medicines

Case Report
Ashi Scalp Acupuncture in the Treatment of Secondary
Trigeminal Neuralgia Induced by Multiple Sclerosis: A
Case Report
Qiong Schürer 1 , Hamdy Shaban 2 , Andreas R. Gantenbein 3 , Giada Todeschini 3 and Saroj K. Pradhan 1,4, *

1 Research Department, Swiss TCM UNI, 5330 Bad Zurzach, Switzerland

2 Department of Psychiatry Private Clinic of UPK, The University Psychiatric Clinics, 4002 Basel, Switzerland
3 Neurology & Neurorehabilitation Department Rehaklinik, ZURZACH Care, 5300 Bad Zurzach, Switzerland
4 Research Department Rehaklinik Bad Zurzach, TCM Ming Dao Bad Zurzach/ZURZACH Care,
5330 Bad Zurzach, Switzerland
* Correspondence: [email protected]; Tel.: +41-56-269-5684

Abstract: Background: Multiple sclerosis (MS) is an autoimmune, chronic, inflammatory, demyeli-

nating, and axonal degeneration disease of the central nervous system. Trigeminal neuralgia (TN),
a neuropathic facial paroxysmal pain, is prevalent among MS patients. Because of the inadequacy
of the comprehension of MS-related TN pathophysiological mechanisms, TN remains arduous in
its treatment approaches. Acupuncture as a non-pharmacological therapy could be a promising
complementary therapy for the treatment of TN. MS gradual neural damage might affect the muscles’
function. This can lead to acute or paroxysmal pain in the form of spasms that might progress to
formation of myofascial trigger points also known in traditional Chinese medicine as Ashi points
(AP). Localising these AP through palpation and pain sensation feedback in patients with MS is an
Citation: Schürer, Q.; Shaban, H.;
indicator of disease progression. Pathologically, these points reveal the disharmony of soft tissue
Gantenbein, A.R.; Todeschini, G.;
and internal organs. Methods: This case report examined the pain relief outcome with Ashi scalp
Pradhan, S.K. Ashi Scalp
acupuncture (ASA) in a secondary TN patient who was unsuccessfully treated multiple times with
Acupuncture in the Treatment of
Secondary Trigeminal Neuralgia
body acupuncture. The main outline measure was to quantify pain intensity using a numerical rating
Induced by Multiple Sclerosis: A scale (NRS) before and after each acupuncture therapy. The patient was treated on the scalp for a total
Case Report. Medicines 2022, 9, 44. of eight times, twice a week over four weeks. Results: A reduction in secondary TN pain intensity
https://doi.org/10.3390/ was observed after each session. On average, the patient expressed severe pain (NRS: 8.0 ± 2.20)
medicines9080044 before ASA treatment, which significantly decreased after therapy to mild pain (NRS: 2.0 ± 1.64).
Academic Editor: James David
Conclusions: Significant improvements in pain intensity reduction after each acupuncture treatment
Adams without any adverse effects were observed.

Received: 1 July 2022 Keywords: secondary trigeminal neuralgia; Ashi point; scalp acupuncture; multiple sclerosis
Accepted: 10 August 2022
Published: 12 August 2022

Publisher’s Note: MDPI stays neutral

with regard to jurisdictional claims in 1. Introduction
published maps and institutional affil- Multiple sclerosis (MS) is an autoimmune-mediated neurological disorder that affects
iations. the central nervous system (CNS), leading to chronic illness affecting the brain and spinal
cord. The underlying mechanism of an MS attack is an aggressive inflammation process in
areas of the white matter of the central nervous system in random patches called plaques.
Upon formation of theses plaques, the destruction of myelin sheaths is triggered. Myelin
Copyright: © 2022 by the authors.
is the insulating sheath of nerves that promotes smooth and high-speed transmission of
Licensee MDPI, Basel, Switzerland.
This article is an open access article
electrochemical messages between the brain, the spinal cord, and the rest of the body. The
distributed under the terms and
damage of the myelin sheath leads to disruptive neuronal communication and slowed
conditions of the Creative Commons electrochemical signalling. The blockade of neuronal transmission causes loss of function
Attribution (CC BY) license (https:// and somatosensory disturbance [1].
creativecommons.org/licenses/by/ Trigeminal neuralgia (TN) involves one or more branches of the trigeminal nerve.
4.0/). Orofacial pain is among the most distinctive and difficult to cure in patients with MS with

