Prana Gogia. DTD2 Term Paper.

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DTD 2 Term Paper

Prepared by Prana Gogia

For Diagnosis & Treatment of Disease 2 course. Faculty: Dr. McCoy L.
Pacific College of Oriental Medicine. CA.

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History
The Chief Complaint (CC): The patient is a 43 year old female with a chief complaint of
Temporal Headaches.
History of Present Illness (HPI):
The patient has been suffering from mild headaches from the age of sixteen. After the age of
twenty eight her mild headaches transformed into the severe left side temporal headache. They
start as mild non localized headache with dull, achy sensation of pain then within an hour they
shift into left sided, pulsating and debilitating temporal headaches. Headaches are not related to
menses. Light does not hurt them but smoke, sound, and strong smell aggravates their headaches.
They dont report any blurred vision or floaters. The temporal headaches are mostly left sided
and rarely ever right sided. Sometime patient wakes up in the morning with mild headache then
within couple of hours they transform into left sided throbbing temporal headache. In their active
episode of temporal headache patient feels irritable, tired, and restless and sometime bitter taste
in their mouth. The headache lasts for hours and sometime for couple days. Some of the triggers
observed by patient are:
Speaking for long hours (teaching class for four or more hours)
Cold head or wet hair
Cold feet for more than two hour
Cold weather or Winter season
Excessive standing for multiple hours

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Lack of caffeine for whole day (drinks only tea, no coffee)

Emotional Stress
Not enough sleep (usually needs min of 8 hours of sleep)
Past Medical History (PMH):
They had tonsillectomy in 1999 and laparoscopic hysterectomy 2011. Her menses were painful
with clots all days of the periods. PMS symptoms included painful low back pain, mood swings,
breast distention, and irritability.
Medications (MEDS):
They are currently not on any prescription medications. They take supplements for B12, folic
acid, Vitamin C and Calcium.
Allergies (ALL):
None noted.
Social History:
They do not consume any alcohol. They do not smoke and never did. Patient is married with fair
sexual history. The patient is very active teaches yoga, walks regularly, and dances for few hours
every week. They like cooking and being in outdoors. They do not like heavy or extraneous
sports.
Work History:
Her work is physically intensive. She teaches yoga and workshops at different locations. She
stands for long hours, speaks continuously and demonstrates various yoga postures for 6 to 8

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hours per day. Stress comes from juggling schedules and continuously thinking about finding,
signing and preparing for next class and/or workshop. Her daily schedule differs a lot and no
days have same schedule.

Obstetric History (if appropriate):

Patients menses started at the age of eleven. They never got pregnant by choice. Had multiple
uterine fibroids and went through partial laparoscopic Hysterectomy in Dec 2011. They still have
functioning ovaries.

10 Questions:

Temperature - prefers warm temperature. The hands and feet are cold on palpation.

Patients confirms that their feet are always cold

Sweat No night sweats and no abnormal sweating.

Appetite Good appetite. Eats three times / day

Diet - Eats lacto-vegetarian balanced diet. Does not eat raw foods, cold smoothies and

consumes minimal amounts of dairy products.

Thirst - feels thirsty and drinks at least 8 glass of water every day

Urination frequency depends on water and caffeine intake. No burning or any other

abnormal sensation.

Bowel Movement - regular two or more times /day and well formed.

Pain dull, achy at the start and in an hour turns into throbbing and debilitating. Some

time nauseating sensation. They also have chronic low back pain. Dull achy headache is 3 out of
10 and throbbing left temporal headache is of severity 8 out of 10.

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Onset cold weather, taxation, stress and not enough sleep

Location left temporal side of head extending anteriorly from just above inner canthus to

mastoid tip on left side.

Sleep normally great but is restless when in pain. They like to sleep for at least 8 hours /

day.

Menses- very heavy, with clots, painful, lethargy, low back pain, bloating, crankiness, but

no headaches unless they feel cold.

Alleviates / Aggravates: Cold, overwork, and stress aggravate and feel better with rest,

warm shower, and caffeine.

Pulse wiry, slow and thin, weak in right third position

Tongue swollen, pale, white coat

Physical Exam:
The patient is 5 1 weighs 158 lbs. Has bright clear skin with long dense hear. Her pulse is 78
beats / min. Blood pressure is 130/80.

Lab Results, Radiology Studies, EKG Interpretation, Etc:

None available. It would be helpful to see CBC with TIBC to rule out any blood iron deficiency.

