In many cases immediate and lasting improvement in pain ▬
Many years of experience in the neural therapy practice shows this.
Summary
Neural therapy is an efficient, inexpensive method with few side effects for the symptomatic and causal treatment of headaches of various origins, as many years of practical experience show. One of the few disadvantages is the interventional character, although the current techniques are relatively painless. The article summarizes the most important infiltration techniques for frequent forms of headache, which often lead to immediate and lasting pain relief.
Headache, along with lower spine discomfort, is the most common reason for visits to the doctor and one of the most common reasons for pain management interventions. In Germany alone, more than 50 million people suffer from episodic or chronic headaches. Chronic headaches cause very high loss of working hours and are often the cause of patient hospitalization and repeated prescriptions of medication. The international classification of headaches of the International Headache Society (IHS) differentiates 14 groups and more than 200 diagnoses, whereby the primary headaches predominate strongly [1]. Tension headaches and migraines make up the lion’s share of chronic recurrent headaches, although from my point of view hemicranias of other origins are often misdiagnosed as migraines. In addition, the primary headaches are cluster headaches and other trigeminal autonomic headaches. In many neurological, psychiatric, and internal diseases, headaches appear as an accompanying symptom and require medication or therapy in addition to treating the main disease. Some of the most common internal diseases with headache as an epiphenomenon include (by no means exhaustive):
• metabolic lapses
• derailed arterial hypertension
• anemia
• electrolyte and water balance disorders
• intoxications
• infections
• oncological diseases
• sinusitis
• inflammatory bowel disease,
• gastritis, stomach ulcer
• pancreatitis
• chronic hepatitis, cholecystitis
• drug-induced headache (almost any substance can cause headaches, as can drug withdrawal)
As with any other pain syndrome, non-pharmacological therapeutic approaches such as physiotherapy, relaxation techniques, to favor stress management and exercise. The success of the therapy, however, is very variable. The more chronic the pain symptoms, the greater the importance of the psychological component in the therapeutic bio-psycho-social model. Treatment forms of this component are, however, only available to a limited extent in the statutory health system. The pharmacological treatment of occasional headaches is largely unproblematic. The drug therapy for chronic headaches is again
a medical challenge that requires the consideration of several patient- and drug-related peculiarities.
As the main representative of the nociceptively effective peripheral analgesics, the group of NSAIDs is the most frequently prescribed class of substances. However, the unfavorable side effect profile of NSAIDs, especially in older patients regarding cardio and nephrotoxicity, is a limiting factor for long-term use. As an alternative to the NSAIDs are increasing
Opiates and opioids are also prescribed for non-malignant pain and headache. The advantage of these substance classes is the favorable side effect profile regarding organ functions, except for constipation and urinary retention. The disadvantages are the impairment of central nervous functions, increased risk of delirium, confusion, and sleep disorders, just to mention the most common.
The antidepressants and anticonvulsants, which are often given for tension headaches and trigeminal neuralgia, are also to be viewed critically in the long term due to central nervous side effects and anticholinergic syndromes. Chronic or chronically recurrent pain predominantly affects the fastest growing population and patient group – the elderly, multimorbid people, for whom poly-pharmacotherapy is very problematic due to unmanageable pharmacodynamics and kinetics.
Neural Therapy – Grateful Technique in Headache Treatment
Experience has shown that neural therapy is an efficient, cost-effective method with few side effects for the symptomatic and causal treatment of headaches of various origins. One of the few disadvantages is the interventional character, although the current techniques are relatively painless. Neural therapy is a system of coordinated diagnostic and therapeutic measures. Small amounts of short-acting local anesthetics (mainly procaine and lidocaine 1%) are applied to specific areas. A precise anamnesis with consideration of all previous operations, trauma, chronic inflammatory diseases and scarring as well as a palpation and functional examination of the patient are prerequisites for the neural therapeutic treatment. By palpation of different tissue layers (superficial palpation, connective tissue palpation, Kibbler fold, muscle palpation) the therapist records segmental reflex regulation disorders.
The local anesthetics can be administered in different ways:
• locally: at the locus dolendi due to wheals, trigger point infiltrations
• segmental: intramuscular, preperiostal, perineural, periarticular, insertions as well as on vegetative ganglia in the sense of extended segment therapy
• systemic (intra- and peri-vasal)
• or around interference fields
Effects and techniques of neural therapy
The neural therapeutic effect lasts much longer than the half-life of the substances suggests and is not dependent on the amount of substance. It is a regulatory method that can remove regulatory blockages by erasing pathological reaction patterns and neurovegetative engrams as well as reducing the overall inflammatory load on the organism. By influencing the segmental innervation as well as by reflex interconnections on the spinal level, super-ordinate neurovegetative structures will be modified and the body’s responsiveness to restore homeostasis improved.
