Headache is pain in the whole or a part of the head. It is common in a variety of illnesses, including both acute and chronic illnesses. Depending on the underlying condition there may be other associated symptoms.
Etiology and Pathology
The location of headache is the head. It develops when the blood vessels go into spasm or lose their nourishment, so that the upper orifices become partially blocked. A number of pathological mechanisms can lead to the production of headache, including invasion by exogenous pathogenic evil and internal injury causing dysfunction of the liver, the spleen and the kidney, and blood stasis.
Headaches caused by Exogenous Evils. Through careless exposure, the climatic pathogenic evils may invade the vertex of the head, where they impede pure Yang-Qi. This may induce Qi stagnation and blood stasis, leading in turn to blockage of the vessels and channels. Wind is the captain of the climatic factors. According to the ancients, “Only Wind can reach the heights of the vertex.” Hence headache is most commonly due to exogenous Wind, alone or accompanied by the other climatic evils. Invasion by Cold-Wind induces gelling of blood, and blood stasis leads to blockage of the channels. Invasion by Heat-Wind disturbs the upper orifices. Invasion by Dampness-Wind impedes pure Yang-Qi and obscures the upper orifices.
Headaches caused by Internal Injury. Two types of liver injury commonly produce headache. In one, pent-up rage can easily trap liver-Qi causing it to stagnate; and stagnant liver-Qi can transform into Fire. In the other, deficiency of liver and kidney Yin permits liver-Yang to become hyperactive and to attack the upper orifices. There are also two main types of spleen injury producing headache. One is impairment of the spleen’s functions by improper diet or excessive strain. Impairment of transformation and transportation of nutrients by the spleen conduces to the production of endogenous Dampness and Phlegm, which can obscure the upper orifices. The other is insufficiency of the spleen due to chronic illness or following pregnancy and delivery. An insufficient spleen cannot deliver adequate nutrients for transformation into Qi and blood. As Qi and blood become deficient the channels lose their nourishment, and headache may result. Kidney related headache arises when depletion of kidney-essence or the sea of marrow leads to failure to nourish the vessels and meridians. This most commonly develops when the inherited constitution is weak or there is sexual overindulgence. Headache due to blood stasis occurs mainly when blood stasis and Qi stagnation result from traumatic injury or chronic illness affecting the vessels and channels.
Clinical Manifestation
Headache may be felt in the forehead, temple, vertex, occiput or the whole head. The quality of pain also varies. It may be tugging, jumping, burning, distending or stretching, heavy, stabbing, tearing, dizzying or vague. The pattern of headache is also variable. It may develop suddenly. It may be incessant or recurrent. It may be protracted with intermittent remissions and attacks. It may be fleeting or transient, or may last for hours, days, or even weeks. In severe cases, headache may be excruciating and accompanied by nausea or vomiting.
Key Points for Analysis
Exogenous Evil versus Internal Injury. Headaches due to attack by an exogenous pathogen tend to appear acutely and be more severe. There are also corresponding accompanying symptoms of the exterior. These are headaches of disease evil strength. Headaches due to internal injury tend to be gradual and chronic, with intermittent and recurrent attacks and remissions. These headaches may be of strength or deficiency, or mixed deficiency and strength.
Quality of Pain. Phlegm-Dampness induced headache is usually dizzying and has a tearing, tugging or distending quality. Blood stasis induced headache is usually lasting and has a stabbing quality; it also tends to be fixed in location. Liver-Fire induced headache usually has a jumping quality. Hyperactive Yang induced headache is usually sharp and has a distending quality. Headache induced by Qi or blood deficiency or deficiency of liver and kidney Yin is usually continuous and has a dull or empty quality.
Location of Pain. Headache due to deficiency of Qi and blood, or of liver and kidney Yin, tends to affect the whole head. Headache of hyperactive Yang tends to be in the occiput with radiation to the neck muscles. Headache of Liver-Fire tends to be in the temples. Headache due to illness affecting the Yangming Meridian tends to be in the forehead and supra-orbital bone. Headache due to illness affecting the Taiyang Meridian tends to be in occiput with radiation to the posterior neck.