Medicines 2022, 9, 44. https://doi.org/10.3390/medicines9080044 https://www.mdpi.com/journal/medicines

Medicines 2022, 9, 44 2 of 7

a prevalence of 0.1% to 9.7% [2]. TN is characterized by severe, mostly unilateral pain. The
electric shock-like, stabbing, or sharp pain usually lasts only a few seconds, sometimes up
to two minutes, and can be accompanied by contractions of the mimic muscles, reddening
of the face, and secretion of tears and sweat [3]. The «The International Classification of
Orofacial Pain, 1st edition» provides an extensive description of all categories of pain in the
orofacial area with a specific benchmark for all of them [4].
The Western medicine pharmacological first-line treatment for TN is with carba-
mazepine and oxcarbazepine. Other treatment choices include lamotrigine, phenytoin,
clonazepam, gabapentin, pregabalin, topiramate, levetiracetam, tocainide, and surgery [5].
Acupuncture as a non-pharmacotherapy seems more effective in the treatment of TN
than pharmacotherapy or surgery [6].
In traditional Chinese medicine (TCM), TN is classified into three different categories.
TN is caused by wind and cold, wind and heat, and evoked by qi and blood stagnation
or congestion [7]. Ashi points (AP) were first specifically described in Sun Si Mao’s
(AD 580-682) book «Prescriptions Worth a Thousand Pieces of Gold for Emergencies», but
the idea originated from «The Yellow Emperor’s Inner Canon» [8]. AP is a point-locating
method obtained through palpation on a certain site. AP are not always located in the area
of pain [9] and are not associated with any meridians. Pathologically, these points reveal
the disharmony of soft tissue and internal organs.
The demand for acupuncture in pain management is steadily growing amongst pa-
tients [10]. Several clinical trials have shown the efficacy of acupuncture in the treatment of
TN with satisfactory results [11,12]
Although the patient had previously and unsuccessfully undergone a total of 27 body
acupuncture treatments, our approach was to use the scalp Ashi acupuncture points (AAP)
on the scalp. We aimed to examine whether the Ashi scalp acupuncture (ASA) method
could contribute to the pain relief management immediately after each acupuncture session
and over a certain period. Our clinical experience over a decade has shown efficacy in pain
relief when ASA was performed for head and facial region symptoms.
The study was conducted according to the criteria set by the Declaration of Helsinki
and written informed consent was obtained from the study participant before participating
in the study. Ethical approval was not required for the single described case.

2. Case Description
A 46-year-old man diagnosed with secondary trigeminal neuralgia (TN) caused by MS
was admitted to our rehabilitation centre (RC) as part of the inpatient, multimodal Zurzach
Headache Program. He was diagnosed with MS in 2014. At that time, his main symptom
was a recurrent pain (in the context of TN) in the right half of his face. As he had taken
part in an in-patient program in another RC in 2016, treatment was implemented for his
repeated psychosomatic state of exhaustion, which had also been an early symptom. In
2018, the patient mentioned a significant increase in attack frequency with typical TN pain.
In the same year, cranial magnetic resonance imaging performed from an external hospital
showed an MS plaque in the core area of the trigeminal nerve.
Due to the patient’s anxiety to undergo surgery, he was treated as an outpatient
27 times with acupuncture over a three-month period. The following acupuncture points
were punctured: ST 2, ST 7, BL 2, LI 4, ST 44, and LV 3. Each time during or after
acupuncture, he experienced an adverse effect and the TN pain became more severe.
Two months later, he was treated with radiofrequency thermocoagulation of the
Gasserian ganglion performed with intubation anaesthesia. This therapeutic approach
brought the patient a minimal improvement in his condition. Five months later, after a test
trial, direct nerve stimulation was implanted under his forehead and cheek. Thereafter,
the patient was free of trigeminal pain for about six months. However, subsequently, the
attack frequency and pain intensity re-occurred. In our RC, he reported experiencing facial
unilateral, stabbing, sharp pain lasting a fraction of a second, but appearing repeatedly up
 Medicines 2022, 9, 44 3 of 7

to 100 times per day. Aggravating factors of pain were triggered by swallowing, speaking,
and stress. He had been unable to figure out strategies to alleviate the pain to date.
Besides MS and secondary TN, the patients’ comorbidities included hyponatremia,
metabolic syndrome, recurrent depressive episodes, cardiac disease, and non-alcoholic
fatty liver disease.