Assessment:
TCM disease category:
The patients chief-complain falls in category of disease called tou tong (headache) specifically,
pian tou tong, one-sided headaches.

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Zang Fu diagnosis:
This is a case of Qi Xu headache leading to Liver Qi stagnation, with an underlying Kidney
Yang deficiency.

Zang Fu differential diagnosis:

The main zang-fu mechanisms of headaches involve the liver. If the liver becomes depressed, the
qi will become stagnant. Because qi is yang and the liver is a yin viscous, either this yang qi will
tend to follow the liver channel upward to the eyes and vertex or shift into the shao yang channel
to rise to the sides of the head, congesting and inhibiting the channels and vessels there. Because
the head is a bony box, counter flowing yang qi, heat or fire, and wind, arriving in the head, has
little or no exit. Therefore, they stagnate and congest, inhibiting the free flow of qi and blood,
thus causing pain. (Flaws & Sionneau, pg 366). The dull and achy sensation at the beginning that
is aggravated by exertion is an indication of an empty or deficiency condition. The throbbing
sensation with debilitating pain that makes patient irritable with nausea indicates full condition.
(Maciocia, pg 21).
In this case, the yang deficiency is apparent from the dull headache that is aggravated by taxation
and tiredness. The clinical manifestation of headache, accompanied by physical cold, cold
extremities, aching lower back, tiredness and fatigue are indications of Kidney Yang vacuity
Headache (Yan & Fischer, pg 168). The dullness of the headaches and the fact that they improve
by resting and warmth indicates that they are due to a qi deficiency, which in this case is from
kidney yang xu. The cold sensation and cold extremities with low back pain is also indication of
Kidney Yang deficiency. Liver Qi Stagnation accounts for the more severe aspect of the

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headache and the feeling of nausea is due to stagnant Liver-Qi invading Stomach preventing
Stomach-Qi from descending. This is a pattern of excess that is arising from underlying
deficiency.

Channel Diagnosis:
The primary channel involved in this case is Shao Yang that travels to the temporal side of the
head.

Etiology:
There are several factors ranging from cold, stress, overexertion, lack of sleep that triggers the
headache in this case, however, the underlying factor is Kidney Yang Xu and taxation. Taxation,
stress and cold deplete kidney yang qi.

Pathomechanism:
The headache from Liver-Qi stagnation is typically caused by anxiety and stress (Maciocia, pg
61). Liver-Qi Stagnation may also derive from Kidney-Yang deficiency. The Kidneys are the
source of all the Yin and Yang energies in the human body. There is a close interaction between
the Yin and the Yang of the Kidneys and the two cannot be separated. Thus, it is not uncommon
for deficiency of both Kidney-Yin and Kidney-Yang to appear simultaneously. Of course the
deficiency of Yin and Yang within the Kidneys is never in a 50/50 proportion, but one is always
predominant. The tongue-body color always shows the predominant deficiency: if it is Pale it
indicates a predominance of Kidney-Yang deficiency and if it is red it indicates a predominance

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of Kidney-Yin deficiency (Maciocia, pg 41). In this case, the pale tongue with white coat
indicates kidney yang deficiency leading to qi xu and liver qi stagnation.

Biomedical differential diagnosis:

The Patient has not been diagnosed by a physician. The Western medical diagnosis of migraines
is largely based on the patients personal and family history and the presenting signs and
symptoms plus an absence of any intracranial pathological changes (Flaws & Sionneau, pg 365).
Based on signs and symptoms this is case of Tension Headache. Tension headaches are the most
common type of headaches among adults. They are commonly referred to as stress headaches. A
tension headache may appear periodically ("episodic," less than 15 days per month) or daily
("chronic," more than 15 days per month). An episodic tension headache may be described as a
mild to moderate constant band-like pain, tightness, or pressure around the forehead or back of
the head and neck. These headaches may last from 30 minutes to several days. Episodic tension
headaches usually begin gradually, and often occur in the middle of the day. The "severity" of a
tension headache increases significantly with its frequency. Chronic tension headaches come and
go over a prolonged period of time. The pain is usually throbbing and affects the front, top, or
sides of the head. Although the pain may vary in intensity throughout the day, the pain is almost
always present. Chronic tension headaches do not affect vision, balance, or strength. Tension
headaches are usually triggered by some type of environmental or internal stress. The most
common sources of stress include family, social relationships, friends, work, and school. (Neil
Lava).

