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Introduction: Pain is one of the most common clinical symptoms in modern medicine. Depending on the nature and location of the pain, there are numerous internal and external treatment methods, and pain-relieving formulas have been countless since ancient times. The author of this article uses "Pain Symptom Decoction" as a foundation, adapting and modifying the herbs according to the syndrome.

Pain Symptom Decoction

Chen Daibin, Luo Hongliu

I. Composition of the "Pain-Relieving Formula"

Danshen (Salvia miltiorrhiza) 30g, Danggui (Angelica sinensis) 10g, Chishao (Red Peony) 30g, Baishao (White Peony) 30g, Chuanxiong (Ligusticum wallichii) 10g, Zhi Ruxiang (Processed Frankincense) 6g, Zhi Moyao (Processed Myrrh) 6g, Gancao (Licorice) 3g.

II. Formula Explanation

This formula is composed of the combination of "Peony and Licorice Decoction" from *Shang Han Lun (Treatise on Cold Damage Diseases)* and "Huoluo Xiaoling Dan" (Effective Elixir for Activating the Collaterals) from *Yixue Zhongzhong Canxi Lu (Records of Medical Insights East and West)*, with the addition of Ligusticum chuanxiong (Chuanxiong).

The pathogenesis of pain syndromes can be summarized by the theories: "Pain results from obstruction," "Pain results from malnourishment," and "All pains pertain to the heart." Mr. Jiaben believes that the primary pathogenesis of pain syndromes is "Pain results from obstruction." Therefore, promoting blood circulation, removing blood stasis, unblocking collaterals, and alleviating pain should be the fundamental treatment principles for pain syndromes. Based on these principles, selecting a specific formula to treat various pain syndromes should adhere to the criteria of being applicable to all types of pain, not biased towards heat or cold, having a rigorous formula, using easily accessible ingredients, and demonstrating confirmed efficacy.

Through long-term clinical validation and repeated exploration by Mr. Jiaben, it has been confirmed that "Peony and Licorice Decoction" from *Shang Han Lun (Treatise on Cold Damage Diseases)* has the effects of relieving smooth muscle spasm, antispasmodic, and analgesic; "Huoluo Xiaoling Dan" from *Yixue Zhongzhong Canxi Lu (Records of Medical Insights East and West)* has the efficacy of treating "qi and blood stagnation, epigastric and abdominal pain, pain in the legs and arms, traumatic injuries with swelling and bruising, internal and external sores and ulcers, as well as masses and accumulations, etc."; the combination of Angelica sinensis (Danggui) and Ligusticum chuanxiong (Chuanxiong) dispels stasis, relieves pain, harmonizes ying and wei, and tonifies qi and blood. The whole formula collectively achieves the effect of treating "various pain syndromes." Clinically, based on the patient's etiology, location and nature of pain, and differences in Western medical diagnoses, modifications are made according to the syndrome, all of which yield results. Therefore, it is named "Tongzheng Tang" (Pain Syndrome Decoction).

III. Modifications

①Addition of herbs based on different etiologies

For cold-related conditions, add Radix Aconiti Preparata, Radix Aconiti Kusnezoffii Preparata, Ramulus Cinnamomi, Radix Aconiti Lateralis Preparata, Herba Ephedrae, Rhizoma Zingiberis, and Radix et Rhizoma Asari.

For heat-related conditions, add Flos Lonicerae Japonicae, Rhizoma Curcumae Longae, Pheretima, Rhizoma Polygoni Cuspidati, Cortex Phellodendri, Radix Gentianae Macrophyllae, and Gypsum Fibrosum.

For deficiency-related conditions, add Radix Astragali, Radix Codonopsis, Cornu Cervi Degelatinatum, and Radix Rehmanniae Preparata

For substantial stasis, select rhubarb, leech, ground beetle, and peach kernel.

For phlegm turbidity, select white mustard seed, Chinese honeylocust abnormal fruit, arisaema with bile, and radish seed.

