Effective Acupuncture in Treating Decade-Long Occipital Neuralgia in an Elderly Patient

Introduction

According to the definition of the International Headache Society, occipital neuralgia is classified as a unique type of headache that generates neuropathic pain caused by the disruption or damage of the greater occipital nerve, lesser occipital nerve, or third occipital nerve [1]. The genesis of pain lies in the suboccipital region and spreads through the vertex, predominantly affecting the upper neck, posterior section of the head, and the area behind the eyes [2]. The painful sensation could be accompanied by hypesthesia or dysesthesia in the affected parts. Compression of the greater occipital nerve or lesser occipital nerve is the most common irritant, and the greater occipital nerve is involved in 90% of cases [3,4]. From its anatomical perspective, the greater occipital nerve is primarily composed of the posterior ramus of the second cervical nerve root. It courses posteriorly, traversing the lateral aspect of the atlantoaxial joint and the transverse processes of the atlas and axis. Subsequently, it encircles the inferior margin of the inferior oblique muscle and proceeds upward and posteriorly, sequentially traversing the semispinalis capitis and trapezius muscles, where it distributes innervation to these muscular structures. The nerve then traverses the aponeurotic arch formed by the aponeuroses of the trapezius and sternocleidomastoid muscles, ultimately reaching the scalp beneath the occipital and parietal regions, where it distributes and manages the sensations in that area. Given its complex trajectory through the posterior head and neck, it is unsurprising that the greater occipital nerve is at heightened risk for compression and entrapment. The anatomical region where the greater occipital nerve traverses between the atlas and axis, as well as its course between the inferior oblique muscle and the semi-spinalis capitis muscle, represents an area where the greater occipital nerve is particularly susceptible to stimulation [5].

Because only one epidemiological dataset has been reported, the prevalence and incidence rate of occipital neuralgia remain uncertain [6]. Nevertheless, the severity of the stabbing pain and its sharp intensity significantly impact patient quality of life. Possible treatment options include various medications (such as nonsteroidal anti-inflammatory drugs, antiepileptics, and antidepressants), pulsed radiofrequency, nerve blocks, and massage therapy. Traditionally, conservative and pharmacological therapies have been the first-line interventions [7]. However, if these methods fail to alleviate symptoms, occipital nerve stimulation may be considered, and acupuncture therapy is one such option. Compared with conventional drugs, acupuncture has the benefit of causing no known adverse effects [8]. Nonetheless, the evidence supporting the use of acupuncture for neuropathic pain is limited and needs to be further accumulated. Despite the scarcity of case reports demonstrating successful outcomes with acupuncture, our patient’s experience suggests that acupuncture could be an effective treatment modality for occipital neuralgia that might also alleviate dizziness (Table 1).

Case Report

FIRST ACUPUNCTURE TREATMENT (OCTOBER 9, 2023):

A 76-year-old male patient had pain in the left occipital and temporal regions for more than 10 years. Recently, he sought medical attention due to worsening pain. He described the pain as unilateral, intense, stabbing, swelling, and located in the left occipital and temporal regions. He said his headache symptoms would suddenly occur for no reason. The location of the headache coincided with the area innervated by the left greater and lesser occipital nerves. There was obvious tenderness and refusal to press at the point of the greater occipital nerve, with no radiating pain. He stated that dizziness and nausea could occur when he changed position, and they subsided after resting for approximately 1 min. The pain severely affected his daily work and life. In terms of medical history, the patient denied having chronic diseases, such as hypertension and diabetes. He reported no history of trauma or surgery. He used to take painkillers for headaches, but due to the gradual weakening of the pain relief effect, he discontinued their use approximately 2 months earlier. The self-reported Leeds Assessment of Neuropathic Symptoms and Signs scale (S-LANSS) score was 14 points, and the validation of visual analog scales indicated severe pain. However, we encountered some difficulties during the diagnosis process. Although the International Classification of Headache Disorders provides diagnostic criteria for occipital neuralgia (Table 1), there is still a lack of clear objective indicators, as they mainly rely on subjective reports of pain or sensory abnormalities in the occipital nerve-related areas. The patient refused to undergo computed tomography scanning and other imaging examinations. Therefore, we diagnosed it as greater occipital neuralgia based on clinical symptoms and physical examination. In addition, according to the International Classification of Headache Disorders, occipital neuralgia can be diagnosed by relieving symptoms through local anesthesia block. We believe that relieving symptoms through acupuncture and moxibustion treatment can play an auxiliary role in its diagnosis [1,9,10]. His tongue edge was red, the tongue coating was thin and white, and the pulse was stringy and small. The Traditional Chinese Medicine diagnosis was headache (liver-yang headache). He was offered medication (details unknown). He was dissatisfied with this option and elected to try acupuncture instead.

