Electric shocks across the face: assessing trigeminal neuralgia and where the boundaries lie

History and prior work-up

Paroxysmal, lightning-like severe pain on the right side of the face for 8 months, several to dozens of attacks daily, each lasting seconds to 2 minutes. The trigger zone lay beside the ala of the nose and at the corner of the mouth; brushing teeth, washing the face, talking, or exposure to wind could set it off, with occasional waking from pain at night.

Brain MRI plus MRA had been performed to exclude intracranial mass lesions, vascular compression, and multiple sclerosis (neurology). Carbamazepine was taken orally, starting at 0.1 g bid and increased to 0.2 g tid, which reduced the pain but caused dizziness and drowsiness; blood count showed no leukopenia. No nerve block or surgical evaluation had been undertaken.

Examination and pattern differentiation

The pattern is mainly wind-phlegm obstructing the collaterals with liver fire flaming upward, combined with blood stasis; a long illness has depleted qi and blood with stasis. The key points are the character of the pain (burning, stabbing, twitching), the triggers (wind, emotion, eating), the tongue and pulse, and the overall state. Classical internal medicine distinguishes facial pain patterns of wind-phlegm, liver fire, and blood stasis.

• Lusterless complexion; tongue dark with a thin white coat; pulse wiry and thready.
• Bitter taste and dry mouth; anxiety and poor sleep; constitution on the weaker side; attacks accompanied by tearing and facial twitching.

Treatment pathway

• External treatment first: local points (Xiaguan ST7, Quanliao SI18, Dicang ST4, Jiache ST6, Yifeng TE17) combined with distal points (Hegu LI4, Taichong LR3, Neiting ST44, Yangbai GB14, Sibai ST2). Facial needling should be gentle, superficial, and sparing, avoiding strong stimulation that could provoke an attack; needle warming (moxa on the needle) or gentle moxibustion may be added at Xiaguan and Yifeng. Twice weekly.
• Herbal decoction as support: for wind-phlegm obstructing the collaterals, the intent of Qianzheng Powder (powder to dispel wind and correct the face) combined with Erchen Decoction (Two Aged Ingredients); for liver fire flaming upward, Longdan Xiegan Decoction with modifications; for blood stasis obstructing the collaterals, the direction of Tongqiao Huoxue Decoction. Classical reference: Chuanxiong Cha Tiao San from the He Ji Ju Fang for head and facial pain from wind attacking upward, and Shaoyao Gancao Decoction to relax spasm and relieve pain. Dosage is set at the in-person consultation.
• Boundary statement: new-onset trigeminal neuralgia must first exclude intracranial mass lesions, vascular compression, and multiple sclerosis — where imaging is normal or the cause is undetermined, the neurology work-up is completed before acupuncture is discussed.

Re-evaluation

Follow-up and advice

We work in coordination with neurology; carbamazepine and similar medication is never stopped or reduced on our own (abrupt withdrawal can worsen attacks). Attacks and medication changes are logged as the basis for adjustment.