2.1. Treatment with Western Medicine

The patient was already taking several medications before RC admission. Table 1
provides an overview of his medication list. Interferon beta-1a and Dimethyl fumarate were
adjourned in 2014 because of adverse drug reactions. The patient then started a therapy
with teriflunomide in 2018. He was therapy-resistant against pregabalin, oxcarbazepine,
and fentanyl. However, he responded completely well to gabapentin in 2019.

Table 1. Legend: Daily medication and dosage.

Medication Dosage
Clonazepam 0.5 mg 6×/day
Aspirin 100 mg 1×/day
Atorvastatin 20 mg 1×/day
Teriflunomid 14 mg 1×/day
Bisoprolol 2.5 mg 1×/day
Colecalciferol 2×/day
Candesartan plus 16/12.5 mg 1×/day
Duloxetine 60 g 1×/day
Gabapentin 700 mg 4×/day
Pantoprazole 40 mg 1×/day
Oxcarbazepine 600 mg 2×/day
Vitamin B-Complex 2×/week

2.2. Treatment with Ashi Scalp Acupuncture

At each therapy session, AAP on the scalp were searched bilaterally with an acupunc-
ture pinhead and subsequently punctured. Each acupuncture session lasted 50–60 min,
which is standard in our RC. Neither tonifying nor reducing manipulation needle technique
was implemented.
Medicines 2022, 9, x FOR PEER REVIEW  4  of 
  The acupuncture direction was an oblique angle. The puncture technique was <15◦
shown in Figure 1. The patient was lying in a supine position during the treatment.

 
1. Schematic diagram of the puncture technique <15◦ and oblique angle puncture direction.
Figure 1. Schematic diagram of the puncture technique ˂15° and oblique angle puncture direction
Figure

Sterile disposable 0.25 × 25 mm stainless‐steel, single‐use needles, manufactured by
Asia‐med GmbH (Pullach, Germany) were used.   
A licensed physician in TCM with over 10 years in clinical practice executed the ther
apeutic regime. 
Medicines 2022, 9, 44 4 of 7

Sterile disposable 0.25 × 25 mm stainless-steel, single-use needles, manufactured by

Asia-med GmbH (Pullach, Germany) were used.
A licensed physician in TCM with over 10 years in clinical practice executed the
therapeutic regime.

2.3. Progression of Symptoms

The patient received individualized ASA twice a week, for a total of eight sessions for
four weeks at the RC.
The documentation was carried out by means of a pain questionnaire with a numerical
rating scale (NRS, 0 = no pain to 10 = the worst imaginable pain) [13]. According to
Salaffi et al., a reduction of 1 cm on the 0–10 cm numerical rating scale represents a “slight
improvement in pain” (slightly better) for the patient and a reduction of 2 cm represents
a “marked improvement in pain” for the patient. A reduction of 1 cm was defined by
Salaffi et al. as the smallest clinically important difference in pain perception [14].
After each acupuncture session, the patient reported a significant reduction in pain
intensity. Average NRS was 8.0 (sd = 2.20) before acupuncture and 2.13 (sd = 1.64) after
acupuncture. This results in a mean difference of 5.88 (sd = 2.03), corresponding to a stan-
dardized response mean (Cohn’d) [15] of 3.07 (95%-CI: 4.14–7.66, Two-tailed p < 0.00009),
meaning a large significant effect. For the first time within the past four months, the patient
was pain-free for 36 h after the third acupuncture treatment. This pain-free state re-occurred
after the seventh acupuncture treatment, which lasted 36 h. The patient was completely
free of pain after the last acupuncture session until his discharge from our RC. Table 2 and
Figures 2 and 3 illustrate the results of pain intensity assessment using the NRS before and
after acupuncture treatments by therapy session.