Headache due to illness in the Shaoyang Meridian tends to be in both temples with radiation to the ears. Headache due to illness in the Jueyin Meridian tends to be in the vertex with radiation to the eyes.
Other Factors. Headache due to Cold-Dampness tends to fluctuate in severity with the weather. Headache due to Liver-Fire tends to be aggravated by emotional distress. Headache due to Qi and blood deficiency is often precipitated by overstrain. Headache due to deficiency of liver and kidney Yin tends to be aggravated by insomnia.
Herbal Treatment
Headaches caused by Exogenous Pathogenic Evils
Wind-Cold
Main Symptoms. Rapid onset headache of tearing quality, radiating to the neck and upper back; aggravated by wind and cold; and absence of thirst. The tongue coating is thin and white, and the pulse floating and tight.
Therapeutic Principle. Dispel Wind and disperse Cold.
Treatment. Chuanxiong Cha Tiao San (Ligusticum Powder). It has the following basic composition: chuanxiong (Ligusticum chuanxiong) 12 g, jingjie (Schizonepeta) 10 g, bohe (Mentha) 12 g, Qianghuo (Notopterygium) 3g, xixin (Asarum) 3g, baizhi (Angelica dahurica) 6g, gancao (Glycyrrhiza) 6g, and fangfeng (Saposh-nikovia) 3 g.
If the patient has chills without fever, omit bohe.
If Cold invades the Jueyin Meridian, marked by pain in the vertex, retching and salivation, use instead Wuzhuyu Tang (Evodia Decoction) augmented with processed banxia (Pinellia), gaoben (Ligusticum sinense) and chuanxiong (Ligusticum chuanxiong). The composition of Wuzhuyu Tang is as follows: wuzhuyu (Evodia), renshen (Panax), dazao (Ziziphus) and shengjiang (Zingiber). It is designed to invigorate Yang and strengthen the spleen, thereby preventing Yin-Cold from invading upwards.
Wind-Heat
Main Symptoms. Distending headache; if severe, splitting headache; fever, windaversion; thirst with desire to drink; constipation and dark urine. The tongue is red, with yellow coating. The pulse is floating and rapid.
Therapeutic Principle. Dispel Wind and cool Heat.
Treatment. Xiong Zhi Shigao Tang (Ligusticum-Dahurica-Gypsum Decoction). It has the following basic composition: chuanxiong (Ligusticum chuanxiong) 10 g, baizhi (Angelica dahurica) 10 g, juhua (Chrysanthemum) 6 g, shigao (gypsum) 10 g, gaoben (Ligusticum sinense) 10 g, and Qianghuo (Notopterygium) 10 g.
For high fever, omit Qianghuo and gaoben, which are warm and acrid, and add huangqin (Scutellaria), bohe (Mentha) and zhizi (Gardenia jasminoides), which are acrid and cool.
For constipation, add dahuang (Rheum palmatum) to promote defecation and purge Heat.
Wind-Dampness
Main Symptoms. Headache as though the head is being bound; heaviness in the body and limbs; anorexia; chest tightness; and difficulty with urination. The tongue coating is white and greasy, and the pulse is soft.
Therapeutic Principle. Dispel Wind and eliminate Dampness.
Treatment. Modified Qianghuo Sheng Shi Tang (Notopterygium Dampness-Defeating Decoction). The modified formula has the following composition: Qianghuo (Notopterygium) 10 g, duhuo (Angelica pubescens) 10 g, fangfeng (Saposhnikovia) 10 g, gaoben (Ligusticum sinense) 6 g, chuanxiong (Ligusticum) 10 g, manjingzi (Vitex trifolia) 10 g, and gancao (Glycyrrhiza) 6g.
If turbid Dampness has obstructed the middle-jiao, manifesting chest tightness, anorexia and loose feces, add cangzhu (Atractylodes), houpo (Magnolia) and chenpi (Citrus tangerina) to dry Dampness and unblock the middle-jiao.