The local anesthetics are used without additives and applied to muscle attachments, trigger points, periosteum, nerve ganglia, neuromodulative triggers (interference fields), scars, acupuncture points.
Safety precautions
Resuscitation set
Neural therapy can be used as monotherapy, or adjuvant with any other therapy. It improves the results of other therapy methods by relieving disrupted control loops, removing regulatory blocks, and reducing the overall inflammatory burden on the organism.
The neural therapeutic treatment begins in the head area as well as in other body regions, generally as local and segmental therapy. If one can achieve sufficient symptom relief or cessation of the complaints using these techniques, no further measures are required.
Neural therapy can be used as monotherapy for tension headaches, neuralgia, vertebral related symptoms, or those with a toxic, climatic, or elementary origin. Adjuvant neural therapeutic treatment is also recommended for all other forms of cephalgia. The application of the method assumes the knowledge of certain infiltration techniques, which are described in the following.
Pre-periosteal Infiltration Techniques
„Crown of thorns“ according to Hopfer
In the case of diffuse or cerebrovascular headaches, dizziness and the beginning forms of dementia, the so-called crown of thorns according to Hopfer is used. This leads to an improvement in cerebral perfusion through stimulation around the trigeminal and spinal innervated structures as well as via the pharmacological properties of the local anesthetics.
Technique
With a 0.4 × 20 mm needle, preperiosteal depots (0.2-0.3 ml local anesthetic per injection) are placed around the largest circumference of the head approximately every 3 cm. The forehead area is usually left out for aesthetic reasons.
Infiltration of nuchal insertion points (A, B, C and T points according to Hackett)
This infiltration technique is a very useful technique for headaches caused by tension in the neck muscles and / or insertion tendinopathies around the superior nuchal line (Fig. 1).
Fig. 1 Infiltration technique of nuchal insertion points. © ÖNR archive
These types of headaches often have an ascending nuchal spread and are often confused with occipital neuralgia. The targeted pressure on these points can trigger the described pain pattern.
Localization
• T point – median point on the external occipital protuberance
• A point – 1 QF lateral to the median line. Corresponds to the insertion site of M. trapezius, which is often in a state of tension due to incorrect posture (computer work).
• B point – 2 QF lateral to the median line and insertion point of the splenius capitis muscle.
• C point – At the transition from mastoid to occiput. Insertion point of the sternocleidomastoid muscle.
Technique
A 0.5 × 40 mm needle is inserted to the point of contact with the periosteum, the needle is withdrawn slightly to avoid subperiosteal hematomas, 0.2 ml of local anesthetic is applied per point. Usually, the points infiltrated are those that can be palpated or are noticeable painful.
The so-called two-finger protection method is used to increase accuracy and avoid complications (Fig. 2).
Fig. 2 Two-finger protection method for infiltration of bony structures, here in the rib area. © ÖNR archive.
This therapy program is usually accompanied by the application of small amounts of local anesthetic to the mastoid.
Bird’s point
Another point that is infiltrated in the preperiosteal technique described is the so-called bird’s point at temporally accentuated headaches or migraines.
Technique A 0.5 × 40 mm needle is inserted into the middle of the temple until it makes contact with the bone, then withdrawn 1 mm and, after aspiration, 0.3-0.5 ml of the local anesthetic is applied.
Infiltration of trigger points
In the modern history of pain syndrome treatment, trigger points play an immense role. These are maximum pain points that have a stereotypical position and are not infrequently congruent with acupuncture points. Pressure around a trigger point leads to pain triggering in a predictable zone (referred pain) and often also to vegetative reactions. Trigger points are activated when the corresponding kinetic chain is stimulated and are often associated with pseudo radicular pain syndromes.
For instance, frontal and temporal headaches can be related to trigger activity in the following muscles and are often confused with migraines: M. Masseter, M. temporalis (Fig. 3–7), M. sternocleidomastoid, M. scalenus, M. trapezius, M. splenius capitis.
