Low saturated fat diet is effective in trigeminal neuralgia

doi:10.4236/ojpm.2013.36054

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Vol.3, No.6, 402-406 (2013) Open Journal of Preventiv e Me dic ine

http://dx.doi.org/10.4236/ojpm.2013.36054

Low saturated fat diet is effective in trigeminal

neuralgia*

Narayan Verma1, Frank Sherwood2

1OUWB School of Medicine, Warren, USA; [email protected]

2BG Tricounty Neurology and Sleep Clinic, Warren, USA

Received 13 June 2013; revised 15 July 2013; accepted 1 August 2013

tion License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Objective: To determine the effectiveness of low

saturated fat diet (LSFD) in patients with trigemi-

nal neuralgia (TN). Design: 1) Internet forum

where patients could request a 10 page LSFD

plan, and 2) Follow-up assessment done by a

retrospective 20-item questionnaire. Duration of

treatmen t—2 months to 13 yea rs. Pain rated on a

Visual Analogue Scale and reported as typical,

atypical, or both, defining typical TN as inter-

mittent quick jolts/stabbing pain and atypical TN

as continuous never ending discomfort. Setting:

General community. Patients: 55 unselected pa-

tients, most with unilateral, severe and daily

symptoms in V2 and V3 distribution for a mean

duration of 8 years and on medications. 84% had

pain level 9 - 10 before treatment, 89% had daily

attacks and 31% had undergone surgical pro-

cedures. Intervention: LSFD for 2 months-13

years (mean 20 months). Main outc ome measure:

VAS score and medication use before and after

LSFD treatment. Results: Reported SF content

was 3 - 25 gm. With treatment 96% typical TN (p

< 0.0001) and 71% atypical TN (p < 0.002) im-

proved to level 0% - 2. 9% improved in less than

a week, 47% in 1 - 2 weeks and 44% in 3 - 4

weeks. 66% rated their compliance with diet as

excellent and 27% as good. There were no side

effects except weight loss. 72% of those on me-

dications reduced or discontinued them. All pa-

tients with post-surgical residual severe typical

TN also improved (p < 0.0001). Conclusions:

LSFD is effective in TN with high compliance,

few adverse effects and may result in reduction/

elimination of medications even in most severe

cases.

Keywords: Trigeminal Neuralgia; Low Saturated

Fat Diet; Cranial Neuropathy; Neuralgia

1. INTRODUCTION

Dietary treatment in neurological illnesses is not a

novelty. The ketogenic diet for intractable childhood

seizures is well known [1]. Efficacy of a dietary regimen

in stabilizing the neuronal/axonal membranes in epilep-

tics, presumed instability of membranes in the patho-

genesis of trigeminal neuralgia (TN) and consequent ef-

ficacy of anticonvulsants in TN provides a therapeutic ra-

tionale for pursuing a dietary interv ention in TN as well.

Late Roy L. Swank (1909-2008) introduced his low

saturated fat diet (LSFD) in multiple sclerosis (MS) in

1948 and published data on 144 patients over a 34 year

period in Lancet (1990) [2] regarding its effectiveness,

and published again as a review in 2003 [3]. Although,

not universally accepted, his results do provide a ration-

ale to try LSFD in TN, as two percent patients with TN

have MS [4].

TN is multi-factorial in etiology. Although vast major-

ity are idiopathic, possible symptomatic etiologies in-

clude aneurysms, tumors, chronic meningeal inflamma-

tion, or other lesions such as abnormal vascular course of

the superior cerebellar artery, primitive trigeminal artery,

venous compression, an area of demyelination from mul-

tiple sclerosis or lesions in the pons at the root entry zon e

(REZ) of the trigeminal fibers, symptomatic intracranial

hypotension, among others [5-8].

According to Weigel [9], no studies have ever tested

the efficacy of diet in TN. This study aims to fulfill that

vacuum.

2. SUBJECTS AND METHODS

One of us (FS) established an internet forum where

patients with known TN could request a 10 page multi-

colored LSFD plan. He was motivated by improvement

*Presented as a poster at AAN conference, New Orleans, April 24,

2012.

N. Verma, F. Sherwood / Open Journal of Preventive Medicine 3 (2013) 402-406 403

in his own serious health issues by this diet and a seren-

dipitous improvement in the symptoms of a friend of his

with severe TN for 21 years who was scheduled to un-

dergo micro-vascular decompression, but was able to

avoid that as she dramatically improved on this diet and

remains so after 13 years.

The TN was diagnosed and treated by a board-certi-

fied neurologist or neurosurgeon in each case and their

clinical characteristics are listed in results below. There

were no exclusion criteria.

Patients rated their pain using the zero to 10 Visual

Analogue Scale (VAS). They were instructed to report

pain as typical, atypical, or both. Typical TN was defined

as intermittent attacks of quick jolts of electrical-like

stabbing excruciating pain and atypical TN as continuous

never ending discomfort.