Headaches due to Internal Injury
Hyperactive Liver-Yang
Main Symptoms. Distending headache, dizziness; restlessness, irascibility; restless sleep; subcostal pain; flushed face and bitter taste in the mouth. The tongue coating is thin and yellow, and the pulse is taut and rapid.
Therapeutic Principle. Calm the liver and subdue hyperactive Yang.
Treatment. Tianma Gouteng Yin (Gastrodia and Uncaria Drink).
If clinical conditions require it, longgu (fossil bone) and muli (Ostrea) may be added to enhance the formula’s ability to suppress hyperactive Yang.
If Liver-Fire blazes, with flushed complexion and red eyes, add longdancao (Gentiana) and xiakucao (Prunella).
If there is deficiency of liver and kidney Yin, with headache that is mild in the morning and severe in the evening and a taut and threadlike pulse, add shengdihuang (Rehmannia), heshouwu (Polygonum), gouqizi (Lycium) and moliancao (Eclipta) to nourish the liver and the kidney.
Kidney Deficiency
Main Symptoms. Headache that feels empty; often dizziness; aching weakness in the waist; lassitude, weakness; tinnitus; insomnia; and spermatorrhea or vaginal discharge. The tongue is red with scant coating, and the pulse is deep, threadlike and forceless.
Therapeutic Principle. Strengthen the kidney and nourish Yin.
Treatment. Da Bu Yuan Jian (Major Genuine Qi Restoring Decoction).
For marked spermatorrhea or vaginal discharge, add lianxu (Nelumbo nucifera), Qianshi (Euryale ferox) andjinyingzi (Rosa laevigata).
For headache accompanied by cold-aversion and cold limbs, it is appropriate to use You Gui Wan ((kidney-Yang-Augmenting Pill)) to warm-restore kidney-Yang.
Patients with headaches due to kidney insufficiency may routinely take Qi Ju Dihuang Wan (Lycium-Chrysanthemum-Rehmannia Pill) to nourish kidney-Yin.
Deficiency of Qi and Blood
Main Symptoms. Headache with dizziness, aggravated by exertion; palpitation of the heart, restlessness; spontaneous sweating; shortness of breath; lassitude, weakness; and a pale complexion. The tongue is pale, with a thin white coating. The pulse is deep, threadlike and feeble.
Therapeutic Principle. Tonify both QI and blood.
Treatment. Ba Zhen Tang (Eight Treasures Decoction).
If the clinical condition requires it, juhua (Chrysanthemum) and manjingzi (Vitex trifolia) may be added for their ability to enter the Liver Meridian and to enhance the actions of removing Heat from the head and the eyes.
Turbid Phlegm
Main Symptoms. Headache with mental clouding; chest and epigastric fullness; nausea and vomiting of sputum and saliva. The tongue coating is white and greasy, and the pulse slippery.
Therapeutic Principle. Dissipate Phlegm and normalize abnormal Qi flow.
Treatment. Banxia Baizhu Tianma Tang (Pinellia-Atractylodes-Gastrodia Decoction).
If gelled Phlegm has given rise to Heat, add zhuru (Phyllostachys nigra), zhishi (Citrus aurantium) and huangqin (Scutellaria) to cool Heat and dry Dampness.
Blood Stasis
Main Symptoms. Persistent headache, fixed in location and prickling in quality; or, history of traumatic injury to the head. The tongue is cyanotic or speckled with purpuric spots. The pulse is impeded.
Therapeutic Principle. Mobilize blood, eliminate stasis, open orifices and relieve pain.
Treatment. Tong Qiao Huo Xue Tang (Orifice-Opening Blood-Mobilizing Decoction).
If shexiang is not available, baizhi (Angelica dahurica) may be substituted.
For severe headache, add quanxie (Buthus), wugong (Scolopendra) that unblock meridians. However, these herbs should be stopped promptly as soon as there is therapeutic response.
Choice of Envoy Herbs
In the treatment of the various types of headache, different envoy herbs may be selected that guide the other herbs into the appropriate meridians, thereby enhancing the therapeutic effect.
For headaches in the Taiyang Meridian, Qianghuo (Notopterygium) and fangfeng (Saposhnikovia) are appropriate.