Red Flags:

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There are no red flags in this case. The red flags to look for will be neurological symptoms such
as fever or abnormalities in breathing, pulse, or blood pressure, infection, nausea, vomiting,
changes in personality, inappropriate behavior, mental confusion, seizures, loss of consciousness,
excessive fatigue, wanting to sleep all of the time, high blood pressure, muscle weakness,
numbness, or tingling, speech difficulties, balance problems, falling, dizziness, vision changes
(blurry vision, double vision, blind spots). These signs and symptoms may indicate diseases of
the brain or nerves that may also cause headaches and migraines, such as multiple sclerosis.
Some of them may also indicate physical or structural abnormality in the brain that may cause
headache, such as: Tumor, Abscess (an infection of the brain), Hemorrhage (bleeding within the
brain), Bacterial or viral meningitis (an infection or inflammation of the membrane that covers
the brain and spinal cord), Pseudotumor cerebri (increased intracranial pressure), Hydrocephalus
(abnormal build-up of fluid in the brain), Infection of the brain such as meningitis or Lyme
disease, Encephalitis (inflammation and swelling of the brain), Blood clots, Head trauma, Sinus
blockage or disease, Blood vessel abnormalities, Injuries or Aneurysm . (Karriem-Norwood
Varnada).

Treatment
Treatment principle:
Zang-fu Treatment principle: Warm and supplement Kidney and relieve pain. In this case,
although the severe headaches are due to Liver Qi Stagnation, the pattern is still primarily one of
deficiency. For this reason, the treatment is aimed primarily at warming Kidney yang and
relieving pain.
Channel Treatment Principle: Temporal headache are associated with Shao Yang channel.

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Acupuncture treatment:
Shao Yang Channel Treatment, (points combination, Maclean & Lyttleton, pg 416, and point
indication from Deadman):
Local points:
GB-20 (fengchi), Downbears Yang from the head and eyes.
ST-8 (Touwei), Eliminates wind and alleviates pain. Headache, splitting headache with chills and
fever, dizziness, vomiting.
GB 8 (Shuaigu), Clears Gall Bladder channel heat benefits sense organs, head and neck.
Taiyang, Benefits, headache, eye diseases, deviation of the eyes and mouth.
Distal points:
SJ 5 (Waiguan) + GB 41 (Zulinqi): Benefits the head and ears. Clears heat. Activates the channel
and alleviates pain. Spreads Liver qi. Clears the head and benefits the eyes.
LIV 3 (Taichong) + LI4 (Hegu): Spreads Liver qi. Subdues Liver yang and extinguishes wind.
Regulates the face, eyes, nose, mouth and ears
Zang-fu treatment (points combination from Wu & Fischer, pg 169, and point indication from
Deadman):
GB - 20 (fengchi) Downbears Yang from the head and eyes.
UB - 23 (shen shu) Tonifies the Kidneys and fortifies yang.
RN - 4 (guan yaun), Tonifies and nourishes the Kidneys.
KID - 3 (tai xi) Yuan Source point of the Kidney channel. Tonifies Yin.
DU - 4 (ming men) Tonifying Kidney point. Tonifies Kidney Yang.

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DU - 23 (shang xing) Eliminates wind, benefits the head and face. Calms the spirit.

Herbs:
Herbal base formal used will here be for Kidney Yang deficiency, which is You Gui Wan [Right
Restoring Pill], (Wu Yan & Fischer pg 169). It contains following herbs:
Shu di hunag, Rehmanniae Radix 24g
Shan yao, Dioscoreae Rhizoma 12g
Shan zhu yu, Corni Fructus 9g
Gou qi zi, Lycii Fructus 12g
Lu jiao jiao, Cervi Gelatinum Cornu 12g
Tu si zi, Cuscutae Semen 12g
Du zhong, Eucommiae Cortex 12g
Dang gui, Angelicae Sinesis Radix 9g
Rou Gui, Cinnamomi Cortex 6g
Zhi fu zi, Processed Aconiti 6g
The above formula will be modified to address Liver qi Stagnation:
Bo He Herba Menthae - 3 g
Chai Hu Radix Bupleuri - 9 g
Cheng Xiang Lignum Aquilariae - 6g

