A 32 year old female patient, referred to the pain unit by the ophthalmology department for pain secondary to herpetic involvement of the ophthalmic branch of the left fifth cranial nerve, with poor response to treatment with tramadol (50 mg/8 h) prescribed by the ophthalmology department.
His past history included repeated episodes of keratitis and uveitis in the last 2 years, labelled as herpetic in origin.
At the first consultation (2001), the patient reported a picture of left eye pain of about 3 months' duration, with paroxysmal episodes that increased with certain stimuli such as wind, cold or dry eyes. Physical examination revealed no neurological deficits. The pain was rated by the patient with a visual analogue scale (VAS) value of a maximum of 7-8 (during paroxysms) and a minimum of 2. The diagnosis was post-kerkeratotic herpetic neuralgia of the ophthalmic branch of the left fifth cranial nerve.
Treatment was started with gabapentin and tramadol in progressive doses, without achieving good pain control and with the appearance of side effects in the form of vomiting and drowsiness. A series of drug rotations were carried out (amitriptyline, topiramate) at different doses which produced no improvement in pain or adverse manifestations.
With the patient's consent, treatment was started with low-frequency electroacupuncture (EA) (2-4 Hz/s), the intensity used being that accepted by the patient as tolerable. It was applied in fortnightly sessions lasting 30 minutes. The points chosen were: yintai, bilateral taiyang, 18 bilateral ID, 4 bilateral IG, 3 bilateral H, initially combined with gabapentin (300 mg/ 12 h).
After 6 sessions of EA, the patient started to report better analgesic control and better drug tolerance, so gabapentin was increased (900 mg/24 h) and tramadol solution (25 mg every 6-8 h) was added for paroxysmal seizure management only. EA sessions were done on a weekly basis. This was followed by improved analgesic quality, but vomiting persisted. It was decided to discontinue tramadol and to progressively increase gabapentin (2400 mg/24 h) for 2 months.
With this new treatment plan, the paroxysmal seizures were gradually controlled in terms of intensity, frequency and duration. After 3 months of clinical stability, the patient reported almost no continuous pain, the paroxysmal crises had decreased in frequency and intensity, and she presented better tolerance to drowsiness. A progressive tapering of gabapentin was started over 3 months until its discontinuation.
At the end of this period, the patient reported only paroxysmal seizures of a lower intensity (VAS 4-5) and with inter-crisis intervals of 7-10 days. These were managed with low doses of tramadol solution (25 mg), which was effective for pain control, but was accompanied by nausea, which is why the patient stopped using it. After a period of 6 months with weekly sessions of EA and acceptable control of the condition, a gradual spacing of these sessions was started.
Currently, the patient continues treatment in our unit (last consultation January 2009), only with EA sessions every 30-45 days, without any other type of medication, with adequate pain control. Attempts have been made to space out the acupuncture sessions every 60 days, but analgesic control is of poorer quality.
