Wiry and rapid.
Tongue exam: Revealed white thin coat with yellowish coat in front and red body.
OM Diagnosis: According to the nature of the pain and other signs, such as the yellow coat, red body of the tongue, a burning sensation in the face and a wiry pulse. The diagnosis was wind-heat invading the face.
Treatment Principle: Dispel wind-heat and treat the pain.
Point Prescription: The first and second treatments were to the right side of the face (opposite to the pain)
ST-4 toward ST-6 with a retention time of 30 minutes - even
ST-6 toward ST-4 with a retention time of 30 minutes - even
SJ-17 with a retention time of 30 minutes - lift and thrust for 1 minute (reduction)
LI-4 to remove qi and blood stagnation - lift and thrust for 1 minute (reduction)
LU-7 to remove qi and blood stagnation - lift and thrust for 1 minute (reduction)
GB-20 to dispel wind, retention of 30 minutes
LIV-3 - retention 30 minutes
The next treatments were to the left side (side of pain)
ST-4 toward ST-6 with a retention time of 30 minutes - lift and thrust for 1 minute
(reduction)
ST-6 toward ST-4 with a retention time of 30 minutes - lift and thrust for 1 minute
(reduction)
SJ-17 with a retention time of 30 minutes - lift and thrust for 1 minute (reduction)
LI-4 to remove qi and blood stagnation - lift and thrust for 1 minute (reduction)
LU-7 to remove qi and blood stagnation - lift and thrust for 1 minute (reduction)
GB-20 to dispel wind, retention of 30 minutes
LIV-3 - retention 30 minutes
Herbal Formula: List of herbs taken for TN and HBP
Da huang 4gms
Huang lian 2gms
Huang qin 2gms
Wu gong 1.5gms
Chan tui 6gms
Tian ma 6gms
Gou teng 6gms
Shi jue ming 15gms
Zhi zi 3gms
Yi mu cao 5gms
Du zong 6gms
San ji sheng 6gms
Fu shen 6gms
Chuan niu xi 6gms
Decoction, 3 cups 3 times a day - 3 wks.
Lifestyle prescription: No alcohol, no caffeine, fat free diet, reduction of intake of red meat. Take Vitamin B complex, B6, C.
Results: Western medical doctors were not able to detect the reason of the trigeminal neuralgia. To minimize the pain and reduce the high blood pressure, the patient was prescribed TEGRETOL AND ATENOLOL for life, with increments of dosage as needed.
Acupuncture treatments:
The first treatment was with no results at all.
The second treatment stopped the pain for about 4 hours, then pain came back about every 2 hours.
After the third treatment the attacks of pain came back every 3 hours more or less but with an intensity of only 20% and only in the day time. His blood pressure remains stable 130/85
Synopsis: The patient was taking medication for the trigeminal neuralgia and high blood pressure. Now he is almost pain free. Once in a while the pain cames back but with an intensity of 3 to 5 % only.
Patient remain in treatment once a month and he is not taking TEGRETOL any longer neither ATENOLOL.
Blood pressure stable 130/85. currently taken Tian ma gou teng yin.
Decoction, one cup a day.
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