The plan had the diet instructions, the saturated fat ( SF)

content in 140 foods, recipes, how to read nutrition labels,

suggestions for restaurant eating and related health in-

formation. Highlights of the diet are summarized in Ta-

ble 1. The goal was to keep the daily saturated fat intak e

to as close to 10 gram as possible. The diet did not need

to be plant based and animal products were not prohib-

ited. Supplements, yoga, sunshine, lifestyle changes,

exercise and smoking cessation were not required. Al-

cohol, salt, sugar, simple sugar products and caffeine

were not restricted.

The follow-up assessment was done using a 20-item

questionnaire administered retrospectively by e-mail.

The questionnaire requested the demographic infor-

mation. Clinical status pre- and post-diet was ascertained

as well.

Patient self-rated their compliance as excellent, good

or poor.

Statistical analyses were done using the 2 tailed paired

student’s t test comparing the VAS scores before and

after the dietary treatment.

Post-surgical subgroup was analyzed both as a part of

the entire group as well as separately.

The questionnaires, the diet plans and mailings were

all self funded.

A control group was not neither felt to be necessary or

practical as patient’s pre-diet status served as control.

Collateral benefits were qualitatively asked to be com-

mented upon in an open ended question.

3. RESULTS

Table 2 illustrates the de mographics and clinical char-

acteristics of 55 unselected patients who returned the

questionnaire. Vast majority had unilateral, severe and

daily symptoms in V2 and V3 distribution for a mean

duration of 8 years and were on medications. Eight pa-

tients (15%) were not on any medication. The pain level

was 9 - 10 in 75 percent of patients not on medications

Table 1. LSFD highlights.

Foods that must be avoided

Lard Butter

Cream Bacon

Full fat Ice cream Cheese

All pastry Nuts

Coconut Avocado

Full fat yogurt Margari n e

Soft candy Pizza

Gravies Sauces

Foods in moderation

3 1/2 ounces (The size of a deck of playing cards)

Liver

Round

Lamb leg

Pork tenderloin

Cured ham

Ham steak

Eggs

Zero to very little saturated fat

Poultry (no skin) Fish

Canadian bacon Veal

Fat free luncheon meat Soy cheese

Spaghetti Beans

Low fat salad dressing Rice

Fat free dairy products Canola oil

Corn flakes Oatmeal

Pancakes Bagels

Cream of wheat Bread

Chestnuts Olives

Angle food cake Pretzels

Fat free ice cream Hard candy

Fat free puddings Gelatin deserts

Trigger foods

Tomatoes Pickles

Citrus fruits Tea

Coffee Sugar

Artificial sweeteners Spices

Hot sauce Salt

Pepper Cocoa

and 85 percent of those on medications. Forty seven pa-

tients (85%) were on medications: 19 on carbamazepine,

15 on gabapentin, 11 patients on oxcarbazepine, 6 pa-

tients on pregabalin, 4 patients on baclofen, 3 patients on

topiramate, 3 patients on hydrocodone-acetaminophen, 2

patients on duloxetine, 2 patients on lamotrigine, 1 pa-

tient on phenytoin, 1 patient on amitriptyline, 1 on nor-

triptyline and one on acetaminophen-codeine.

Seventeen patients (31%) had 35 surgical procedures

with residual severe pain for a mean dura tion of 11 years:

5 microvascular decompressions, 7 glycerol injections, 7

N. Verma, F. Sherwood / Open Journal of Preventive Medicine 3 (2013) 402-406

404

Table 2. Clinical characteristics of TN before treatment.

N = 55

Gender: F 42, M 13

Age: 28 - 89 (mean 58)

Type: typical 48, atypical 4, both 3

Laterality: unilateral 46, bilateral 9

Branches affected: V2 and/or V3 in all except 2, V1 also

affected in addition to V2 a n d V3 in 15

Duration: 4 months-34 years (Mean 8 years)

Co-existing MS: yes 3, no 52

Medications: On meds 47, not on meds 8

Intensity on VAS: 9 - 10 (46), 7 - 8 (7), 5 - 6 (2)

Mean intensity on VAS for typical TN (N = 51) = 9.55 ± 0. 94 *

Mean intensity on VAS for atypical TN (N = 7) = 8 .57 ± 1.13**

Frequency: daily 49, weekly 6, monthly 0

Surgery: yes 17 (total 35 pro c ed u res), no 38

Occupation: Various (see text)

*, **These 2 lines add to 5 8 as 3 patients had both typical and atypical TN.

gamma knife surgeries, 12 radiofrequency ablation, 2

cyber knife surgeries, 1 balloon compression, and 1 sur-

gery for neural gi a in duced cavitati onal ost eo-necrosis.

