REVIEW
A SYSTEMATIC REVIEW ON ACUPUNCTURE
FOR TRIGEMINAL NEURALGIA
Hua Liu, MD; Hong Li, PhD; Min Xu, PhD; Ka-Eai Chung, MBBS, MRCPsych; Shi Ping Zhang, PhD
Background • Trigeminal neuralgia (TN) is a commonly seen
pain condition with limited treatments available, and acupunc-
ture is widely used for pain conditions, including TN.
Objectives • To review the efficacy of acupuncture treatment for TN.
Methods • English and Chinese databases were searched exten-
sively to identify randomized controlled studies of acupuncture
treatment for TN. Selected studies were assessed for method-
ological quality. Odds ratios (OR) hetween treatment and con-
trol groups were used to assess efficacy.
Results • Twelve studies met tbe inclusion criteria with 506 peo-
ple in the acupuncture arm and 414 people in the control arm, in
wbich carbamazepine (CBZ) was used as the control treatment.
Hua Liu, MD, is a postdoctoral fellow in the School of Chinese
Medicine, Hong Kong Baptist University, Hong Kong, PRC,
and an associate professor in the Department of Neurology,
the Second Clinical Medical College of North Sichuan
Medical College, Nanchong, PRC. Hong Li, PhD, is a lecturer;
Min Xu, PhD, is an assistant professor; and Shi Ping Zhang,
PhD, is an associate professor, all in the School of Chinese
Medicine, Hong Kong Baptist University. Ka-Fai Chung,
MBBS, MRCPsych, is a clinical associate professor in the
Department of Psychiatry, University of Hong Kong.
Corresponding author: Shi Ping Zhang, PhD
E-mail address: spzhang@hkbu.edu.hk
T
rigeminal neuralgia (TN) is characterized by recurring
attacks of paroxysmal, shock-like pain within the distri-
bution of one or more branches of the trigeminal
nerve. It is one of tbe most common forms of neural-
gia, with an annual incidence of approximately 4.3 per
100000 population.'Although pharmacological and surgical
therapies are effective for TN, each treatment has its own
limitations. Eor example, anticonvulsants such as carbamazepine
(CBZ) and oxcarbazepine have adverse effects including sedation,
dizziness, ataxia, and nausea, and their therapeutic effect decreases
with long-term use.' Surgical procedures, on the other hand, are
invasive, costly, and may cause neurological complications.
Acupuncture has been used for 3000 years in China, and it
30 ALTERNATIVE THERAPIES. NOV/DEC 2010. VOL. 16. NO. 6
They were all low-quality studies, hence precluding meta-analysis.
Only four trials reported that acupuncture was superior to CBZ,
and the remaining eight studies showed no difference between the
treatment and control groups. Adverse effects of acupuncture,
which were reported in three studies, were mild.
Conclusion • The evidence reviewed previously suggests that
acupuncture is of similar efficacy as CBZ hut with fewer adverse
effects in treatment of TN. However, the evidence is weak
because of low methodological quality of the reviewed studies.
Further studies witb improved methodologies are recommend-
ed to support the use of acupuncture for TN. (Altern Ther Health
Med. 2010;16(6):30-35.)
is generally regarded as a safe treatment.' The use of acupuncture
for pain relief is becoming increasingly common in developed
countries."" The traditional Chinese medicine paradigm holds
that the free flow of qi is essential for normal body functioning,
and pain is a sign of blockage of the flow of ^;. By inserting
acupuncture needles at points (ie, acupoints) along the passages
of the flow of qi, which are termed meridians, acupuncture
treatment is purported to unhlock the fiow of ^/, thus eradicating
pain." Physiological studies show that acupuncture stimulation
can induce changes in the nervous system, particularly in pain
inhibitory pathways.'
Though there have heen anecdotal reports and clinical trial
studies about the use of acupuncture for TN,"° no systematic
review to date has heen presented to support the efficacy of
acupuncture treatment. Therefore, we conducted this review to
assess the evidence of acupuncture treatment in TN.
METHODS
Acupuncture is defined as the use of a needle to stimulate spe-
cific loci of the body, either manually by thrusting or twisting the
needle in situ (manual acupuncture) or by way of electric current