We thought that his pain was probably caused by occipital nerve compression due to myofascial tension. In terms of treatment, local Ashi acupoint acupuncture, supplemented with conventional acupuncture, was selected as the main treatment. The local selection included the transverse process of the second cervical vertebra (approximately at the junction of the horizontal line of the mandibular angle and the posterior border of the sternocleidomastoid muscle), the inferior oblique muscle near the second cervical spinous process (approximately 1 cm from the second cervical spinous process), the greater occipital nerve point (approximately at the junction of the middle and inner one-third of the line connecting the occipital protuberance and the mastoid apex), the lesser occipital nerve point (at the midpoint of the line connecting the second cervical spinous process to the mastoid apex), and the branches of the occipital nerve in the occipital and temporal regions (selecting pain points). Conventional acupuncture points were chosen based on the traditional Chinese medical diagnosis of “Liver Yang Rising” and “Liver Blood Deficiency” (select: LI4, LR3, LI11, SJ5, GB20, GB8, GB15, GB34 and SP6).

The patient was in lateral recumbence on the massage bed. The patient’s skin was cleaned with iodophor prior to needle insertion. Prefabricated and single-use 0.25×40-mm stainless steel acupuncture needles were inserted into the acupoints. For the Ashi acupoint located at the transverse and spinous processes of the cervical spine, the required depth of needle insertion is up to the bone surface, with a sense of tightness at the needle tip. The insertion depth for other acupoints was approximately 20 mm. The GB20 acupoint was punctured toward the nasal tip. GB8 and GB15 were transversely inserted along the meridians and collaterals. After the arrival of qi (patients typically experience a sour or numb sensation at the acupoints), the twirling method was applied instead of the lifting and inserting method. All acupoints were subjected to neutral supplementation and drainage. The needles were retained for 30 min. Upon completion of the acupuncture treatment, the patient reported feeling very relaxed, with a reduction in the severity of his head pain, and there were no adverse reactions. The patient was informed to repeat acupuncture treatment and to refrain from undergoing any other treatments.

THIRD ACUPUNCTURE TREATMENT (OCTOBER 16, 2023):

The patient reported “feeling much better” after 3 treatment sessions. He reported that the pain in the left occipital and temporal parts was significantly relieved, with little swelling and pain remaining. The dizziness and nausea symptoms caused by the change in neck position disappeared. There was still slight tenderness near the outlet of the left greater occipital nerve when it was pressed by hand. His symptoms improved by 80%. The validation of visual analog scales suggested mild pain. The original acupuncture treatment strategy and point selection procedure were repeated for 3 times.

SIXTH ACUPUNCTURE TREATMENT (NOVEMBER 23, 2023):

The patient received 6 acupuncture treatments over the course of 12 days. Following treatment, he reported a substantial resolution of his head pain, including his “swelling” sensations. He denied head pain, neck pain, or dizziness. The S-LANSS score was 0 points, and the validation of visual analog scales indicates no pain. He reported that his previous symptoms had been completely relieved and had not since recurred.

FOLLOW-UP AFTER TREATMENT:

Three months later, we maintained a regular phone follow-up with the patient, and he reported no headaches. Six months in, he mentioned occasional headaches when tired. Nine months after treatment, he reported occasional headaches, about 1 to 2 times a month. He believed that the headache was relatively mild, and no further treatment was needed.

Discussion

Occipital neuralgia is a prevalent medical condition that can sometimes be incapacitating and is caused by compression, entrapment, or stretching of the occipital nerves. The chief symptom of this condition is sudden, intense burning or piercing pain, which typically occurs along the cutaneous pathway of the affected nerve. Entrapment of the greater occipital nerve in its peripheral course is a significant source of pathology in patients with occipital neuralgia [11].

