Welcome to the Interdepartmental Cluster SeminarDEPT. OF MANO VIJYAN EVUM

MANAS ROGA

Case Presentation

Presenter :Dr Prabhakar Manu2nd Year PG Scholar

Dept. of Manas Roga

Guide:Dr Suhas Kumar Shetty

ProfessorDept of Manasa Roga

Vital Data

Name : XYZ

Age : 31 yrsSex : MaleAddress : TumkurReligion : HinduEducation: GraduationOccupation : NGO

(field officer)Marital status: Married

IPD no : 11972Bed no : 23DOA : 16/4/16

Pradhana Vedana

1. Severe pain (Electric shock like) in the left cheek area of the face, difficulty in chewing hard food, lock jaw- 3 yearsIncreased since 1 week

Aggravating factors – Cold stimuli, early morning and after

sunset.

Relieving factors – Afternoon & hot climate

Vedana Vruttanta

Patient was apparently normal 3 years back.

As per the patient statement gradually he noticed pain in the left cheek region of the face. Pain is like electric shock . In cold season especially in Nov, Dec, Jan he will feel more pain.

Onset of pain was acute with gradual worsening and episodic in nature without nausea and vomiting.

Then he consulted in NIMHANS , Bangalore in 2013. They conducted MRI scan of brain revealed, compression of trigeminal root by vascular loop on left side and found compression in trigeminal nerve. They prescribed medicine and he felt gradual decreasement in the symptoms.

Since last 1 week, pain has been increased severely, earlier prescribed drug was taken but symptoms not reduced.

On 16th of this month he came to Manas opd with same complaints and was advised admission.

Poorva vyadhi vruttanta N/H/O DM, HTN, infectious diseases, Disease

related to eye, ear & dental, head injury or surgery, meningitis.

Koutumbika vruttanta Nobody in his close family circle is suffering from

similar diseases.

Chikitsa vruttanta T. Tegrital CR 400mg 1 BD since 3 years Not Underwent any ayurvedic treatments before

Vayaktika Vruttanta

Appetite – goodBowel – Regular (1-2/day)Micturition – (6-7 times/day) Straw colored

urine Sleep – Disturbed due to painHabits – 2-3 times tea/dayAllergy – No allergyDiet - Mixed

Vital Signs

BP - 130/90mmHgTemperature – 98.6o FPulse rate- 84/minRespiratory rate – 16/min

Samanya Pareeksha

Built: ModerateNourishment: ModeratePallor : absentIcterus : absentCyanosis: absentClubbing: absentKoilonychia : absentLymphadenopathy: absentEdema: absentFacies : Normal

Ashtasthana Pareeksha

Nadi – 86/minMootra - PrakrutaMala - PrakrutaJihwa - LiptaSabda – SpashtaSparsha - AnushnasheetaDrik - PrakrutaAkriti – Madhyama (good posture)

Dasavidha Pareeksha

Prakriti - VKVikriti - Dosha- Vata Kapha Dooshya- RasaSara - MadhyamaSamhanana - MadhyamaPramana - MadhyamaSatwa - MadhyamaSatmya - MadhyamaAharasakti - MadhyamaVyayamasakti - MadhyamaVaya - Madhayama

Systemic examination

RS – NVBS heard, no additional sounds

CVS – S1,S2 heard, no murmur/clicks

GIT – Soft, non tender, no organomegaly, tympanic note on percussion.

CNS Examination

1.HMF – Pt is conscious, well oriented to time,

place and person. Recent and remote memory are

intact. Speech is normal. No dysarthria.

CNS Examination

2.CRANIAL NERVES – Olfactory Nerve (1st) Optic Nerve (2nd) Oculomotor Nerve (3rd)Trochlear Nerve (4th)Trigeminal Nerve (5th)- sensory loss in left cheek region+Abducens Nerve (6th)Facial Nerve (7th)Vestibulocochlear Nerve (8th)Glossopharyngeal Nerve (9th)Vagus Nerve (10th)Accessory Nerve (11th)Hypoglossal Nerve (12th)

Trigeminal Nerve Examination

Mental Status Examination

Attitude & Behavior – CooperativeSpeech – MonotonousMood – Mild DepressedThinking – intactJudgment –intactInsight –intellectualSensorial cognition – intact

Report

Nidana Panchaka

Nidana – Rooksha aahara and vihara, ratri jaagarana, ati gamana

Poorvaroopa - Nil

Roopa – SENSORY-Suptata & shool in vaam mukhardha, shool while charvana (Chewing), MOTOR-Hanugraha (Lock Jaw)

Upashaya – Ushna Vihara

Samprapti

Dosha- Vata Kapha Udbhava sthana – Pakvasaya

Dushya – Rasa Sanchara sthana – Mukha pradesh

Srotas – Rasa Agni – Dhatvagni vaishamya

Dushti – Vimarga gamana, Sanga

Rogamarga – Madhyama

Differential Diagnosis- Modern Sciences

Bell’s Palsy Trigeminal Neuralgia

Causes temporary partial facial paralysis in one side of the face

It is quite literally pain in the trigeminal nerve or areas affected by the trigeminal nerve.

Pain is rarely present in the face Electric shock like pain in part of the face

Affects only on one side of the face It can affect on both the sides

Cold exposure Certain factors severs to be trigger in causing pain like brushing teeth, chewing , eating , shaving etc.

Dysfunction of the 7th cranial nerve. One , two or all the three branches of the nerve may be affected.