(electroacupuncture). Studies were included if they were random-
ized controlled trials (RCTs) that examined the efficacy of acupunc-
ture treatment, comparing it witb either a placebo treatment or
anotber standardized treatment. The following terms were used
for tbe database search: acupuncture or needle; and trigeminal
neuralgia, tic douloureux, trigeminal nerve, or prosopalgia. A
Acupuncture for Trigeminal Neuralgia
comprehensive search was undertaken in the following databases
up to December 2009: Cochrane Neuromuscular Disease Group
Trials Register for randomized trials, the Cochrane Central
Register of Controlled Trials (CENTRAL), MEDLINE (from
January 1966), EMBASE (from January 1974), LILACS (Latin
American and Caribbean Health Sciences), AMED (Allied and
Complementary Medicine, from 1985), HKInChiP (Index to
Chinese Periodicals of Hong Kong, from 1990), and the Chinese
Biomédical Literature Database (CBM, from 1979), which is a
database of Chinese biomédical research literature. The same
search terms were also apphed to ClinicalTrials.gov, ProQuest
Digital Dissertations (PQDD), BIOSIS Previews (from 2001),
ChiCTR (www.chictr.org, Chinese Clinical Trial Register),
Electronic Theses and Dissertations System (Taiwan, from 1983),
and CNKI (China National Knowledge Inftastructure, from 1915)
for "gray literature" such as unpublished studies, dissertations,
and conference reports. English and Chinese were used in our
search terms, with no language restriction on target papers.
Specialized journals in acupuncture were also hand-searched.
Possible eligible studies in the references of retrieved studies,
review articles, and abstracts from conferences also were
searched. Where a report overlapped with a more detailed publi-
cation, only the latter was used. When more than one publica-
tion described a single trial, only one report was included.
Reports identified by the searches were examined indepen-
dently by two authors (Liu H and Li H), and each author made a
decision on whether a study met the inclusion criteria. Then the
results were compared, and any disagreement was resolved by
discussion. We excluded trials that used transcutaneous electrical
nerve stimulation and manual acupressure because they did not
involve needle insertion into the body. We also excluded studies
that compared two different forms of active acupuncture as well
as trials that used acupuncture in combination with other
treatment modalities, such as traditional Chinese herbs, massage,
or acupoint injection. If information about study design or assess-
ment was unclear, the study authors were contacted by phone or
mail for clarification. At the same time, the authors would also be
asked whether they have done any further study on the same
topic. If they had, the data would be included in the review.
For each study, the following variables were extracted: study
design; patient characteristics including gender, age, and dura-
tion of TN; acupuncture treatment protocol; control interven-
tion; and outcome measures. Missing data were obtained from
the authors directly whenever possible.
The methodological quality of identified studies was
assessed by two authors (Liu H and Li H) using the modified
Jadad scale," taking into account the difficulties in blinding of
the acupuncturist. For a total of 5 points, we awarded 1 point
each if the study met the following criteria: described as random-
ized; used appropriate randomization method; subjects were
blinded to intervention; evaluator was blinded to intervention;
and/or contained a description of withdrawals and dropouts.
We used the Cochrane Collaboration Review Manager soft-
ware (RevMan 5.0, The Cochrane Collaboration, The Nordic
Acupuncture for Trigeminal Neuralgia ALTERNATIVE THERAPIES, NOV/DEC 2010, VOL 16, NO. 6
Cochrane Centre, Copenhagen, Denmark) for statistical analysis.
A meta-analysis would be performed only if the studies had suffi-
cient similarity in clinical characteristics and high methodologi-
cal quality (modified Jadad score 3 or more). The results were
reported as odds ratio (OR) with corresponding 95% confidence
interval (95% CI) for dichotomous data.'^Pooled ORs were calcu-
lated by the fixed-effects method of Mantel and Haenszel" and