Table 2. Results of pain intensity assessment using the NRS before and after acupuncture treatments
by therapy session. m = arithmetic mean.

Session Pre (m) Post (m) Difference (m)

1 8.0 4.0 4.0
2 8.0 3.0 5.0
3 8.0 0.0 8.0
4 9.0 4.0 5.0
5 10.0 3.0 7.0
6 8.0 2.0 6.0
7 10.0 1.0 9.0
8 3.0 0.0 3.0
Total 64.00 17.00 47.00

A three- and six-weeks follow-up was carried out via telephone, in which the patient
reported a pain-free status (NRS 0 = no pain). Changes in the NRS between discharge and
follow-up were evaluated by standardized mean difference. Score changes on the NRS,
from discharge time and follow-ups, remained unaltered (NRS 0 = no pain).
The patient reported very positively at the last visit and at follow-ups. He mentioned
that he was free of pain and his quality of life had improved significantly. Symptoms of
depression were also no longer to be observed.
No adverse effects were observed during all acupuncture sessions.
Medicines 2022, 9, x FOR PEER REVIEW  5
 
Medicines 2022, 9, x FOR PEER REVIEW  5  of  8 
 

Medicines 2022, 9, 44 Total    64.00  17.00    47.00 

5 of 7  

Total    64.00  17.00    47.00   

   
Figure 2. Results of pain intensity assessment before and after acupuncture treatments by the
Figure 2. Results of pain intensity assessment before and after acupuncture treatments by therapy 
Figure 2. Results of pain intensity assessment before and after acupuncture treatments by therapy
session. The pain intensity (expressed in NRS) sank after every single session, showing a maxim
session. The pain intensity (expressed in NRS) sank after every single session, showing a maximum 
session. The pain intensity (expressed in NRS) sank after every single session, showing a maximum
pain reduction of −9 points (from 10 to 1 NRS) in one single session. 
pain reduction of −9 points (from 10 to 1 NRS) in one single session. 
pain reduction of −9 points (from 10 to 1 NRS) in one single session.

  
Figure 3. Time‐lapse of changes in pain intensity (NRS) after each session.    
Figure 3. Time‐lapse of changes in pain intensity (NRS) after each session. 
Figure 3. Time-lapse of changes in pain intensity (NRS) after each session.
A three‐ and six‐weeks follow‐up was carried out via telephone, in which the patient 
3. Discussion
reported a pain‐free status (NRS 0 = no pain). Changes in the NRS between discharge and 
A three‐ and six‐weeks follow‐up was carried out via telephone, in which the pat
In this case, a substantial short-term pain reduction was observed after all acupuncture
follow‐up were evaluated by standardized mean difference. Score changes on the NRS, 
reported a pain‐free status (NRS 0 = no pain). Changes in the NRS between discharge
session’s standardized response mean (SRM) (SRM = 3.07) with the ASA technique.  The
from discharge time and follow‐ups, remained unaltered (NRS 0 = no pain). 
follow‐up were evaluated by standardized mean difference. Score changes on the N
size of those effects may be clinically relevant because SRMs ≥ 0.50 are very likely to be
The patient reported very positively at the last visit and at follow‐ups. He mentioned 
from discharge time and follow‐ups, remained unaltered (NRS 0 = no pain). 
subjectively perceived by the patients [16]. The hypothesis that the subjectively perceived 
that he was free of pain and his quality of life had improved significantly. Symptoms of 
secondaryThe patient reported very positively at the last visit and at follow‐ups. He mentio
TN pain is less severe after the application of ASA technique than prior ther-
depression were also no longer to be observed. 
apy has been confirmed in this case. ASA seemed to   be superior in secondary TN pain
that he was free of pain and his quality of life had improved significantly. Symptom
No adverse effects were observed during all acupuncture sessions. 
management when compared to classic body acupuncture.
depression were also no longer to be observed.   
    ASA treatment was effective while the patient experienced adverse effects when he
No adverse effects were observed during all acupuncture sessions. 
received meridian acupuncture (ST 2, ST 7, BL 2, LI 4, ST 44, and LV 3). ASA points in
   