Explanation of formula: Rou Gui (Cortex Cinnamomi) and Fu Zi (Radix Aconiti Lateralis
Praeparata) warm Kidney yang and raise ming men (life gate) fire. According to the yin -yang
theory of mutual dependence, in order to effectively tonify Kidney yang, Kidney yin must also

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be nourished. Thus, this formula uses Shu Di Huang (Radix Rehmanniae Praeparata), Shan Zhu
Yu (Fructus Corni), Shan Yao (Rhizoma Dioscoreae), and Gou Qi Zi (Fructus Lycii) to nourish
Kidney yin and replenish jing (essence). Lu liao liao (Colla Comus Cervi), Tu Si Zi (Semen
Cuscutae), and Du Zhong (Cortex Eucommiae) warm Kidney yang, replenish jing, and tonify the
Liver and Kidney to strengthen the bones and tendons. Dang Gui (Radix Angelicae Sinensis)
tonifies the blood and nourishes the Liver.
Rou Cui (Cortex Cinnamomi) and Fu Zi (Radix Aconiti Lateralis Praeparata) Warms and
Kidney yang and raise ming men fire. Shu Di Huang (Radix Rehmanniae Praeparata), Shan Zhu
Yu (Fructus Comi), Shan Yao (Rhizoma Dioscoreae) and Cou Qi Zi (Fructus Lycii) nourish
Kidney yin and replenish jing. Lu Jiao Jiao (Colla Comus Cervi), Tu Si Zi (Semen Cuscutae),
and Du Zhong (Cortex Eucommiae) warm Kidney yang, replenish jing, and tonify the Liver and
Kidney. Dang Cui (Radix Angelicae Sinensis) tonifies the blood and nourishes the Liver (Chen
& Chen, pg 679).

Explanation for Modification: Bo He and Chai Hu eliminate stagnation of Liver-Qi. Although

Chai Hu is, strictly speaking, contraindicated in headaches, the overall effect is is such that it can
be used for headaches from Liver-Qi stagnation, especially with the addition of Chen Xiang
Lignum Aquilariae which moves Qi and has a strong effect in subduing rebellious, for this
reason, it is suitable to treat headaches (Maciocia, pg 63).

Herb drug interaction: One study found You Gui Wan to be effective in reversing corticosteroidinduced immune suppression in rats. The mechanism was attributed to the "yang-tonifying"
effect of the formula, as subjects who use steroids for a long period of time often have "yang

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deficiency" signs and symptoms, such as edema, swelling, and immune-suppression (Chen &
Chen, pg 680).

Lifestyle recommendations:
A diagnosis of Kidney Yang deficiency means that the reserves that warm the body are weakened
and unable to perform their functions. A diet that includes nourishing and warming foods can
help to preserve and restore Kidney Yang. Digestion in TCM is viewed metaphorically like a pot
of soup sitting on a fire. It is the bodys metabolic fire that cooks ingested food, allowing to
body to extract nourishment from the food. With Yang deficiency, this fire is weakened and
unable to perform its needed functions. For a Kidney Yang deficiency diet it is best to consume
fresh foods that are cooked. Food that is lightly prepared helps to ensures that nutrients are
preserved and are more readily digested and absorbed. Also eating smaller meals more frequently
and enjoying meals by sitting down to relax while you eat and chewing thoroughly to savor
flavors is recommended. Meals should consist largely of easily digested complex carbohydrates
like grains and starchy root vegetables. 30 - 40% of the diet should be comprised of cooked
vegetables and proteins should comprise only 10 - 20% of the diet. Warming foods and spices
like animal meats and cinnamon are recommended. Cold natured foods such as raw vegetables
need to be avoided to avoid further damaging the Yang. Specific foods for Kidney Yang
deficiency are cooked grains, soups, rice, oats, roasted barley, sweet rice, spelt parsnips, sweet
potatoes, onions, leeks, pumpkin, squash, carrots, yams, peas, garlic, turnip, stewed fruits chick
peas, black beans, walnuts, chestnuts, pistachios lamb, beef, chicken, lamb, veal, goat, venison
and beef kidneys mackerel, tuna, anchovy, prawns, mantis shrimp, salmon, mussels black pepper,
fresh ginger, dry ginger, cloves, cinnamon, cardamom, rosemary, turmeric, star anise, nutmeg,

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fenugreek, chives, spring onions, fennel, molasses, rice syrup, barley malt, dates. Foods to
restrict or avoid are raw fruits, raw vegetables, sprouts, spinach, salads soybeans, tofu, soy milk,
glutinous rice, seaweeds dairy (cheese, milk, yogurt, etc.) cold foods like ice cream or smoothies
iced drinks including ice water excessive salt, vinegar and refined sugars (Saper James, 2006).
Along with diet change, patient is recommended to create a work-life balance to reduce stress
and avoid the triggers that start the headache or cause taxation, such as, exposure to external cold
environment.