by the random-effects method of DerSimonian and Laird.'^
Heterogeneity between trial results was assessed using the
Cochran Q statistic'^ and was considered to be statistically signif-
icant iiP< .10." Funnel plots were used to detect publication and
other bias (Egger's test), and asymmetry was considered present
RESULTS
Study Identification and Characteristics
Our initial search yielded 389 English and 741 potential
Chinese articles for review. After skimming through them, 58
were selected for further study. Forty-four of the 58 studies were
excluded because the test treatment was not compared with a
standardized treatment, within which 16 studies compared dif-
ferent types of acupuncture treatment. Of the remaining 14 stud-
ies, two were excluded after further investigation. The study of
Zhang et al" was excluded because it was part of a bigger study"
included in this review. Another study, which described the effect
of acupuncture on chronic facial pain, was excluded because we
could not obtain further information about the trial from the
authors to determine if it satisfied the inclusion criteria." Finally,
12 studies were included for analysis (Table 1). The 12 included
studies, consisting of 11 full-length journal reports""^* and one
master's dissertation,^' were all conducted in China and pub-
lished in Chinese. They involved a total of 920 patients, with 506
patients in the acupuncture treatment arm and 414 in the control
arm. The clinical samples were obtained from hospitalized
patients and outpatients. Of the 12 studies, eight were described
as randomized trials,"^'^"*"^' and four did not describe the
method of randomization, although participants were said to be
assigned randomly. "^^^•'^'
With further information provided by the authors, we
found that only two trials used appropriate randomization meth-
ods, in which allocation of intervention was made by a random
number table."^" One study used a quasi-randomization method
by tossing a coin.^ The other nine trials allocated intervention by
the order of visit."^'"^'In all trials, the treatment group had acu-
puncture and the control group was given CBZ. Ten of the 12
included trials used a two-armed, parallel group design, and two
used a three-armed, parallel group design, in which a second
treatment group received another form of acupuncture or
acupuncture in combination with medication (CBZ).^'^' One trial
used CBZ in both the treatment and control groups as a baseline
treatment, with the treatment group receiving acupuncture in
addition.^' The definition of TN was similar across all included
trials, but the reference source quoted for the diagnostic criteria
of TN varied between studies. The age of participants included in
31
these studies ranged from 18 to 82 years in the treatment arm
and 20 to 78 years in the control arm. The duration of TN, which
had been described in nine trials, varied fi-om 7 days to 28 years.
The duration of treatment ranged fiom 10 to 60 days in the acu-
puncture arm and 10 to 60 days in the control arm, with 50 mg
to 200 mg CBZ administered orally two to three times per day.
The follow-up duration ranged from 3 months to 1 year. The
characteristics of the 12 studies are shown in Table 1.
Quality Assessment
None of the included trials described allocation conceal-
ment and blinding or reported dropouts and withdrawals. On
the modified five-point Jadad scale for quality assessment, 10
studies were given one point, and only two studies"^' were given
two points. Thus, they were all low-quality studies. Heterogeneity
between studies was found, with P value being 76% for the OR (P
< .0001). Due to the low quality of the included studies, meta-
analysis was not performed. A funnel plot of the 12 included
studies is shown in the Figure and indicates no significant
publication or other bias {P=.114, Egger's test).
Efficacy Analysis
The included studies used pain relief as assessment of
treatment efficacy, classifying the outcomes into several catego-
ries: cured, outstandingly effective, effective/improved, and inef-
fective. Seven studies""™-^'^""' used all four categories, and the
remainingfive^''^"^*^used only three categories. "Cured" referred
to "disappearance of pain and other associated symptoms,"

