Case Study: 53y.o Female, life long debilitating headache resolved in one week with Chinese Medicine

She came to me to treat life long headache that she had had everyday for as long as she can remember.

Her headache was on the front of the head, side of the head, back of the head and top of the head. When she has a migraines, they usually started from the right temporal region, however, she could have regular headaches in both side. There is also throbbing nature in the temporal headache

Her headache was worsened with certain weather such as cold and damp day, with certain foods as she had digestive issues as well, and with stress and fatigue. She said the headache was sometime better with use of essential oil and pain relief medicines such as ibuprofen.

Other relevant symptoms

  • low energy 5/10
  • feel cold and warm (she feels cold until she has a hot flash)
  • poor body temperature control (always too hot or to cold)
  • upper body is warm and lower body cold
  • hands and feet cold
  • hot flash
  • disliking being exposed to wind, cold and damp weather, humid hot (like Ontario summer)
  • spontaneous sweat and night sweat
  • running nose
  • sinus congestion
  • neck and shoulder tightness and pain
  • constant low back pain that is better with resting,
  • hip pain that is better with exercise but cannot over do it
  • leg muscle clamps (once a month)
  • high pitch tinnitus,
  • bitterness in the mouth
  • cough and phlegm in a morning which is yellow phlegm
  • bleeding gum
  • dry mouth
  • throbbing headache
  • thirst with no desire to drink water
  • multiple thoughts in night time disturbing her sleep
  • hard to fall asleep, dreamful, disturbing dreams
  • light sleeper
  • wake up tired and heavy – it is better with exercise
  • constipation or dry stool w/o magnesium
  • sticky, smelly stools, occasional feeing of incompleteness
  • foggy head, confusion
  • poor mental stamina
  • occasional dizziness
  • bloating
  • frequent urination (water go through her)
  • poor night vision, dislike light during headache
  • history of uterine fibroids, dysmenorrhea (painful menstruation)
  • depression (not medically diagnosed but feeling of it)
  • sadness, grief, lack of joy
  • impatience, occasional uncontrollable anger
  • negative thinking
  • tongue – swollen, teeth marks, thick white tongue coating
  • pulse – thin weak hasty pulse

Her main concern is her headache that she gets in her forehead, right side which usually become migraines, and in the occipital area that radiates up. Frontal headache is due to damp retention in the frontal cortex. The dampness is often comes from the digestive system and it ascended to the head to cause the headache. Often dampy weather and pressure in the air can cause this type of headache. Pressure behind of eyes is the same logic. Side headache that happens in one side or both sides are usually from the poor circulation of Qi and the Blood, and can be triggered with stress, fatigue and at the end of the day. Occipital headache is from the tight muscle of the neck and the shoulder or from the getting a cold. Also top headache is often from the fatigue and Blood deficiency.

For her, her issues started from her digestion. Her poor digestion failed to digest food and undigested rheum started to accumulate. Eventually the dampness travelled up to her head and caused the frontal headache. Her ongoing stress impaired the Qi circulation and triggered the temporal headache. The stress and constant pain caused her muscle to be tense and that caused the occipital headache.

Diagnosis in Classical Chinese Medicine: Tai Yang, Shao Yang, Yang Ming, Tai Yin and Blood deficiency and the stasis.

Formula 1: Da Chai Hu Tang – With her temporal headache, one side tinnitus, bitter taste as well as poor digestion, she fits Shao Yang syndrome. With her difficulty in her bowel movements and bloating as well as her blood deficiency indicates for Da Chai Hu Tang.

Formula 2: Gui Zhi Fu Ling Wan – The history of fibroids and painful menstruation is the sign of blood stasis. Also her emotional challenges, warmth in the body and again her difficulties in defecation fits Gui Zhi Fu Ling Wan.

Modification: Shi Gao (for irritability, bleeding gums and dry mouth), Sun Zao Ren (for her difficulties in falling asleep), Chuan Xiong (for her headaches and is a part of Suan Zao Ren Tang), Zhi Zi (for her negative thinking and feeling of “stuck in ife”), Long Gu & Mu Li (to stop spontaneous and night sweating), Jie Geng (sinus congestion)

Chai Hu 12, Huang Qin 10, Ban Xia 18, Zhi Shi 10, Bai SHao 20, Da Zao 20, Sheng Jiang 15, Zi gan cao 6, Da Huang 6, Gu ZHi 15, Fu Ling 20, Chi Shao 15, Mu Dan Pi 10, Tao ren 10, Shi Gao 45, Suan Zao Ren 20, Zhi ZI 10, Jie Geng 12, Long Gu 30, Mu Li 30, Chuan Xiong 6

Scalp Acupuncture: Du 20, and Liver lines (on her temples)

Body Acupuncture: Wheel of Life (RN12, 6, 4, ST25, 21), ST36, GB34, SJ5, SJ6, LI4, LR3, SP9, Hand Shao Yang Water (to nourish KD water)

Result: After her first week dose of herbs and the acupuncture treatment, her headache disappeared. Also her night sweating and tinnitus disappeared. Back/knee pain, alternating chills and warmth of body temperature improved. her emotion and cognition as well as bloating is about 50% improved. Sinus congestion still fully remained.

Follow-up treatments: same acupuncture + SJ2. Same herbs with increased Jie Geng.

Every week, she shows improvements. She is enjoying her life without headache at all!!

Published by Yumi Ridsdale R.TCNP. R.Ac

From Japan. Living in Canada since 2001. I am a registered practitioner of Chinese Medicine with special interest in Classic herbal therapies.

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