For dampness, select atractylodes rhizome, coix seed, tsao-ko, fourstamen stephania root, large-leaved gentian root, and kadsura pepper stem.

For parasitic accumulation, select betel nut, stone-like omphalia, smoked plum, pricklyash peel, and Szechwan chinaberry root bark

For pain due to stones, add seaweed, sargassum, chicken gizzard lining, and Chinese clematis.

②Modification according to pain location

For headache, optionally add dahurian angelica root, kudzu vine root, notopterygium root, scorpion, honeycomb, and earthworm;

For chest pain, optionally add trichosanthes fruit, Chinese chive bulb, dalbergia odorifera, pseudo-ginseng, safflower, and peach kernel.

For epigastric pain, optionally add Bupleurum, Immature Bitter Orange, Cyperus, Corydalis, and roasted Sichuan Chinaberry;

For hypochondriac pain, optionally add Bupleurum, Curcuma, Turmeric, roasted Sichuan Chinaberry, Green Tangerine Peel, Feces Trogopterorum, and raw Typha Pollen;

For abdominal pain, optionally add Saussurea, Cyperus, Corydalis, Feces Trogopterorum, and raw Typha Pollen;

For lower back pain, optionally add Eucommia Bark, Dipsacus Root, Morinda Root, and Cibotium Rhizome

For shoulder and back pain, select and add Puerariae Lobatae Radix, Vespae Nidus, Ephedrae Herba, Asari Radix et Rhizoma, Notopterygii Rhizoma et Radix, Angelicae Dahuricae Radix, Saposhnikoviae Radix;

For upper limb pain, select and add Saposhnikoviae Radix, Notopterygii Rhizoma et Radix, Scolopendra, Ephedrae Herba, Angelicae Dahuricae Radix;

For lower limb pain, select and add Cyathulae Radix, Clematidis Radix et Rhizoma, Chaenomelis Fructus, Angelicae Pubescentis Radix, Hirudo.

③ Addition according to the different nature of pain.

For distending pain, additionally select Xiangfu (Cyperus rotundus), Chaihu (Bupleurum), Zhishi (Citrus aurantium), and Guang Muxiang (Aucklandia lappa);

For stabbing pain, additionally select Honghua (Carthamus tinctorius), Taoren (Prunus persica), Shuizhi (Hirudo), Ezhu (Curcuma phaeocaulis), Sanleng (Sparganium stoloniferum), Tubiechong (Eupolyphaga sinensis), and Jiu Dahuang (wine-processed Rhubarb);

For referred pain, additionally select Baizhi (Angelica dahurica), Baijiezi (Sinapis alba), Xixin (Asarum), Wugong (Scolopendra), and Fengfang (Nidus Vespae);

For dull and lingering pain, additionally select Mahuang (Ephedra), Fupian (processed Aconite lateral root), Xixin (Asarum), and Ganjiang (Zingiber officinale);

For colicky pain, select and add fried Sichuan chinaberry, yanhusuo, flying squirrel feces, and raw cattail pollen;

For referred pain, select and add kudzu root, white angelica, bupleurum, and cyperus;

For migratory pain, select and add ledebouriella root, cyperus, earthworm, and white angelica;

For dull pain, select and add astragalus, white atractylodes, cinnamon twigs, and jujube;

For stabbing pain, selectively add stir-fried Chuanlianzi (Melia toosendan), Juehe (Citri Reticulatae Semen), Lichee Seed (Litchi Semen), and Fennel (Foeniculum vulgare);

For throbbing pain, selectively add Dandelion (Taraxacum mongolicum), Violae Herba (Viola philippica), Gentian (Gentiana scabra), Giant Knotweed (Polygonum cuspidatum), and Paris Root (Paris polyphylla).

④ Modify based on diseases confirmed by Western medicine diagnosis

For angina pectoris, add Peach Kernel (Prunus persica), Safflower (Carthamus tinctorius), Dalbergia odorifera, and Sanqi (Panax notoginseng).