Prognosis:
The patient has been suffering for few years and hence it is chronic disease that involves Kidney
Yang deficiency. However, they have not yet experienced signs and symptoms of Kidney yin
deficient which means if they comply with treatment, herbs, diet and change their life style to
address taxation aspect than prognosis of their getting better is good.

Summary / Conclusion:
The patient is a 43 year old female with a chief complaint of chronic left side Temporal
Headaches. This is a case of pian tou tong, one-sided headache. TCM pattern is of for this case is
headache due to Qi Xu leading to Liver Qi stagnation, with an underlying Kidney Yang
deficiency. From biomedicine perspective this is a case of Tension Headache. Treatment will be
to warm and supplement Kidney and relieve pain. Although the severe headaches are due to
Liver Qi Stagnation, the pattern is still primarily one of deficiency. For this reason, the treatment
is aimed primarily at warming Kidney yang and relieving pain.

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Acupuncture treatment for Shao Yang Channel headache will be GB-20 , ST-8, GB 8, SJ 5 and
LIV 3. Acupuncture treatment for Zang-fu pattern will be, GB - 20, UB - 23, RN - 4 , KID - 3,
DU-4, and DU - 23. You Gui Wan [Right Restoring Pill] will be used as base herbal formula for
this pattern. The base formula will be modified to include Bo He (Herba Menthae), Chai Hu
(Radix Bupleuri) and Cheng Xiang (Lignum Aquilariae) to address temporal headache pain.

For a Kidney Yang deficiency diet it is best to consume fresh foods that are cooked. Food that is
lightly prepared helps to ensures that nutrients are preserved and are more readily digested and
absorbed. Warming foods and spices like animal meats, spring onions, dry ginger, cloves,
cinnamon, rosemary, turmeric, star anise, and nutmeg, are recommended. Cold natured foods
such as raw vegetables need to be avoided to avoid further damaging the Yang. Along with diet
change, patient is recommended to create a work-life balance to reduce stress and avoid the
triggers that start the headache or cause taxation, such as, exposure to external cold environment.

The patient has been suffering for few years and hence it is chronic disease that involves Kidney
Yang deficiency. However, they have not yet experienced signs and symptoms of Kidney yin
deficient which means if they comply with treatment, herbs, diet and change their life style to
address taxation aspect than prognosis of their getting better is good.

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References

1. Flaws & Sionneau. The Treatment of Modern Western Medical Diseases with Chinese
Medicine. Blue Poppy Press, Second edition, Oct. 2005.
2. Maciocia Giovanni, The Practice of Chinese Medicine, Churchill Livingstone, 1994.
3. Neil Lava, 2012. Retrieved from WebMD, Tension Headaches.
http://www.webmd.com/migraines-headaches/guide/tension-headaches
4. Karriem-Norwood Varnada , 2013. Retrieved from WebMD, Making-Diagnosis.
http://www.webmd.com/migraines-headaches/guide/making-diagnosis-doctors-exam
5. Chen K. John K. and Chen T Tina, Chinese Herbal Formulas and Appl ications. Art of
Medicine Press. 2009.
6. Saper James, 2006, www.eastmountain.ca. (based on references from MacLean &
Lyttleton, Clinical Handbook Of Internal Medicine, Vol. 2. University of Western
Sydney: Australia. 2002 and Zhao & Ellis, Chinese Dietary Therapy. Liu, J. Churchill
Livingston: Edinburgh. 1995. The Healing Cuisine of China. Healing Arts Press:
Vermont. 1998.)
7. Maclean, Will & Lyttleton, Jane. Clinical Handbook of Internal Medicine. Pangolin
Press, 2010.
8. Wu Yan & Fischer Warren. Practical Therapeutics of Traditional Chinese Medicine.
Paradigm Publications, Taos, New Mexico, 2009.
9. Deadman Peter, Al-Khafaji Mazin, Baker Kevin. A Manual of Acupuncture, Publisher:
Journal of Chinese Medicine Publications; 2 edition (2007).