Medicines 2022, 9, 44 6 of 7

Figure 1 differ from GB 15, GB 16, GB 17, and GB 18. These latter mentioned points mainly
treat paresis, headache, vertigo, cervical pain, nausea, Eyestrain, and fever. Therefore,
it is important to emphasize that Ashi points reveal the disharmony of soft tissue and
internal organs.
In literature, many reports about scalp acupuncture (SA) can be found. In their case
report, Hao et al. (2013) concluded that SA was a better therapy approach in bringing about
rapid advancement in patients with MS correlated to other acupuncture methods to the
same degree as acupuncture on the ear, body, and hand [17]. In a randomized controlled
clinical trial, the initial SA interference after acute ischaemic stroke with hemiplegic paraly-
sis showed an enhanced myodynamia of the afflicted limbs, but also an improvement of
neurological deficiency severity and quality of life [18]. A meta-analysis result reported that
SA improved motor function in patients with stroke, whether ischemic or hemorrhagic [19].
In a systematic review and meta-analysis evaluating the efficacy and safety of SA for insom-
nia, the authors could provide insight of the effectiveness and safety treating insomnia [20].
Liu et al. (2019) conducted a systematic review and meta-analysis about SA in children
with autism spectrum disorders (ASD). The main results in their meta-analysis advocated
that in comparison with behavioral and educational interventions, SA was more effective
in lowering Childhood Autism Rating Scale and Autism Behavior Checklist scores and
promoting Psychoeducational Profile scores in communication, physical ability, and behav-
ior. Accordingly, the authors ensured that SA may show positive effects on the treatment
for children affected by ASD [21]. Therefore, patients with MS, as well as patients who
have suffered from a stroke, patients with insomnia, and children with autism spectrum
disorders might benefit from SA. In previous years, large efforts were made to understand
the effect of acupuncture in MS [17,22,23] and TN [6,24], and further research studies are
still ongoing. The outcome of these studies is favourable for acupuncture.
These studies have been carried out in patients with a broad spectrum of neurological
and non-neurological diseases, and research still has to be carried out in several fields of
Western medicine, but the studies carried out until now have shown favourable results for
the effectiveness of acupuncture as a symptom-reliever.
Moreover, Edwards et al. (2020) showed that acupuncture was more effective than
pharmacotherapy or surgery in the management of TN, cost-effective in comparison to
surgery or pharmaceutics, and caused significantly fewer adverse effects [6].
The limitation of this study is that a follow-up of 3 and 6 months could not be con-
ducted due to the inaccessibility of the participant during the pandemic.
In conclusion, the outcome of this case report provides findings that ASA has potential
in the treatment of trigeminal pain management. The local pain network modulation with
Ashi acupuncture can possibly change pain perception in patients who were unsuccessfully
treated with “general” acupuncture before obtaining a more specific and targeted treatment.
We do recommend experts in acupuncture to make use of our method with patients who
have been previously unsuccessfully treated with body acupuncture.

Author Contributions: Conceptualization: Q.S., S.K.P. and G.T. Data Curation: H.S., G.T., S.K.P.,
Q.S. and A.R.G. Writing—Original Draft Preparation: Q.S. Writing—Review & Editing: A.R.G., G.T.,
S.K.P., Q.S. and H.S., S.K.P. took care of the therapeutic regime. Supervision: A.R.G. All authors have
read and agreed to the published version of the manuscript.
Funding: This case report received no external funding.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki. Ethical approval was not required for the described case.
Informed Consent Statement: Written informed consent was obtained from the patient for publica-
tion of this case report and any accompanying images.
Data Availability Statement: All data used to support the findings of this study are included within
the article.
Medicines 2022, 9, 44 7 of 7

Acknowledgments: The authors thank the patient who participated in this case report and his
cooperation throughout the study. This case report was supported by the Zurzach Rehabilitation
Foundation SPA and Swiss TCM UNI.
Conflicts of Interest: The authors declare no conflict of interest.

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