For patients with biliary or renal colic, add Wulingzhi (Trogopterus Dung), Sheng Puhuang (Typha Pollen), Yanhusuo (Corydalis Rhizoma), Chaihu (Bupleurum), and Zhishi (Immature Bitter Orange).

For cancer pain, additionally select and add Wugong (Centipede), Quanxie (Scorpion), Fengfang (Honeycomb), Baizhi (Angelica Dahurica), Xixin (Asarum), Xionghuang (Realgar), and Shexiang (Musk).

For trigeminal neuralgia, add Quanxie (Scorpion), Gegen (Kudzu Root), Wugong (Centipede), Baizhi (Angelica Dahurica), and Qianghuo (Notopterygium Rhizome or Root)

For patients with cervical spondylosis, add Huangqi (Radix Astragali), Gegen (Radix Puerariae), Baizhi (Radix Angelicae Dahuricae), Qianghuo (Rhizoma et Radix Notopterygii), Shuizhi (Hirudo), Taoren (Semen Persicae), and Honghua (Flos Carthami)

For intercostal neuralgia, add Chaihu (Bupleurum), Yujin (Curcuma), Zhishi (Citrus Aurantium Immaturus), Jianghuang (Turmeric), and Zaoxiu (Paris Polyphylla);

For non-suppurative costochondritis, select and add Jinyinhua (Honeysuckle), Xuanshen (Scrophularia), Taoren (Peach Kernel), Shuizhi (Leech), Pao Chuanshanjia (Prepared Pangolin Scale), and Wangbuliu Xing (Vaccaria Seed);

For herpes zoster, select and add Jiu Dahuang (Wine-processed Rhubarb), Chaihu (Bupleurum), Huangqin (Scutellaria), Huzhang (Giant Knotweed), Longdancao (Gentian), Zaoxiu (Paris Polyphylla), and Qingdai (Indigo Naturalis);

For sciatica, select and add Wugong (Centipede), Duhuo (Angelica Pubescens), Baizhi (Angelica Dahurica), Dilong (Earthworm), Shuizhi (Leech), Chuan Niuxi (Cyathula Root), Qiannian Jian (Homalomena), and Weilingxian (Clematis);

For frozen shoulder, consider adding centipede, kudzu root, ephedra, notopterygium root, asarum, angelica dahurica, and leech;

For rheumatoid arthritis, consider adding fibraurea recisa, centipede, asarum, prepared Sichuan aconite, prepared wild aconite, honeycomb, notopterygium root, and pubescent angelica root;

For gouty arthritis, consider adding clematis root, earthworm, turmeric, caulis sinomenii, Sichuan cyathula root, papaya, sweetgum fruit, giant knotweed, Sichuan aristolochia stem, fibraurea recisa, peach kernel, and safflower;

For thromboangiitis obliterans, consider adding honeysuckle flower, scrophularia root, Sichuan cyathula root, leech, white mustard seed, peach kernel, and safflower;

For those with dysmenorrhea, add motherwort (Leonurus japonicus), hyssop (Houttuynia cordata), madder root (Rubia cordifolia), nutgrass flatsedge rhizome (Cyperus rotundus), and Corydalis yanhusuo.

IV. Case Study Sharing (Trigeminal Neuralgia)

Case 1: Mr. Wang, male, 53 years old. Initial consultation on February 20, 1968.

The patient has suffered from recurrent headaches for several years, with significant worsening over the past 10 days. A hospital diagnosed him with "trigeminal neuralgia," but treatment with painkillers and alcohol injections showed limited effectiveness.

Current presentation: bluish-gray complexion, pained expression, continuous moaning, holding his head. There is paroxysmal, needle-like shooting pain in the left temple and left eye socket. Triggering the "trigger point" can provoke pain episodes. The tongue is purplish-dark with a thin coating, and the pulse is thin, wiry, and forceful.