TABLE 1 Characteristics and Efficacy of the Twelve Included Studies*

Design; Follow- Intervention, Treatment Duration Cured (No./Total no., %) Cured rate:
Studies up Period Acupuncture group Control group Acupuncture Control OR (95% CD

Ü2OO(P 2 parallel arms; N=42. Acupuncture daily for a N=40.CBZ(200mg,3 18/42 18/40 0.92(0.38-2.19)
total of 20 d times/d)for20d 42.9% 45.0%

Zhou 2004" 2 parallel arms; N=31. Acupuncture daily for 28 d N=18.CBZ(100mg,3 6/31 3/18 1.20(0.26-5.52)
6 mo time.s/d) for 30 d in total 19.4% 16.7%
Guo 2005" 3 parallel atmsf ; N=40. Acupuncture dañy for 20 d N=20.CBZ(150mg,3 14/40 3/20 3.05(0.76-12.23)
3 mo times/d)for20d 35.0% 15.0%
Wang 2006^' 2 parallel arms; N=32. Acupuncture daily for 30 d N=28.CBZ(200mg,3 28/32 4/28 42.00t
3 mo times/d)for30d 87.5% 14..3% (9.47-186.23)
Zheng 2008^ 2 parallel arms; N=45. Acupuncture daily for 28 d N=45.CBZ(100mg,3 16/45 5/45 4.41t (1.45-13.42)
6 mo times/d)for30d 35.6% 11.1%
Xu2008" 2 parallel arms; N=26. Acupuncture daily for 30 d N=24.CBZ(200mg,3 21/26 5/24 15.96t
3au> times/d) for 30 days 80.8% 20.8% (3.99-66.84)

Shi 2008^ 2 parallel arms; N=32. Acupuncture daily N=21.CBZ(50mg,3 23/32 13/21 1.57(0.49-5.07)
no description until pain disappears, up to a times/d) for 20-30 d 71.9% 61.9%
of follow-up maximum of 30 d
Gao 2008^'' 2 parallel arms; N = 32. Acupuncture daily for 30 d N=32. CBZ (100-200 mg, 13/32 8/32 2.05(0.71-5.96)
ly 3 times/d) for 30 d 40.6% 25.0%

Jiao2008" 2 parallel arms; N=96. Acupuncture daily for 28 d N=96.CBZ(100g,3 10/96 18/96 0.50(0.22-1.16)
ly times/d) for 30 d 10.4% 18.8%

Fu2008" 2 parallel arms; N=80. Acupuncture daily for 30 d N=40.CBZ(100mg,2 53/80 18/40 2.40t
ly times/d) for 30 d 66.3% 45.0% (1.10-5.21)

Han2009'' 2 parallel arms; N=30. Acupuncture daily for 10 d N=30.CBZ(100mg,3 18/30 14/30 1.71
3 mo as a course; total no. of courses dmes/d) for at least 10 d 60.0% 46.7% (0.62-4.77)
not described
Zhao 2009^ 3 parallel arms§; N=20. Acupuncture daily for 45 d N=20.CBZ(100mg,2 12/20 15/20 0.50
6wk dmes/d or more) for 45 d 60.0% 75.0% (0.13-1.93)

*CBZ indicates carbamazepine; OR, odds ratio; CI, confidence interval.

fP < .05, statistically significant.
fTwo different fortns of acupuncture were combined in the acupuncture treatment group.
§Only data involving acupuncture alone vs CBZ control were analyzed.

32 ALTERNATIVE THERAPIES, N O V / D E C 2010, V O L 16. N O . 6 Acupuncture for Trigeminal Neuralgia

 could provide a consistent assessment of improvement across
studies, we analyzed the cured rate in this review." Thus, the
cured rate, defined as the proportion of subjects who achieved
complete relief of symptoms related to TN in both the treatment
and control groups within the follow-up period, was used to
assess efficacy. The OR of the cured rate in each study is shown in
Table 1. As seen in Table 1, four of the 12 studies had results
favoring acupuncture treatment, and the remaining eight showed
no significant difference between acupuncture and CBZ.

The Nature of Acupuncture

0.01 0.1 1 10
FIGURE Funnel Plot of Included Studies Using Cured Rate as
Outcome Measure. No obvious funnel asymmetry was observed
(ft = .114, Egger's test).
"disappearance of all symptoms," or "able to return to work or
resume normal activities" and "no recurrence of attack" (within a
3- to 12-month period, depending on the follow-up time of the
study). "Outstandingly effective" indicated reduction in the
severity of pain but with recurrence of symptoms occasionally.
"Effective/improved" referred to relief of symptoms, and
"ineffective" meant little relief of pain or no improvement.
Because the "cured" category appeared to be the only one that
Eight of the included studies used manual acupuncture, and
100 the remaining four employed electroacupuncture. None of the
studies mentioned the background of the acupuncturist. The
methods of acupoint selection, which mainly used acupoints
located at the affected region, were generally consistent among
studies. The top five most commonly used acupoints were
Xiaguan (ST7; 7/12), Chengjiang (RN24; 6/12), Jiache (ST6;
6/12), Sibai (ST2; 5/12), and Quanliao (SI18; 4/12). De-qi sensa-
tion, a characteristic of the traditional style of acupuncture, was
induced in all studies, and reducing needling technique was used
by most studies. The acupuncture protocols are summarized in
Table 2. There was no obvious difference in the acupuncture pro-
tocol between studies with positive results and those with
negative findings.