The following occupations were reported: college

graduates, teachers, nurses, business owners, PhD can-

didate, senior vice president of finance, certified nutri-

tionist, director of health services, physical therapist,

hospital director of qu ality and risk management, creden-

tialing, deputy prothontary, acupuncturist, defense con-

tractor technician, geologist, NASA employee, university

administrator, print shop coordinator, business consultant,

para-optometrist, office manager, CPA, IT consultant,

realtor, lifestyle counselor, computer operator, computer

programmer, pastor, cosmetologist, secretary, salesmen,

seamstress, domestic, homemaker and farmer.

Post-Diet

Table 3 shows results after LSFD treatment. Ninety

six percent typical TN and 71 percent atypical TN im-

proved to a pain level of 0 - 2 after 4 weeks of treatment.

Thirty four (72%) of those on medications (47/55) re-

duced or discontinued them. Those who continued

medications did so because either they were frightened

or wanted to increase the percentage of LSFD to a toler-

able level. Compliance was excellent or good in 93 per-

cent.

Table 4 outlines the results in post surgical patients as

a subgroup. All patients with post-surgical residual typi-

cal TN responded to LSFD except one patient whose

typical TN improved but not the atypical TN. The speed

of improvement was slightly longer (mean 20 days) than

that for the entire group (mean 16 days). However, the

mean duration of pain in the po st surgical gro up was also

longer (11 years vs. 8 years).

Table 3. Results wit h LSFD.

Reported daily

saturated fat intake: 3 - 25 gm (mean 10 gm)

Duration: 2 months-13 years (mean 20 months)

Excellent: 36

good: 15

Compliance:

poor: 4

Noticeable pain relief: 1 week 26, 2 weeks 25, 3 - 4 we ek s 4

Maximum pain relief: 1 week 5, 2 weeks 27, 3 - 4 weeks 23

(mean 16 days)

0.14 ± 1.45 typical TN* (0 - 2 49/51)

Intensity on VAS: 2.28 ± 2.92 atypical TN** (0 - 2 5/7)

Discontinued meds: 16/47#

Reduced meds: 18/47##

*, **3 patients had both typical and atypical pain; *paired 2 tailed student’s t

test t 65.685, SED 0.143, df 50 (p < 0.0001)*; **paired 2 tailed student’s t

test t 5.197, SED 1.209, df 6 (p < 0.002)**; #, ##8 patients were not on

medications.

Table 4. Post surgical patients.

N = 17

Procedures: 35 (see text)

Type: typical TN 16, both 1

Laterality: unilateral 14, bilateral 3

Duration: 2 - 34 years (mean 11 years)

Frequency: daily 16, weekly 1 , monthly 0

Reported daily

saturated fat intake: 3 - 16 gm (mean 11 gm)

Excellent: 10

good: 5

Compliance:

poor: 2

Noticeable pain relief: 1 week 10, 2 weeks 6, 3 - 4 weeks 1

Maximum pain relief: 1 week 1, 2 weeks 8, 3 - 4 weeks 8

(mean 20 days)

Pre-diet: 6 - 10 (mean 9.53 ± 1.07)

Intensity of typical

TN on VAS: Post-diet: 0 - 2

(mean 0.29 ± 0.59) 17/17*, **

Pre-diet: On meds 15, not on meds 2

Medications: Post-diet: Discontinued meds 4,

reduced 9, continued 2

*paired 2 tailed student’s t test t = 31.7 SED = 0.291, df = 16 p < 0.0001;

**One patient had atypical TN as well, with intensity of 8, which did not

change at all post-diet .

The data storm diagrams (Figures 1(a)-(c)) show that

the VAS scores in typical TN, atypical TN and post-sur-

gical patients respectively have virtually no overlap in

the data before and after diet accounting for the statisti-

cally significant results.

Only side effect reported was weight loss. The amount

of weight loss varied from 5 lbs to 75 lbs.

Collateral benefits qualitatively rep orted were lowered

cholesterol levels and trig lyceride lev els, improved blood

pressure, improvement of long standing itching, im-

N. Verma, F. Sherwood / Open Journal of Preventive Medicine 3 (2013) 402-406 405

(a) (b) (c)

Figure 1. Data storm diagram compar ing the VAS score before

and after LSFD diet in each of the 3 groups: Typical TN,

atypical TN and post-surgical TN showing hardly any overlap.

(a) Typical TN (N = 51); (b) Atypical TN (N = 7); (c) Post-

surgical subgroup (N = 17).

proved GERD, reduction in wart size on hands, more

energy level, more endurance and improved fibromylagic

symptoms, constipation, hemorrhoids, migraines, sleep

and Irritable bowel symptoms. One patient reported im-

proved symptoms of glossopharyngeal neuralgia and

another showed improvement in post-herpetic neuralgia

which co-existed with TN.