This is what Western medicine calls "trigeminal neuralgia," corresponding in Traditional Chinese Medicine to the pattern of blood stasis headache. The method of promoting blood circulation, removing stasis, and unblocking collaterals to relieve pain is applied, selecting the Modified Huoluo Xiaoling Dan formula.

Prescription: Chinese Angelica Root (Danggui), Prepared Frankincense (Zhi Ruxiang), and Prepared Myrrh (Zhi Moyao) 10g each; Salvia Root (Danshen), Szechuan Lovage Rhizome (Chuanxiong), Dahurian Angelica Root (Baizhi), Red Peony Root (Chishao), and Kudzu Root (Gegen) 30g each; Centipede (Wugong) 2 pieces, and Scorpion (Quanxie) 6g (added later during decoction). 3 doses, decocted in water, 1 dose daily.

Second consultation: February 23. The patient's headache was greatly reduced; touching the "trigger point" no longer induced pain. The tongue was still dark purplish, and the pulse was thready and wiry.

Continuing with the same formula, the previous amounts of Chuanxiong Rhizoma (Ligusticum chuanxiong) and Angelicae Dahuricae Radix (Angelica dahurica) were each reduced to 15g, while Processed Olibanum (Boswellia carterii) and Myrrha (Commiphora myrrha) were each reduced to 6g. After administering another five doses, the condition resolved.

Upon follow-up for several years, there was no recurrence of trigeminal neuralgia.

Note: In the early stages of using Huoluo Xiaoling Dan, Dr. Jiaben followed the original prescription, using raw Olibanum and Myrrha. However, after administration, patients experienced vomiting and poor appetite. Considering that both Olibanum and Myrrha are resins, when raw herbs are decocted to extract the juice, their volatile oil components can irritate the gastric mucosa, making it difficult for the stomach to tolerate, thus leading to vomiting and poor appetite. Later, they were changed to vinegar-processed Olibanum and Myrrha, reducing their volatile oil content. After administration, vomiting and poor appetite no longer occurred, resulting in a significant improvement in efficacy.

Case 2 Patient Li, male, aged 53. Initial consultation: January 22, 1983.

The patient had been suffering from headaches for nearly 10 days, and taking painkillers, alcohol nerve block, and several doses of traditional Chinese medicine had been ineffective. A hospital diagnosed "trigeminal neuralgia."

The left temple and left orbital area exhibited paroxysmal, burning, pulling pain. Triggering the "trigger point" could induce an episode. The left eye was slightly red with a sensation of burning heat and a foreign body. The patient reported a bitter taste in the mouth. The tongue was red with thin, yellow coating; the pulse was wiry and rapid.

The syndrome is attributed to liver yin deficiency with wind-fire disturbing upward. The treatment should be directed at calming the liver, dispelling wind, relieving urgency, and alleviating pain, using Modified Peony and Licorice Decoction.

Prescription: White peony root 60g, licorice root, tribulus terrestris, chrysanthemum flower, earthworm, and cicada slough 10g each, kudzu root and uncaria stem with hooks (added later) 15g each, and scorpion 5g (added later). Decoct in water for oral administration.

After taking 4 doses (with white peony root increased to 90g starting from the third dose), the patient experienced significant relief from headache. Left orbital numbness and itching persisted, along with a foreign body sensation in the inner canthus of the left eye. The tongue was red with a grayish coating in the center, and the pulse was wiry.

The liver channel wind-fire is gradually subsiding, so the previous dosage of white peony root is reduced to 30g, with slight adjustments to the remaining herbs, and another 3 doses are administered. The headache is essentially controlled, and orbital numbness, itching, and the sensation of a foreign body in the eye are alleviated.

Switched to Four Substances Decoction plus angelica dahurica, tribulus terrestris, cicada molt, silkworm, and chrysanthemum for treatment, administered for 5 doses. Except for itching at the original pain site, all other symptoms disappeared completely. Following the above method, another 3 doses were administered. Follow-up to date shows no recurrence.

Case 3 Li, female, 50 years old, civil servant. Initial visit on May 6, 2012.