For the treatment of occipital neuralgia, conservative drug therapy is typically the first choice. However, unsatisfactory results are not uncommon with drug therapy alone, often necessitating invasive treatments for long-term and substantial pain relief [12]. Chowdhury et al reported a study in which 22 patients received greater occipital nerve blockade with lidocaine. The therapeutic effect observed was better than that of the control group. Nevertheless, 16 patients experienced adverse reactions, indicating a certain requirement for drug tolerance [13]. Finiels et al conducted a retrospective review of 33 patients with severe occipital neuralgia and demonstrated significant pain relief after botulinum toxin type-A injection [14]. Studies have revealed that botulinum toxin type-A injection was more effective than blocks using other analgesic formulations [15]. Cohen et al compared pulsed radiofrequency with steroid injections for the treatment of occipital neuralgia. The authors found that pulsed radiofrequency resulted in a greater reduction in occipital pain at 6 weeks than did steroid injections. Additionally, the worst occipital pain for patients treated with pulsed radiofrequency was also improved at 3 months, although the extent of pain relief diminished by 3 months. Although pulsed radiofrequency requires a longer treatment time, its efficacy in reducing occipital pain is worthy of recognition [16]. In addition, neurectomy and neurolysis are widely accepted surgeries for symptom relief in treatment-resistant occipital neuralgia [17].

Through a comprehensive literature review, we found that no studies have consistently favored or recommended one specific treatment modality over another. Consequently, we are unable to definitively comment on the superiority of any one treatment approach over another [18]. Acupuncture, as a therapeutic technique rooted in traditional Chinese medicine, has garnered widespread recognition for its effectiveness in alleviating a diverse array of pain syndromes [19]. Li et al and Chen et al compared acupuncture to medication for occipital neuralgia and demonstrated that acupuncture had a significantly higher effective rate of treatment. The acupuncture group exhibited a notably lower incidence of adverse events than the control group [20,21]. Recent systematic reviews have concluded that acupuncture is a safe, cost-effective treatment modality with minimal adverse effects. Till now, none of the randomized controlled trials encompassed within these reviews have documented any life-threatening complications associated with acupuncture therapy [8,22,23].

For selected patients with chronic headaches caused by occipital neuralgia, acupuncture treatment seems to provide effective and long-lasting pain relief. Endogenous pain modulators, such as endorphins, are believed to be primarily responsible for the pain-relieving effects of acupuncture in the central nervous system, as well as for some level of inhibitory control over painful stimuli [24]. There is strong evidence supporting the notion that high-threshold, small-diameter nerves in the musculature can be mobilized by acupuncture to initiate analgesia. The nerves possess the ability to transmit signals to the spinal cord and activate various neurons, such as the brainstem, hypothalamic neurons, and endogenous opioid mechanisms. Through this interaction with nociceptive afferent signals at different levels of the central nervous system, the transmission and expression of nociceptive information can be inhibited, thus producing an analgesic effect [25,26]. Interestingly, the discovery of β-endorphin as the primary soluble mediator for the pain-sealing effects of acupuncture is a significant success in the field of acupuncture research [27]. In contemporary times, the ability of acupuncture to activate mast cells and cause their degranulation has also been found to result in an analgesic effect [28]. Furthermore, additional studies indicate that acupuncture can promote the vagus nerve and TNF-α signaling pathways to attain anti-inflammatory and analgesic benefits [29]. Additionally, acupuncture can effectively release tense muscles and fascia, relieve tissue compression on nerves, reduce local soft tissue tension, and alleviate pain by altering local blood flow through somatosensory reflexes [30,31].

Regrettably, most current studies are plagued by low quality and small sample sizes, making the determination of the efficacy of acupuncture and moxibustion inconclusive. We, therefore, hold that additional high-quality research endeavors are critically needed in this field.

Conclusions

Acupuncture has emerged as a highly valuable modality for treating occipital neuralgia, as evident in this case report. The swift and significant relief achieved after just a single session underscores the remarkable potential of this ancient practice within modern medicine. We firmly believe that further extensive research and clinical trials are imperative to fully explore the vast possibilities of acupuncture in the treatment of various headache types and neurological conditions.