Treatment of Headache with Chinese Medicine

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This article is an excerpt from the Clinical Handbook of Internal Medicine: The Treatment of Disease with Traditional Chinese Medicine, Volume 3 by Will Maclean and Jane Lyttleton. While the book also contains sections that discuss herb and formula recommendations, for compliance reasons those sections cannot be presented by Mayway. Please see the book for this information.

Headache (tou tong 头痛）is pain in the head. Almost everyone will experience a headache at one time or another. As an isolated event in response to some postural, physical or emotional state, a headache is part and parcel of life. When persistent or recurrent, or when they interfere with normal functioning, headaches suggests chronic imbalance that requires intervention.

The headaches likely to bring a patient into the Chinese medicine clinic are the chronic, recurrent types. Most chronic headaches have an internal and an external component. What this means is that the underlying internal imbalance is frequently complicated by pathological (myofascial) lesions in the soft tissues of the neck and upper back. These lesions are associated with specific changes in muscle architecture, and can be felt as tight knots or painful bands of tissue. These lesions can cause pain to be referred to various areas of the head, and are commonly known as trigger points. Trigger points in the muscles of the neck and upper back are a common finding in patients with chronic headaches. Trigger points can develop in response to the underlying pathology, or may develop independently due to mechanical and postural forces. In either case, successful treatment of chronic headaches usually involves both constitutional treatment and the removal of as much tension and trigger point activity as possible.

ETIOLOGY
External pathogens
Invasion by external pathogens is a common cause of acute, usually self limiting headaches. Wind, cold, damp and heat, either singly or in combination may be involved. The taiyang channels of the back of the neck are most commonly targeted as they are the most exposed to the environment and the first point of contact between the pathogen and the host. In most cases, these headaches will be accompanied by exterior signs and symptoms, but occasionally the headache may appear before the onset of other symptoms. Each pathogen produces a characteristic type of headache, and may affect different parts of the head. The headache is the result of disruption to the distribution of qi and blood through the superficial tissues of the head and neck by the pathogen.

Emotional Factors
Emotions are significant contributors to both acute and chronic headaches. Liver qi constraint from unexpressed frustration, anger, worry or other internalized emotion, leads directly to the common tension headaches that afflict a large proportion of humanity. Chronic qi constraint, in turn, sets the scene for the development of more serious pathology, such as blood stasis, yin deficiency with ascendant yang and Liver wind. In addition, chronic qi constraint can weaken the Spleen and lead to qi and blood deficiency, damp and phlegm. Prolonged qi constraint also contributes to the chronic muscle tension in the upper back and neck that leads to the development of trigger points.

Some emotional states may weaken the Spleen and Lungs and lead to qi deficiency. Qi deficiency, in turn, can be complicated by excess pathology in the form of phlegm damp or qi constraint. Worry, obsessive thinking or rumination deplete Spleen qi or cause Liver Spleen disharmony. Grief, prolonged sadness or bereavement can weaken the Lungs and deplete Lung qi. Weak Lung qi loses the ability to restrain the Liver through the controlling cycle (metal controlling wood) which encourages both qi constraint and the chaotic ascent of qi.

Diet
The diet is a common contributor to headaches. Insufficient food or lack of protein can lead to qi and blood deficiency. Foods or dietary habits that weaken the Spleen, such as raw and cold foods, and restrictive or rigid diets, can lead to qi and blood deficiency and the generation of damp and phlegm. An excess of sweet, oily, rich food and dairy products directly introduces phlegm damp into the body. Some medications weaken the Spleen, deplete Spleen yang qi, or create damp and phlegm when used inappropriately. These include heat clearing herbs, hypoglycemic agents, antihypertensive drugs, laxatives and antibiotics. Excessive reliance on analgesics can damage Stomach and Liver yin.

Overconsumption of heating foods, in particular red wine and spirits, chocolate, coffee, shellfish, chillies, cheese and some spices can heat the Stomach, Liver and Gallbladder, leading to heat or fire patterns.

A common and often overlooked cause of headache is dehydration. This is seen in those who do manual or outdoor work, as well as those who work in hot environments or in the desiccating environment of air conditioned buildings.