The patient has been experiencing recurrent headaches for over 10 years, diagnosed as "trigeminal neuralgia" at a hospital. The pain has intensified over the past 5 days, and even painkillers have failed to alleviate it. She was referred to Dr. Zhu Jiaoben for treatment.

Presenting symptoms: dusky gray complexion, pained expression, continuous moaning, holding the head in hands, paroxysmal stabbing pain in the right temple and right orbital region. Touching the "trigger point" can provoke an episode of pain. The tongue is dark purplish-red with thin white coating, and the pulse is thready, wiry, and forceful.

Differentiation identifies blood stasis headache. Treatment focuses on activating blood circulation, dispelling stasis, unblocking collaterals, and relieving pain. A modified self-formulated "Pain Pattern Formula" is used.

Prescription: Processed Boswellia carterii (Ru Xiang) 10g, Processed Commiphora myrrha (Mo Yao) 10g, Salvia miltiorrhiza (Dan Shen) 30g, Angelica sinensis (Dang Gui) 10g, Paeonia rubra (Chi Shao) 30g & Paeonia alba (Bai Shao) 30g, Ligusticum chuanxiong (Chuan Xiong) 10g, Scorpio (Quan Xie) 10g (added later), Pueraria lobata (Ge Gen) 30g, Scolopendra subspinipes mutilans (Wu Gong) 3 pieces (added later), Angelica dahurica (Bai Zhi) 15g, Notopterygium incisum (Qiang Huo) 15g, Glycyrrhiza uralensis (Gan Cao) 3g. 3 doses, decocted in water for oral administration, one dose daily.

Second Consultation: May 8. The patient's headache has alleviated, and stimulation of the "trigger point" no longer induces headache episodes. The tongue remains purplish-dark, and the pulse is wiry. Maintaining the previous prescription with continued efficacy, modify the dosage of centipede to two pieces and administer for seven more doses.

After 2 years of follow-up, the patient's trigeminal neuralgia never recurred.

V. Commentary

Trigeminal neuralgia belongs to the categories of "facial pain," "headache," "head wind," and "migraine" in Traditional Chinese Medicine. The head is the convergence of all yang energies and the dwelling of clear yang, while the face is governed by the Yangming channel. The essence of qi and blood from the five zang and six fu organs all ascend to the head and face. Only wind can reach the head and face. Invasion by wind-cold, upward assault by wind-heat, emotional injury leading to liver qi stagnation, which transforms into fire and disturbs the clear orifices, or excessive heat in the Yangming channel with stomach fire flaring upward, ascending along the foot Yangming channel to attack the head and face—all these can cause stagnation of qi, blood, and meridians, leading to pain. This results in pain in the head and face. The basic pathogenesis involves wind and fire, and over time, phlegm and stasis obstructing the collaterals.

Mr. Jiaben said: Cases 1 and 3 are classified as blood stasis headaches, so the Huoluo Xiaoling Dan with modifications was used to achieve efficacy. Case 2 is a headache due to liver yin deficiency with wind-fire disturbing upward, so it was treated with the Shaoyao Gancao Tang.

In the latter formula, Paeonia and Glycyrrhiza are the sovereign herbs, leveraging their sour-sweet nature to transform yin, relieve urgency, and alleviate pain; Salvia miltiorrhiza serves as the minister herb to nourish blood and unblock collaterals; Scorpio and Lumbricus are used as assistant herbs to extinguish wind, relieve spasms, unblock collaterals, and relieve pain, assisting the sovereign herbs in pain relief; Angelica dahurica, pungent and warm, disperses and unblocks orifices to relieve pain; Ligusticum chuanxiong invigorates blood and promotes qi, with a nature that favors dredging and dispersing, ascending to the head and face, and reaching the skin and muscles externally. When combined, all these herbs work together to achieve the effects of dredging meridians and collaterals, extinguishing wind and relieving spasms, and invigorating blood to relieve pain.