Differential diagnosis according to Ayurveda

Ardhavabhedaka Vataja Shirahshoola AnantavataArdha parshwa-Unilateral

Severe pain in forehead

Intense pain at manya (carotid artery region)

Bheda, Toda, Shoola- Pulsating, throbbing type of pain

Giddiness Pain in nape of the neck

Pakshat, Dashahat, Akasmat-Paroxysmal

Stiffness at shoulder and neck

Twitching near cheecks

Prakasha Asahishnuta-Photophobia

Lock jaw

Vyadhi Vinischaya

Adharvabhedaka/Anantavata

Chikitsa sidhantaAs per Acharya Vagbhatta Adharvabhedaka should be treated as same as Vataja Shirahshool.

Diagnosis:

Trigeminal Neuralgia or Tic douloureux

Trigeminal Neuralgia (TN) is a unilateral disorder characterized by brief shock like pain which are abrupt in onset and termination , limited to the distribution of one or more divisions of the trigeminal nerve. The attacks are initiated by non-painful physical stimulation of specific areas (trigger points or zones) that are located ipsilateral to the pain. Chewing, speaking , washing the face, tooth brushing , cold winds or touching a specific ‘trigger spot’ . TN more commonly affects females and patients over 50 years of age. The pain rarely occurs bilaterally and never simultaneously on each side.

Diagrammatic Representation

TreatmentDay Treatment Medicines Remarks16/4/16 – 22/4/16

Mukhaabhyanga+Nadi swedan

Nasya

Shiropichu

Dashmoola Yavagu twice daily at 11:30am & 3:30pm

Physiotherapy

Ksheerabala taila

Karpasthyadi taila4drops – 4 drops

Shatapaka bala taila

Tab. BVC Gold1 -0-1

Cap. Palsineuron 1- 0-1

Why Carbamazepine is first line of Treatment

Antiepileptic drugs (AEDs) work well for trigeminal neuralgia (TN) and have been known to do so since a study was completed with phenytoin (PHE) in 1942 (Bergouignan) and another with carbamazepine (CBZ) in 1962 (Blom). With 3 placebo-controlled crossover studies validating its efficacy in trigeminal neuralgia, providing relief by roughly 75% versus only 25% in the placebo arms (Killian, Nicol, Campbell), carbamazepine is the best studied drug for this disorder and the only one with US Food and Drug Administration (FDA) approval in this setting.

It will decrease the nerve firing and overactive neurons .Blom S. Trigeminal neuralgia: its treatment with a new

anticonvulsant drug (G-32883). Lancet. 1962 Apr 21. 1:839-40.

Pathophysiology of Trigeminal Neuralgia: the ignition hypothesis

The ignition hypothesis of trigeminal neuralgia is based on recent advances in the understanding of abnormal electrical behavior in injured sensory neurons, and new histopathologic observations of biopsy specimens from patients with trigeminal neuralgia who are undergoing microvascular decompression surgery. According to the hypothesis, trigeminal neuralgia results from specific abnormalities of trigeminal afferent neurons in the trigeminal root or ganglion. Injury renders axons and axotomized somata hyperexcitable. The hyperexcitable afferents, in turn, give rise to pain paroxysms as a result of synchronized afterdischarge activity. The ignition hypothesis accounts for the major positive and negative signs and symptoms of trigeminal neuralgia, for its pathogenesis, and for the efficacy of treatment modalities. Proof, however, awaits the availability of key experimental data that can only be obtained from patients with trigeminal neuralgia.

Devor M, Amir R, Rappaport ZH. Pathophysiology of Trigeminal Neuralgia: The Ignition Hypothesis. The Clinical Journal Of Pain 2002;18:4–13.

Ayurvedic Understanding of TN

Shiras is the Kapha Sthana

TN – Vata is aggreavated in Kapha sthana (shiras)

Kapha and Vata is having sheeta guna and in TN sheetvatam and chalatvam is increased.

So treatment plan will be ,

Kaphavrutta Vata Chikitsa Ushna virya dravya – later phase snigdha guna dravya Nasya Karma – Ushna virya aushadha

Some Ayurvedic Medicines in Ayurveda for TN

1. Kashayam Rasonadi KashayamRasna Dashmoola Kashyam

2. ChurnamPippali churnam

3. VatiRasonadi Vati

Some Ayurvedic Medicines in Ayurveda for TN

For Nasya Karpasthayadi taila Shadbindu Taila

Kshira DhumamBala kshira dhumamDashmula kshira dhumam

KavalamArimedadi taila

Aetiology

•A blood vessel presses against the root of the trigeminal nerve.

•Multiple sclerosis - due to demyelinization of the nerve. Trigeminal neuralgia typically appears in the advanced stages of multiple sclerosis.

•A tumor presses against the trigeminal nerve. This is a rare cause.

•Physical damage to the nerve - this may be the result of injury, a dental or surgical procedure, or infection.

•Family history (genes, inherited) - 4.1% of patients with unilateral trigeminal neuralgia (affects just one side of the face) and 17% of those with bilateral trigeminal neuralgia (affects both sides of the face) have close relatives with the disorder. Compared to a 1 in 15,000 risk in the general population, 4.1% and 17% indicate that inheritance is probably a factor.

Conclusion

No specific disease mentioned in ayurveda relates with TN.

Based on the line of treatment of Vataja shirah shoola chikitsa, it can be efficiently treated.

Life style and dietary modifications are advised.

THANK YOU