The Treatment of Headaches with Acupuncture and Chinese Medicine


Chief Complaint: Headache

Medical History: Patient is a 56 years old male with general normal appearance, obesity: weight: 213 Lbs, height: 5’4″, red face and strong voice.

Chief Complaint: headache on and off for about 5 months, the pain is mostly “behind the eyes” and on parietal side of head, sometimes accompanied with nausea and vertigo, usually he has from 5 to 6 attacks/week. Blood tests are unremarkable, blood pressure in the range of 140 to 145/80 to 85 mmHg. MRI and X ray shown no abnormal. He recently eating a lot of “fast food” due to lack of time for meals at work. He drinks from 2 to 5 cups of coffee/day and 1 to 2 drinks (red wine) after diner. Lack of exercise and physical activities due to very tired and heaviness sensation in body. Taking medications for pain with temporary relief but having a lot of side effects (especially stomach problems).

Questioning exam: Patient always feels warmer than others, sometimes hot sensation on face, spontaneously sweating especially upper part of his body. Very strong appetite and prefers sweet, refined foods and big dinner with a lot of meat and starch. Bowel movement has tendency to be constipated, dry stools and incomplete feeling. He has infrequent urination with dark yellow color urine and scanty amount. Thirsty and prefer cold drinks and drink large amount of water during the day. Sleeping OK unless headache. He is easy to be angry and sometimes stress triggered the headache.

Pulse exam: Pulse:

Right side: superficial wiry, slightly rapid.

Left side: superficial slippery and slightly rapid.

Palpation: no abnormal lymph node palpable on neck, sub mandible and other areas. No stiffness of neck. Palpation exam on abdominal found no tenderness or abnormal mass. Liver and Spleen in normal shape and position, slight discomfort in epigastrium area aggravate by deep pressure. Other sensitive areas found on UB 18 + UB 19 areas especially on right side.

Tongue exam: Tongue

Body: deep red, especially on sides, swollen and rough sides with red spots on tip and sides of tongue.

Coating: thick yellow greasy coating from mid to rear of tongue, slight scanty coating front.

Movement: normal. (Bad breath). Patient has a red face and said it redder with red eyes when he has headache.

OM Diagnosis: Headache due to Liver Fire uprising and stagnated of Liver Qi

Damp-Heat accumulated in Middle Jiao Deficiency of Spleen Qi

Treatment Principle: Relief the pain

Extinguish Liver Fire, soothing Liver Qi

Eliminate Damp+ cool Heat in Middle Jiao

Strengthen Spleen Qi

Point Prescription: Local/symptomatic relief points: Du 20, Tai Yang, GB 14, GB 20 (sedate)

Liver Fire: LI 4, LV 2 (sedate )

Spleen/Damp: SP 9, Ren 12 (tonify)

Acupuncture treatment schedule: 3 treatments / week for the first week, 2 treatment for the second week. From the third week he just need to come back for maintenance and preventive treatment once every other week, then once per month after that.

Herbal Formula: Long Dan Xie Gan tang 35gms

Add: Fu Ling 5gms, Ze Xie 2gms, Xia Ku Cao 8gms.

Dosage for 5 days: take 2 time/day (between meals); 5gms/time (total)

Dissolve the extract herb into room temperature water and drink.

(herbs use as extract form, ratio 5:1)

After finish take 3 days break then go to next formula:

Jia Wei Xiao Yao San 50 gms

Add: Xia Ku Cao 6gms

Dosage for 7 days: take 2 times/day (between meals); 4gms/time (total)

Dissolve the extract herb into room temperature water and drink.

(herbs use as extract form, ratio 5:1)

Lifestyle Prescription: Dietary change: Avoid fat, greasy sticky (oily) foods, cold foods (ice-cream ….) and cold drinks especially with meals or right after meals.

Alcohol, coffee, refined foods (canned foods, well preserved foods, sweets…), spicy foods. Moderate eating time (avoid eat on the run, skip meal, doing something else while eating…).

Good foods: increase vegetable, especially vegetables with bitter taste. Fruit to replace refined sweets, more fish less meat but avoid other sea foods like: shrimp, crab (and other crustaceans).

Exercises: must have a regular exercise in a daily basic. The exercises need not too much at a time but need to be everyday. Walking outdoor is consider good if the weather not too hot or too damp.

Results: Patient responded very good to the treatment: headache significantly reduced to 1 mild attack for the 1st week of treatment (instead of 5 to 6) also he didn’t have to take pain pills for the headache. Even though patient can not fully conform the lifestyle change we recommended, he keep taking the provided herbs and acupuncture treatment as scheduled. He reported slight discomfort in head and stomach the following week and no significant symptoms the weeks after that. He also loosing weight with the treatment, feels more energy and easier to control his mood under stressful situations. Patient is very happy with the result and wants to come back for maintenance and preventive treatments as recommended.

Synopsis: Patient came to the treatment with a doubting state of mind of the effectiveness of acupuncture and herbs on his conditions. However, he stated that he felt very good right after the first treatment and that changed his mind. A comprehensive exam, diagnosis and treatment combine with proper change of lifestyle: diet, exercises not just help to treat the condition but also prevent it to come back.

Last modified: September 8, 2009  Tags: , ,  В·  Posted in: Neurological