Overwork
Working excessively long hours or laboring to the point of exhaustion depletes Spleen and Kidney yang qi. Insufficient sleep depletes Heart and Kidney yin. Headaches are quite common in people who expend lots of mental energy while being largely sedentary, a frequent finding in students, academics and office workers. This is due to the combined effects of qi and blood deficiency, the creation of damp as a result of qi deficiency, and the postural stresses associated with prolonged sitting. In addition, excessive use of the eyes, in combination with working long hours or working at night, depletes Liver blood.

Constitution
Chronic headaches can be associated with constitutional or inherited imbalances. Migraine headaches often run in families, and many patients report a history of headaches that start from a young age. This may involve aspects of Kidney jing deficiency and subsequent yin deficiency causing ascendant yang, or an inherited tendency to phlegm damp, qi constraint or qi and blood deficiency.

Trauma
A fall or blow to the head is a common cause of blood stasis type headaches. The headaches may not necessarily appear immediately following the trauma, but can occur months or years later, initiated by another illness, or a decline in general health and circulation.

Trigger points and mechanical stress
Trigger points (TPs) are focal contracted and irritated areas within a muscle that produce pain signals. Pain is referred to a location some distance from the site of the trigger point. Muscles of the neck and upper back are especially prone to develop trigger points and frequently refer pain to specific regions of the head. TP’s are characterized by an area of focal tenderness and knots within a tight band of contracted muscle and can be easily located by palpation.

Many chronic types of headache have both a constitutional and muscular component. Some conditions, notably the Liver patterns (qi constraint, ascendant yang and wind) and yin and blood deficiency patterns, predispose patients to the formation of trigger points. The resulting trigger points then become a source of pain in the head themselves, and overlapping patterns of pain may emerge. For a thorough discussion of trigger points, see Travel and Simons (1983), Legge (2010) and Baldry (1993).

Trigger points can develop because of mechanical stress, as the result of internal pathology, or a mixture of both. The pathology most likely to produce TPs is associated with Liver pathology, in particular Liver qi constraint and related complications, and deficiency of Liver blood and yin which fails to nourish the muscles and sinews, leaving them prone to mechanical strain and injury.

The mechanical causes of TP formation include sudden unaccustomed overload of a muscle, traumatic injury, repetitive activity or postural stress. Mechanical stresses that specifically give rise to headaches include postural stress associated with poorly designed furniture, sitting hunched for hours in front of a computer, a cramped sleeping position, an excessively soft or high and hard pillow or prolonged head extension while engaged in a task requiring an awkward orientation. The muscles implicated in headaches are noted in Boxes 9.5-9.8.

Once trigger points have formed, they generally persist unless actively treated. Many people harbor latent TPs that can be activated by seemingly trivial events such as coughing or sneezing, overexertion, a long drive or sudden rotation of the head.

PATHOLOGY
There are two mechanisms of headache production, those associated with deficiency and those associated with excess. These two types produce quite different types of headache.

The excess types of headache are more severe, and can be debilitating. They are caused by obstruction to the circulation of qi and blood by a pathogen. The nature of the obstructing pathogen has a direct bearing on the quality of the pain. The more substantial the obstruction, the more intense the headache. Trigger point activity in associated tissues is common.

The deficient types of headache are due to insufficient qi, blood, yin or yang reaching the head. They are mild to moderate and dull, and are associated with mental and physical fatigue. Mixed deficiency and excess headaches are common, with some patients experiencing both at the same time, or sequentially. A common example is the persistent dull headache of yin and blood deficiency which occasionally yields to the intense and splitting headache of ascendant yang.

TREATMENT
Treatment of the acute headache aims at immediate relief with the use of acupuncture to disperse stagnation, deactivate trigger points, dispel wind and so forth, or with swift acting herb decoctions and prepared medicines. Between episodes the treatment focuses on the underlying condition. As a general rule, headaches due to deficiency, in particular blood and yin deficiency, respond best to herbal therapy, while the Liver patterns respond well to regular acupuncture, massage and deactivation of associated trigger points. Blood stasis patterns can do well with acupuncture, but will often need herbs to obtain a sustained result. Headaches due to external pathogens usually respond quickly to both herbs and acupuncture.