TABLE 2 Summary of Acupuncture Protocol

Study Acupoint Selection Stimulation Methods

Ü2000 Ipsilateral BL2, GB14, ST8, ST2, GB3, U20, ST6, RN24, U4 Reducing technique was applied for 5 min, and needles were
retained for 25 min
Zhou 2004 IpsilateralSI18,GB34,ST40 Even reinforcing-reducing technique was applied for 2 min every
10 min, with needles retained for 40 min
Guo 2005 BUateral ST7, EX-HN4, ST2, Ex-HN14 Reducing technique was applied every 10 min for 30 min
Wang 2006 ipsUateral ST7, SP3, EX-HN4, TE23, ST2, RN24, ST6, ST4 Manual manipulation was used to obtain De-qi, with needles
retained for 30-60 min
Zheng 2008 Ipsilateral ST7, GB14, BL2, ST2, LI20, ST4, ST6 Electroacupuncture for 30 min, with deep insertion at ST7
Xu2008 Ipsilateral GV24, EX-HN3, GV26, GB20, GB12, BLIO, U4, TE5 Reducing technique was applied andrepeatedtwice during the
20-min treatment \
Shi 2008 Ipsilateral ST7 and a trigger point or an acupoint at the aflFected regioti Reducitig technique was applied, followed by electroacupuncture
forlh
Gao 2008 Ipsilateral EX-HN4, ST7, Ex-HN14 Even reinforcing-reducing technique was applied for 1 min
Duration of treatment not specified
Jiao 2008 IpsUateral SI18 and bilateral GB34, ST40 Even reinforcing-reducing technique was applied for 2 min every
10 min with needlesretaitiedfor 40 min
Fu2008 Ipsilateral GB20, TE17, EX-HN5 and trigger points Manual manipulation every 10 min to create aradiatingsensation
towards the affected area, with needles retained for 30 min
Zhao 2009 Ipsilateral ST7, trigger points or acupoints at the afikted area, such as Manual matiipulation was used to obtain De-^i, followed by
BL2, ST8, SI18, ST6, RN24 electroacupuncture for 1 h
Han 2009 IpsUateral ST7, U4, ST44, SI18, BL2, ST2, Ex-HN14 Reducing technique was applied, followed by electroacupuncture
for 30 min j