Fig. 3 Temporalis muscle. Source: [6] Fig. 4 M. temporalis trigger point 1 with Fig. 5 M. temporalis trigger point 2 with pain pain projection area. Source: [6] projection area. Source: [6]
Fig. 6 Temporalis muscle trigger point 3 Fig. 7 Temporalis muscle trigger point 4 with pain projection area. Source: [6] with pain projection area. Source: [6]
If the trigger points are correctly identified by palpation, their neural therapeutic treatment is relatively simple. In many cases, it can lead to an immediate and lasting improvement in painful conditions.
Technique
The trigger point is fixed with 2 fingers and after inserting a 0.5 × 40 mm needle, 0.2-0.3 ml of the local anesthetic is applied. Reaching the trigger point with the needle tip is clearly felt by the therapist based on a change in tissue resistance. Repeated treatments every few days are often required. In a session are generally several trigger points treated. The trigger point technique is shown in Fig. 8 where the trigger of the trapezius muscle is infiltrated.
Fig. 8 Infiltration technique of a trigger point of the trapezius muscle. © ÖNR archive
Intra- and extravascular infiltration
The classic neural therapeutic treatment according to Huneke begins with an intravascular injection of 1 ml local anesthetic and a perivascular flooding with 0.5 ml when pulling out the needle to reach the perivascular sympathetic plexus. This injection can be used to increase the effect of local and segmental therapy.
The procaine base infusion as a systemic neural therapy is becoming more and more important. Reliable data are now available for their efficiency and safety.
100-300 ml procaine 1%, 40-120 ml sodium hydrogen carbonate 8.4% in 250-500 ml 0.9% NaCl solution are infused over 60-90 min depending on the amount of procaine. The method is particularly effective in chronic and multisegmented pain syndromes for reducing pain and inflammation. The role of sodium hydrogen carbonate and the dispensability of this substance in procaine infusions have not yet been conclusively clarified.
In the treatment of headaches, extravascular injections of the carotid artery and superficial temporal artery can also be performed to better assess the vasomotor component.
Technique
1 ml of procaine 1% or lidocaine 1% is injected into the pulsating artery, parallel to the course of the vessel. For all injections near the carotid artery, one must carefully aspirate in 2 planes to avoid intravascular injections with possible serious neurological complications.
An improvement in headaches can also be achieved through neural therapy by activating the lymphatic drainage. (Fig. 9)
Technique Several intracutaneous wheals with 0.1 ml of the local anesthetic per wheal are placed on the anterior border of the sternocleidomastoid muscle.
Fig. 9 Wheal technique to activate the lymphatic drainage. © ÖNR archive
Infiltration of neural structures
If there is clinical suspicion of real occipital neuralgia, in neural therapy the N. occipitales major and minor can also be flowed.
As always with infiltrations close to the nerves, this is a perineural and not intraneural technique.
Technique
Performed with a 0.4 × 20 mm needle. The occipital artery is palpated 3 cm lateral to the occipital protuberance. The puncture site for the infiltration of the greater occipital nerve is somewhat medial to it. The needle is directed slightly cranially, the penetration depth is approx. 1 cm.
The infiltration of the minor occipitalis nerve occurs one finger’s width medial to the posterior margin of the mastoid process on the lower edge of the occiput and perpendicular to the skin [5].
Infiltration of the temporomandibular joint
In the treatment of chronic headaches, it is mandatory to record pathologies of the temporomandibular joint. Craniomandibular dysfunctions are more common than expected and often maintain therapy-resistant pain syndromes for a very long time. In the case of appropriate anamnestic information, tenderness, incomplete mouth opening or conspicuous palpation of the temporomandibular joints, neural therapy can be used to flood the joint.
Technique
The temporomandibular joint gap is palpated a finger’s width in front of the tragus by repeatedly opening and closing the mouth, a 0.4 × 20 mm needle is inserted 1–1.5 cm deep and 1 ml of the local anesthetic is applied.
Infiltration of nerve ganglia
In cases of chronic headaches triggered by chronic sinusitis, trigeminal neuralgia, cluster headache, atypical facial and upper jaw pain, or a special form of headache (Sluder’s neuralgia), flooding the pterygopalatine ganglion is often effective.
If despite exhausting the possibilities of segment therapy, headaches of a different origin persist or if pain reduction is insufficient and limited in time, then neural therapeutic infiltrations in the extended segment are also carried out on other ganglia (superior cervical ganglion, stellate ganglion, or pterygopalatine ganglion). The description of the corresponding injection techniques would, however, go beyond the scope of this article. These neural therapeutic techniques belong to the segment therapy in neural therapy. Segment therapy is based on the knowledge that all body structures that are innervated by the same spinal nerve respond to stimuli as a unit. In neural therapeutic treatment, segmental reflex reaction processes are set in motion, regardless of this, various properties of the local anesthetics come into play:
• Vasodilation
• Sympatholysis
• Stabilization of the cell membrane
• Normalization of perfusion
• Matrix reset through interruption of the irritation
• Anti-inflammation
Particularly interesting regarding anti-inflammation are the not long known „alternative“ properties of local anesthetics that do not occur via sodium channel blockade. This mainly concerns signal transduction at membrane G-protein receptors and the resulting reduction in the expression of inflammatory mediators [4].
