CASE STUDY OF TRIGEMINAL NEURALGIA USING NEUROFEEDBACK AND PERIPHERAL BIOFEEDBACK

Andrea Sime, LCSW, BCIAC
First Step Wellness Center

Trigeminal neuralgia or tic doloureaux is characterized by brief episodes of extremely intense facial pain often radiating down the jaw. These episodes can occur spontaneously or can be triggered by light touch, chewing or changes in temperature (i.e. cold). The pain is so intense as to be completely disabling. In addition, weight loss is common because oral triggers prevent affected individuals from eating enough to maintain adequate nutrition. Trigeminal neuralgia is caused by irritation of the fifth cranial nerve (the trigeminal nerve) which is responsible for providing sensation to the face. This irritation is occasionally due to benign tumors or to multiple sclerosis either of which can usually be detected by a high quality MRI of the brain. In the majority of cases, however, imaging of the brain does not reveal a cause of the nerve irritation. In such cases a small vessel (usually an artery but occasionally a vein) is often found to be compressing the root entry zone of the trigeminal nerve at the brainstem. (http://neurosurgery.mgh.harvard.edu/mvd.htm)

A 46 year-old nurse had heard of biofeedback for pain control and presented herself for peripheral biofeedback training for trigeminal neuralgia of 15 months duration. Other symptoms noted were bruxism, sleep maintenance and lower leg swelling that she attributed to hypothyroidism. Medications included: Synthroid, Triphasil, Amitriptyline and generic Darvocet (100mg Darvocet with 650 mg. Tylenol for the past year). Past treatments have included a variety of anti-seizure medications which she did not tolerate well, massage, acupuncture and healing touch. Her neurologist's next planned intervention was to sever the trigeminal nerve with a laser knife.

The client is a divorced mother with three children. She held a full-time position as a grant writer for a hospital. Pertinent history includes as a child, being frequently slapped on the left side of her face by her right-handed mother, and trauma to the left side of her head resulting from a motor vehicle accident by hitting her head on the driver's side window. The client describes herself as having very high expectations and driving herself in her work and in her personal life.

METHOD AND STEPWISE PROGRESS

The client initially received six sessions of peripheral biofeedback (J & J I-330 EMG and PNG only) with diaphragmatic breathing technique, cognitive behavioral therapy and stress management included. As a result of the peripheral biofeedback training, she became more cognizant of her dysponetic tendencies especially in her masseter, cervical and upper trapezius muscles. She responded well to muscle awareness and relaxation training but it was difficult for her to slow down from her hurried and pressured lifestyle. However, as she did this and incorporated the peripheral biofeedback strategies, her pain levels began to decrease. She used less Darvocet and she was sleeping slightly better. She knew neurofeedback was part of her treatment plan and requested to begin it early.

Neurofeedback was begun at the seventh session with the Neurocybernetics system following the Othmer protocols. By the end of the initial session, pain levels decreased from #4 (on a scale of 1-7 with 7 being severe pain) to #1 using a T4 placement referenced to A2 and the ground at A1. Inhibit frequencies were 2-7 and 22-30 Herz. Reward frequency was 7.5-10.5 Herz. After the second session, the client reported that her sleep was deeper and she was more rested in the morning although she still awoke frequently during the night. C3 placement referenced to A2 with the ground at A1 was added for sleep maintenance. Reward frequency was 12-15 Herz, inhibit frequencies were 2-7 and 22-30 Herz. By the third neurofeedback session, she had voluntarily discontinued the Amytriptyline and had reduced her Darvocet due to the lowered pain levels. Spending a holiday with her now emotionally abusive mother, however, resulted in recurrence of increased pain and sleep symptoms.

During the thirteenth neurofeedback session, a change in protocol was made to T3-T4, ground at A1. Reward frequency was 7.5-10.5 Herz, inhibit frequencies were 2-7 and 22-30 Herz. This change resulted in a dramatic decrease in pain after nine minutes of training in the first trial of this placement. In this session, the client reported a reversal in the progression of pain and other symptoms (itching and tingling), saying that she had felt these same sensations in her teeth and gums with the initial onset of the trigeminal neuralgia. Over-all pain levels and nausea from the pain lessened substantially after this session. She had again reduced her Darvocet use by the next session. This protocol of C3 as needed for sleep and T3-T4 in each session thereafter almost always resulted in a dramatic reduction in pain in each of the remaining neurofeedback sessions as well as better sleep maintenance.

In the seventeenth session, the client reported she was "more focused and on track" though she was still using about ½ Darvocet daily. The increased focus may have been a result of the C3 neurofeedback training. She also noticed her lower leg swelling was significantly improved. She felt this was due to the C3 neurofeedback. During the nineteenth session, her pain levels were reduced to from #3 to being pain free.

As a result of the earlier stress management techniques supplementary to her peripheral biofeedback program, the client had been setting better limits on her stress levels both at work and in her personal life. One of her main concerns (life stressors) was the uncontrolled asthma-related chest pain of her 16 year-old daughter who has a personality much like her own, very hard-driving and perfectionistic. (Later, the daughter saw this therapist and developed good self-regulation skills which improved her asthmatic symptoms.) However, like many clients, when the pain decreased, the mother began resuming her more hectic lifestyle. Not surprisingly, her pain and sleep problems returned. She had been using only Advil and ½ Darvocet per day up until this time. She had completed 21 neurofeedback sessions (27 total sessions including peripheral biofeedback) at this point. When the therapist noted cervical and upper trapezius muscle bracing, the dynamic EMG training program was resumed and completed. She has several trigger points under the left scapula that might have played a part in triggering her trigeminal pain. After four dynamic EMG sessions, her pain symptoms again reduced in concert with the absence of dysponesis. She was also taught hand-warming techniques. She resumed setting better limits on work and family stressors, continued with neurofeedback and her pain relief was reduced again. After 23 neurofeedback sessions plus 10 sessions of peripheral biofeedback, she had withdrawn from Darvocet and was using only Ultram (50 mg) for the pain. By the twenty-ninth session she was using 25 mg of Ultram daily.

OUTCOME AND DISCUSSION

The client's trigeminal nerve pain dramatically diminished over the course of 37 weeks. Neurofeedback training (29 sessions) was apparently a key component of this success, especially the T3-T4 placement. The T3-T4 placement also eliminated her bruxism. Sleep symptoms, focus and concentration and lower leg swelling improved after the initiation of C3 neurofeedback. The client has significantly improved her self-regulation skills through peripheral biofeedback training (10 sessions). This case study suggests that a multi-modal approach of neurofeedback, peripheral biofeedback, stress management and cognitive behavioral therapy is useful in treating this difficult and painful condition.

The client still experiences episodes of increased pain in certain situations. Coughing induced by respiratory illness, dealing with her abusive mother, a cool breeze and touch can still initiate or aggravate the pain. However, she is now much better able to manage her pain. And, most importantly in her view, she has been able to avoid the facial surgery which she dreaded and which involved a certain degree of risk.

Communications should be sent to:
Andrea Sime, LCSW, BCIAC
First Step Wellness Center
1919 South 40th Street Suite #212
Lincoln, NE 68506