Acupuncture for Trigeminal Neuralgia ALTERNATIVE THERAPIES, NOV/DEC 2010, VOL. 16, NO. 6 33
Adverse Event Reporting
Adverse events about acupuncture and CBZ were mentioned
in three studies.^^"^' Wang reported that two of the 32 patients
(6.25%) in the acupuncture group were found to have increased pig-
mentation in the vicinity of the needled points, and dizziness and
ataxia were reported in six patients and exfoliative dermatitis in one
patient in the CBZ group.^^ Another two studies^'^' reported that no
adverse events were found in the acupuncture group, whereas
adverse events, including somnolence, gastrointestinal dysfijnction,
abnormal blood tests, liver and kidney fiinction disorders, and
mental and skin symptoms, were found in the CBZ group.
Discussion
This is the first comprehensive review of acupuncture treat-
ment for TN. We identified 12 studies, all of which used CBZ as
control. CBZ has been recommended by the American Academy
of Neurology and the European Federation of Neurological
Societies as the first-line treatment for TN.' Thus, it is reasonable
to compare acupuncture with CBZ. Eight trials (with 600 partici-
pants in total) showed no difference in the cured rate between
acupuncture and CBZ, whereas the remaining four (with 320
participants in total) suggested that acupuncture was superior to
CBZ. Because of the larger number of participants in the no-
difference trials, the balance of evidence seems to support the
conclusion that acupuncture is at best of similar efficacy as CBZ.
It should be noted, however, that all studies included in this
review scored 2 or less in the modified Jadad scale and were
deemed to be of low quality in study methodology. Thus, the
validity of any findings regarding efficacy or even safety is ham-
pered by the low quality of these studies.
UMITATIONS
Homogeneity
The acupuncture treatment protocols varied in the reviewed
studies, which may be a factor that led to the heterogeneity in
treatment outcome hetween studies. We found that treatment
procedures, including acupoint selection, stimulation methods,
and treatment duration, varied among the trials reviewed.
Selection of acupoints was based mainly on the principle of using
local acupoints for the affected region, with some studies also
using distal acupoints as an adjunct. Heterogeneity of treatment
outcome may be related to the differing dosages and treatment
durations of CBZ, the control treatment used in all of the trials in
this systematic review.
Quality of Research Methodology
In more than half of the included trials, the procedure of ran-
domization was not descrihed. Our telephone inquiry to the
authors found that the methods of randomization in most studies
were inappropriate. As well, there was no description of withdraw-
als and dropouts in all studies. Furthermore, there might be bias in
patients' perceptions of effectiveness, such that the Asian popula-
tion might favor acupuncture rather than Western medicine
because of cultural beliefs. However, patients' attitudes toward acu-
34 ALTERNATIVE THERAPIES, NOV/DEC 2010. VOL. 16. NO. 6
puncture and CBZ were not assessed in any of the studies. Another
problem of the reviewed studies was that blinding or allocation
concealment was not applied. No studies reported blinding the out-
come evaluator, and assessor bias could not be discounted.
Additionally, due to the nature of the studies, the acupuncturists
were not blind to the purpose of the study, and they might have
communicated with participants their opinions regarding the
treatments. On the other hand, inert treatment such as noninvasive
placebo acupuncture would be a better control to assess the efficacy
of acupuncture treatment per se. Other methodological problems
included lack of precise inclusion criteria, nonstandardized out-
come measures, poor description of acupuncture procedures, and
lack of adverse event reporting. These methodological problems
reduced the credibility of our current findings regarding the efficacy
of acupuncture treatment.
Outcome Measures
Different outcome measures were used across these studies.
Categorical ratings of treatment outcome were used in all studies,
but each study may have inferred a different meaning for a given
outcome category. We simplified the outcome measures by compar-
ing only the "cured" rate." However, even the interpretation of
"cured" may have heen applied differently between trials. Moreover,
such a strategy did not allow the analysis of treatment outcomes
into other categories, such as "significant improvements."
Language
A final limitation was that only studies published in Chinese
were found in this review, which may have led to language bias. In
addition, the methodological quality of acupuncture studies
published in Chinese is generally felt to be poor." '^ Other limita-
tions include the paucity and imprecision of the primary data.
Safety of Acupuncture
Previous reviews found that acupuncture treatments were
associated with very mild adverse effects. In the present review, only
one study assessed the adverse events of acupuncture treatment,^'
but no fijrther description was provided, and two other reports
mentioned that no adverse event of acupuncture was observed dur-
ing the study.^*™ Thus, no reliable conclusions on safety can be
drawnfi-omthese studies.
CONCLUSIONS
In summary, this systematic review found that only trials from
China were available on the subject of acupuncture treatment for
TN. Although acupuncture had mainly been reported to be of simi-
lar efficacy as CBZ, the reviewed studies were of low methodological
quality, and the results must be interpreted with caution. It is sug-
gested that fiiture studies with improved methodologies, including
adding a placebo acupuncture control arm, blinding of assessor,
larger sample size, concealment of study objective, validated instru-
ments for pain assessment, and accurate description of acupuncture
procedures, are needed to assess the efficacy and safety of acupunc-
ture for TN.
Acupuncture for Trigeminal Neuralgia
Acknowledgments SOCIETY/or
INTEGRATIVK
This article was supported by Hong Kong Baptist University Wofoo Postdoctoral Fellowship ONCOLOGY

Scheme of Chinese Medicine.

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ATHM@innovisionhm.com
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