For headaches in the Yangming Meridian, baizhi (Angelica dahurica) and gegen (Pueraria) are appropriate.
For headaches in the Shaoyang Meridian, chuanxiong (Ligusticum) and chaihu (Bupleurum) are appropriate.
For headaches in the Taiyin Meridian, cangzhu (Atractylodes lancea) is appropriate.
For headaches in the Jueyin Meridian, wuzhuyu (Evodia) and gaoben (Ligus-ticum sinense) are appropriate.
For headaches in the Shaoyin Meridian, xixin (Asarum) is appropriate.
Acupuncture Treatment
Headaches caused by Exogenous Pathogenic Evils
Select the acupoints Baihui (GV-20), Taiyang (HN-5), Fengchi (GB-20) and Hegu (LI-4). Use filiform needles and apply the reducing method.
For frontal headache, add Yintang (HN-3).
For temporal headache, add Waiguan (SJ-5).
For occipital headache, add Tianzhu (BL-10).
For headache in the vertex, add Sishencong (HN-1).
Headaches due to Internal Injury
Hyperactive Liver-Yang. Select the acupoints Baihui (GV-20), Fengchi (GB-20), Taichong (LR-3) and Taixi (KI-3). Use filiform needles and apply the reducing method.
Kidney Deficiency. Select the acupoints Baihui (GV-20), Shenshu (BL-23), Taixi (KI-3), Xuanzhong (GB-39). Use filiform needles and apply the reinforcing method.
Blood Insufficiency. Select the acupoints Baihui (GV-20), Xinshu (BL-15), Pishu (BL-20) and Zusanli (ST-36). Use filiform needles and apply the reinforcing method.
Turbid Phlegm. Select the acupoints Touwei (ST-8), Taiyang (HN-5), Fenglong (ST-40) and Yinlingquan (SP-9). Use filiform needles and apply the reducing method.
Blood Stasis. Select the acupoints Ashi acupoints, Hegu (LI-4), Xuehai (SP-10) and Sanyinjiao (SP-6). Use filiform needles and apply both the reinforcing and the reducing methods.
Case Study
The patient was a 63-year old female who had headache with dizziness. The headache was spastic in quality and was worst in both temples. She also had palpitation of the heart, a bitter taste in the mouth, a red tongue with scant coating and a taut and threadlike pulse.
Diagnosis. Headache due to hyperactive liver-Yang causing upward disturbance.
Therapeutic Principle. Harmonize the liver and suppress hyperactive Yang.
Treatment and Course. The prescribed formula had the following composition: raw shijueming (Haliotis) 30 g, tianma (Gastrodia) 10 g, juhua (Chrysanthemum) 10g, xiakucao (Prunella) 15 g, yimucao (Leonurus) 15 g, gouteng (Uncaria) 10 g, jili (Tribulus terrestris) 10 g, manjingzi (Vitex trifolia) 10 g, chuanxiong (Ligusticum) 10 g, gaoben (Ligusticum sinense) 10 g, andniuxi (Achyranthes) 10 g. Note: shijueming was decocted first.
After six daily doses, the patient returned for follow-up visit. The temporal headache had lessened, with less spasm. Her eyes were irritated and had a burning sensation. She had epigastric fullness and pain. Her tongue was red, with a thin yellow coating. Her pulse was threadlike and taut. Further treatment continued to aim at harmonizing the liver and suppressing Yang, but also to regulate Qi and stop pain.
The new prescribed formula had the following composition: raw shijueming (Haliotis) 20 g, juhua (Chrysanthemum) 10 g, muzeicao (Equisetum hiemale) 10 g, jili (Tribulus terrestris) 10 g, baishaoyao (Paeonia) 10 g, zhiqiao (Poncirus trifoliata) 10 g, yanhusuo (Corydalis) 10 g, chuanlianzi (Melia) 10 g, chuanxiong (Ligusticum) 10 g, zisu root (Perilla) 10 g, and chaihu (Bupleurum) 10 g. Note: shijueming was decocted first.
After six daily doses, the patient recovered completely.