Biomechanical and ergonomic factors need to be addressed. Sleeping position, pillow height, computer keyboard and screen placement, office furniture and couch design are frequent factors in chronic headaches, regardless of the systemic pathology also present.

Selection of acupuncture points
Acupuncture points are selected on the basis of the pattern involved, the location of the headache and the presence of trigger points. During a headache, the main points will be selected from those that influence the location of the headache (Boxes 9.5-9.8). In between headaches, points are selected primarily on the basis of the diagnostic pattern. Points can be selected on the basis of their specific effects on headache (Table 9.1, p.419-420 of Clinical Handbook of Internal Medicine, Volume 3 ). Trigger points, when present, should be treated until they resolve.

Manual therapy
Massage and passive mobilization of the neck and upper back are helpful for alleviating muscular tension and deactivating trigger points. Strong massage is most suitable for the excess patterns. Patients with blood or yin deficiency patterns should be treated gently, as deep massage can irritate the muscles, aggravate tension and trigger points, and worsen the headache.

Hot Spot therapy
Hot spot therapy (see Appendix 2, p.923 of Clinical Handbook of Internal Medicine, Volume 3 ) is a method of self treatment of trigger points done at home in between formal treatment sessions. Hot spot therapy is particularly useful for Liver qi constraint and ascendant yang patterns. The most common location to find active trigger points potentially contributing to headache, is in the paraspinal muscles between T3-Tl0.

Hot spot therapy is not suitable for yin and blood deficiency due to the characteristic irritability of the tissues of the neck and upper back. Headaches and muscular pain of a deficiency type can be aggravated by hot spot therapy.

Medications
The following pharmaceutical medications are commonly used for headaches. Patients with chronic headaches will often be taking multiple medications, both preventively and for acute episodes. The use of preventive medication may mask the underlying pattern and can impede diagnosis and treatment. As treatment progresses, the aim should be to reduce all medications, including Chinese herbs, but this should be done slowly, following the patients decreasing requirements as their condition improves. Withdrawal of some medications can lead to rebound headaches if done too quickly.

Analgesics and Non-Steroids Anti-inflammatory Drugs (NSAIDS)
This group includes aspirin, paracetamol, indomethacin, iboprufen, naproxen and diclofenac, the most common medications used for common headaches, and widely available over the counter. In Chinese medical terms they tend to be cooling and dispersing to qi, yin and blood. Overuse may damage Liver and Stomach yin.

Ergotamine (Cafergot, Ergodryl)
Ergotamine is used at the onset of a migraine headache. It produces vasoconstriction peripherally, and in high doses can damage peripheral epithelium and contribute to blood stasis, thrombosis and gangrene.

Pizotifen (Sandomigran)
Used to prevent migraine headaches, pizotifen is a serotonin antagonist and also has some activity as an antihistamine. Side effects include dry mouth, drowsiness, increased appetite and weight gain. Pizotifen is pungent, warm and dispersing, and may disperse and damage zheng qi and yin.

Sumatriptin (Imigran)
A strong drug used at the onset of migraine. Used frequently, it can lead to increased frequency of headache. Sumatriptin is pungent, warm and dispersing to qi and yin. Side effects include flushing, feelings of heat, weakness and fatigue.

Please see William Maclean’s Clinical Handbook of Internal Medicine, Volume 3 for a detailed discussion of herb and formula recommendations. For compliance reasons those sections cannot be presented by Mayway.

 Bio: William Maclean, M.Sc Chin. Med. is an internationally renowned practitioner, teacher and author from Australia, with 25 years of clinical experience in the field of Chinese medicine. Will teaches in the Masters programs at the University of Sydney and University of Technology Sydney, and lectures to students and practitioners around the world. In addition to his long years in practice, Will is the author (with Jane Lyttleton) of the Clinical Handbook of Internal Medicine series Volumes 1, 2 and 3, the Clinical Manual of Chinese Herbal Patent Medicines (revised version coming soon!), and the recently published Clinical Handbook of Chinese Herbs: Desk Reference.