Neural therapy as interference field therapy
In case of therapy resistance or recurring complaints, the therapeutic concept is extended by the targeted treatment of neuromodulative triggers or interference fields after 2 to 3 times of segmental neural therapy without sufficient effect.
In today’s research, more and more attention is paid to the phenomenon of the interference field. Histologically, subclinical inflammation is thought to occur in tissues below the pain threshold [2]. This subclinical inflammation can be a consequence of various mechanical, thermal, or chemical noxae and is characterized by constant irritation of sympathetic fibers as well as activation of cytokine cascades in the tissue. The signals from these interference fields are transmitted to the rest of the organism via this biochemical alteration in the basic system or via neural circuitry. The triggered subclinical inflammation (silent inflammation) and sympathetic activation blocks several immunological mechanisms and prevents the organism from remedying or neutralizing additional stressors or pathogenic factors in terms of a „second strike“ according to Speransky [3].
Accordingly, neural therapy is the best method for detecting and eliminating interference fields that can lead to regulation and reaction blockages. An interference field can be any part of the body after trauma or chronic inflammation. It can remain in a state of clinical latency for a long time, cause no or only underlying symptoms and can manifest itself through an additional harmful agent or stimulus (second strike according to Speransky) and trigger or maintain location dependent symptoms.
Most interference fields are localized in the head area (infected teeth, chronic sinus infections, tonsils). However, all scars on the body or chronic inflammation of the internal organs can have interference field characteristics. Whether a potential interference field also manifests itself clinically depends on the body’s constitution, the additional exposure, and the summation of all stresses.
The repeated flooding of an interference field with local anesthetics causes an irritation pause in the matrix and in the neurovegetative nervous system, extinction of peripheral stimuli, reduction of the whole inflammatory load of the system and reduction of the complete sympathetic tone. Civilization diseases and pain syndromes of modern man are known to result from a permanent state of activation of the sympathetic nervous system.
The interference fields in the head area are neuronally interconnected with the cervical spine and the atlantoaxial joints via the trigeminocervical complex. They can control tonus changes of the neck muscles as well as misalignments of the cervical spine and, above all, of the entire spine. The trigeminocervical complex contains neuronal connections between the supply area of the trigeminal nerve and the spinally supplied areas of segments C 1 – C 3 at the level of the reticular formation (Fig. 10). Vagal connections to the core area of the vagus nerve are also formed there.
visual spatial orientation, higher-level vegetative coordination of food intake swallowing core area for expiration core area for inspiration pneumotactic core area, acoustic-vestibular spatial orientation vasomotor control ambiguous nucleus
Fig. 10 Structure-function relationships of the reticular formation. Source: [8]
The interference fields in the head region can cause or maintain pain both in the head area and in the entire rest of the body via these neuronal circuits. They should be included in the further therapeutic concept in case of local segmental therapy failure. Like all other infiltration techniques, the infiltration from the head disturbance fields can be learned in the training courses of the neural therapy societies.
Literature
1 Headache Classification Committee of the international Headache Society. The international classification of headache disorders, 3 rd edition (beta version). Cephalalgia 2013; 33 (9): 629–808
2 Heine H. Lehrbuch der biologischen Medizin. 2. Aufl. Stuttgart: Hippokrates; 1997
3 Speranskij AD. Grundlagen der Theorie der Medizin. Berlin: Saenger; 1950
4 Weinschenk S, Hrsg. Handbuch Neuraltherapie. München: Elsevier; 2010
5 Fischer L. Neuraltherapie nach Huneke. Stuttgart: Hippokrates; 2007
6 Hecker HU, Steveling A, Peuker ET, Liebchen K, Hrsg. Taschenatlas Akupunktur und Triggerpunkte. Stuttgart: Haug; 2015
7 Schünke M, Schulte E, Schumacher U. Prometheus. LernAtlas der Anatomie. Kopf, Hals und Neuroanatomie. Illustrationen von M. Voll und K. Wesker. 2. Aufl. Stuttgart: Thieme; 2009