4. DISCUSSION

LSFD for TN differs from other low saturated fat diets

such as Ornish’s [10] and Esselstyn’s [11]. The Ornish

diet is restrictive for patients because it limits alcohol,

salt, oils, sugar, simple sugar derivatives, and does not

allow caffeine. Ornish diet allows fish supplements and

occasional consumption of animal products. Also for

maximum results, the Ornish diet is to be used in con-

junction with a holistic health program including, exer-

cise, yoga, meditation, lifestyle changes, stress reduction ,

nutritional supplementation and smoking cessation.

LSFD diet does not impose any such restrictions. Essel-

styn diet is mostly plant-based vegan diet, which is hard

to follow. LSFD does not require TN patients to be vegan.

It simply strives to limit saturated fats to abo ut 10 grams

a day. Perhaps that is why the compliance was good to

excellent in 93 percent. It cannot be compared to Medi-

terranean diet [12] as the latter has much higher saturated

fat content-up to 8 percent and relies on the beneficial

effects of wine, healthy lifestyle and sunlight as well.

Our results demonstrate that LSFD is a quick, safe and

reliable method to treat both typical and atypical TN.

Ninety six percent typical TN and 71 percent atypical TN

improved from a severe pain level to minimal (0 - 2) in 1

- 4 weeks (average 2 weeks). Seventy two percent of

patients on medications reduced or discontinued them.

Typical TN in all surgical failures improved as well.

Weight loss was the only side effect.

Women were overrepresented in our population, per-

haps as they are more likely to surf the net for diets. Bi-

laterality was slightly more (16%) than in the literature

(12%) and MS was more frequent (5.5%) than in the

literature (2%) likely related to overrepresentation of

women in the sample. Women are more likely to have

MS and MS is the most common (18%) known cause of

bilateral trigeminal neuralgia [13,14]. Aside from this,

the demographics and clinical features of our patients are

in line with the literatu re indicating that even though they

were not consecutive patients-impossible to obtain the

low cost and novel method employed-they truly repre-

sent most TN patients. Given their background, it is

likely that they answered the questionnaire honestly and

accurately.

Some of the proposed mechanisms of TN [15-17] are

as follows:

1) Neuropathic p ain may be due to the small unmyeli-

nated and thinly myelinated primary afferent fibers that

sub serve nociception. 2) The pain mechanisms them-

selves may be altered. 3) Microanatomic small and large

fiber damage in the nerve, essentially demyelination,

commonly observed at the REZ, leads to ephaptic trans-

mission, in which action potentials jump from one fiber

to another. 4) A lack of inhibitory inpu ts from large mye-

linated nerve fibers may play a role. 5) A reentry mecha-

nism may cause an amplification of sensory inputs such

as from vibration, to trigger an attack. 6) Features also

suggest an additional central mechanism (e.g., delay be-

tween stimulation and pain, refractory period).

LSFD is known to improve endothelial dysfunction

and reduce inflammation by increasing the number of

LDL receptors on mononuclear cells, influencing type 1

plasminogen inhibitor and V W factor, decreasing P-

selectin plasma levels and improving vasomotor function

[18-20]. An improvement of the endothelial dysfunction

and reduction of inflammation may well improve one or

more underlying mechanisms detailed above. Reduced

blood viscosity and decreased aggregation of blood cells

[3] noted almost immediately after starting LSFD may

improve circulation and blood-nerve barrier.

Whether long-term reduction of cholesterol levels and

weight loss is operative in the improvement of TN is

debatable as improvement occurred too soon for reduced

cholesterol and weight loss to be a decisive factor. Rela-

tively slow improvement in post-surgical group (mean of

20 days vs. 16 days) may well be related to longer dura-

tion of pain in that group (11 vs. 8 years) prior to treat-

ment.

N. Verma, F. Sherwood / Open Journal of Preventive Medicine 3 (2013) 402-406

406

The shortcomings of our study are that the data are

self-reported from patients who are not directly under

our care and the retrospective nature of the questionnaire.

However, the technique employed by us is novel, low

cost and deserves a second look for collecting data in

difficult situations such as this. The placebo effect is not

excluded although dramatic and sustained improvement

even in post-surgical group with severe and intractable

pain makes it unlikely. Dramatic and quick results may

raise the question of biological improbability of the re-

sults but they are presented here as many novel therapies

are initially serendipitous, and appear dramatic and im-

probable. A well designed prospective study with inclu-

sion of a control group is necessary to further buttress the

results. We also do not suggest that this improvement is

specific for TN and overall contributions of unintentional

life style modifications, which may occur while using

this diet regardless, is not excluded, although the rapidity

of improvement makes this possibility unlikely.

OPEN A CCESS

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