Books by William Maclean

Clinical Handbook of Internal Medicine, Vol. 1, Lung, Kidney, Liver, Heart - William Maclean, Jane Lyttleton

The first of a 3-volume TCM clinical guide, covering Lung, Kidney, Liver and Heart disorders. Within each organ’s section, pathologies are organized by established TCM patterns within biomedical categories. All disorders are discussed with reference to etiology, pathophysiology, clinical features, treatment principle, prescription, modifications, patent medicines, applicable acupuncture points and clinical notes. Where applicable, variations and additional prescriptions are referenced. In addition, appendices contain information on original unmodified formulas, processing methods, delivery methods, herbs contraindicated during pregnancy, incompatible and antagonistic herbs, toxic substances, and medicinals derived from endangered species and animals. A comprehensive and intuitive index makes it easy to search for topics by biomedical application, formula name or TCM pattern.

Clinical Handbook of Internal Medicine, Vol. 2, Spleen and Stomach - William Maclean, Jane Lyttleton

The second of a 3-volume TCM clinical guide, with in-depth analysis of more than 20 common disorders affecting the Spleen and Stomach. Each pattern is discussed from the perspective of its presentation and treatment in a Western context, with insights, practical advice and clinical tips relevant to Western patients. Keys to diagnosis and pattern identification accompany major disorders. Disorders are discussed with reference to etiology, pathophysiology, clinical features, treatment principle, prescription, variations, modifications, patent medicines, applicable acupuncture points and clinical notes. The clinical notes section offers general prognoses to help elucidate the kind of results that may be reasonably expected when correct treatment is applied, as well as a general estimate of the length of treatment required. As an added benefit the text includes a section on diet which includes information on what foods help treat common TCM patterns as well as a section on the properties and TCM actions of common foods.

Clinical Handbook of Internal Medicine, Vol. 3, Qi, Blood, Fluid, Channels - William Maclean, Jane Lyttleton

This is the final volume of a 3-volume TCM clinical guide. It focuses on diseases of qi, blood, and fluids, and contains chapters on abdominal masses, blood stasis, colds and flu, depression, diabetes, edema, fainting, fits and funny turns, acute fever, persistent and recurrent fever, gallbladder disorders, headache, hysteria, neck lumps, numbness, obesity, painful obstruction (bi), phlegm disorders, purpura, sweating, thin mucus syndromes, and tiredness. All disorders are discussed with reference to etiology, pathophysiology, clinical features, treatment principle, prescription, modifications, patent medicines, applicable acupuncture points and clinical notes. A comprehensive and intuitive index makes it easy to search for topics by biomedical application, formula name or TCM pattern.

The Clinical Manual of Chinese Herbal Patent Medicines - WillIiam Maclean, Kathryn Taylor

The extensively revised second edition (August 2003) of the Clinical Manual of Chinese Herbal Patent Medicines is an essential addition to the desk and bookshelf of all practitioners and students interested in using patent medicines. One nice feature of the text is its use of small icons in the left margin to highlight useful information. Each formula is discussed in terms of its TCM Actions, Biomedical actions, Indications, Composition, Combinations, Dose and Method of Administration, and Cautions and Contraindications. A feature that facilitates quick reference is the authors’ use of simple line drawings to illustrate the key symptoms and signs for each formula/pattern. These are often expressive of the emotional and psychological characteristics that match the pattern indicated. The text also includes: - An intuitive 75 page index, complete with listings for both biomedical and TCM disorders. - Tables of comparisons between similar formulas designed to aid differentiation. - Potential herb drug interactions laid out in table form. - A glossary describing the TCM medical terms used in the text in clear language.

Clinical Handbook of Chinese Herbs - William Maclean

Proficiency in the prescription of Chinese herbs depends not only on good diagnosis but on an intimate knowledge of the raw materials. This in turn depends on being able to discriminate the fine points of difference between the similar herbs within a group, and a deep understanding of the unique characteristics of each herb. This volume of comparative charts is designed to aid the student or the busy practitioner in selecting the optimal medicinals for their patients. Each table describes the characteristics of a group of herbs, including extensive indications with relative strengths of action and function, the domain, flavor, nature, and dosage guidelines. The tables and text in this book will facilitate efficient comparative study for the student, as well as make clear the fine points of discrimination for the experienced practitioner. Easy to use, with clear and accurate tables comparing all the main herbs used in a modern clinic, this tome is a practical assistant to the complex world of Chinese herbal prescription.