HEAD

Chapter 34


imageHEAD






WHEN WE ASK


Questions about the head are obviously particularly important in patients who suffer from headaches; however, they are also important in the elderly and in those suffering from hypertension or tinnitus. In the elderly they have particular importance because head symptoms such as headache, dizziness, feeling of distension of the head, etc. often occur with serious pathologies such as hypertension or may be prodromal signs of Wind-stroke.


I also ask about head symptoms whenever there is Liver-Qi stagnation or Liver-Blood stasis to check whether there may be also Liver-Yang rising or Liver-Fire, which tend to cause symptoms in the head. For example, a woman may complain of premenstrual tension characterized by irritability and breast distension. She may also suffer from premenstrual headaches but may not relate them to the premenstrual phase. The presence of headaches would confirm that there is Liver-Yang rising in conjunction with Liver-Qi stagnation; if we did not ask about the headache, we would never know this. This situation arises especially in Liver disharmonies because in such disharmonies it is common for a patient to suffer from two, three, or even four concomitant Liver patterns.




HEADACHE


Symptoms and Signs, Chapter 55


Headache is one of the most common presenting symptoms in Western patients; Chinese books differentiate first of all between headaches of internal origin and those of external origin, but the latter are not frequently seen in practice.


When asking a patient about headaches it is important to ask systematically about onset, time, location, character of pain and ameliorating or aggravating factors.





Location





• Occiput: here the location is the Greater-Yang channels (the headache can be from exterior invasion of Wind-Cold if the pain is severe or from interior Kidney deficiency if the pain is dull) (Fig. 34.1).



• Vertex: here the location is the terminal Yin channels (the headache is usually from deficiency of Liver-Blood) (Fig. 34.1).


• Forehead: here the location is the Bright-Yang channels (the headache can be from Stomach-Heat or Blood deficiency) (Fig. 34.2).



• Temples and sides of the head: here the location is Lesser-Yang channels (the headache can be from exterior Wind in the Lesser-Yang or from Liver-Yang rising) (Fig. 34.3).



• Temple, side of head and eye: here the location is the Lesser-Yang channels (the headache is usually from Liver- Yang rising) (Fig. 34.4).



• Behind the eyes: here the location is the Liver channel (the headache cause is either Liver-Yang rising or Liver-Blood deficiency) (Fig. 34.5).



• Whole head: this is caused by exterior invasion of Wind-Heat or Kidney deficiency.






Internal and exterior origin


The differentiation of headaches is best done by distinguishing headaches of interior origin from those of exterior origin.



Headaches of internal origin


In headaches of internal origin, it is very important to differentiate between those deriving from Fullness and those deriving from Emptiness. The most common headaches from Fullness include Liver-Yang rising, Liver-Fire, Phlegm, Blood stasis, Liver-Wind, Stomach-Heat and retention of food; the most common headaches from Emptiness include Blood deficiency, Stomach- and Spleen-Qi deficiency and Kidney deficiency.


The headache from Liver-Yang rising manifests with a throbbing pain, which is usually unilateral, often moving from side to side and located behind the eye, on the temples or on the lateral side of the head along the Gall-Bladder channel. It is often accompanied by nausea and vomiting, dizziness, blurred vision, flashing lights and a Wiry pulse.


The headache from Liver-Fire, which is less common, is similar in character to that from Liver-Yang rising but it is accompanied by Liver-Fire symptoms and signs such as intense thirst, bitter taste, red face, dark urine and dry stools.


Another very common type of headache is that from Phlegm obstructing the clear orifices of the head: in this case the headache is dull in nature and the head feels as if it were wrapped in or full of cotton wool and with a pronounced feeling of heaviness, muzziness and blurred vision. Other manifestations include a feeling of nausea, a feeling of oppression of the chest, a Swollen tongue and a Slippery pulse.


A very common type of chronic headache is the one due to a combination of Phlegm and internal Wind. Such a headache has all the characteristics as the one from Phlegm but is characterized by occasional bouts of severe headaches from Wind. Such a pattern is called ‘Wind-Phlegm’. However, Phlegm as a cause of headache is frequently also associated with Liver-Yang rising, with the Phlegm being carried upwards by the ascending Liver-Yang; a person suffering from these two patterns will suffer from chronic, dull headaches with a feeling of muzziness and dizzines (caused by Phlegm) punctuated by occasional, acute attacks of severe, throbbing headaches (caused by Liver-Yang rising). Such pattern is also called ‘Wind-Phlegm’.


The headache from Blood stasis is characterized by an intense, fixed, boring pain, usually unilateral, and accompanied by a Purple tongue and Wiry pulse. In very chronic, long-standing cases of headache, the Blood stasis type of pain may often be combined with other types; the chronic recurrence of a headache in the same part of the head may by itself cause local Blood stasis. For example, if a patient suffers from a Liver-Yang type of headache for many years occurring always on the right side, this may by itself cause a local stasis of Blood in the head on that side and thus the headache will manifest with symptoms of both Liver-Yang rising and Blood stasis.


The headache from Liver-Wind is characterized by a pulling pain, accompanied by severe dizziness and tremors.


The headache from Stomach-Heat is characterized by an intense frontal pain and is accompanied by epigastric pain, thirst, sour regurgitation and a yellow tongue coating.


The headache from retention of food is charac-terized by a diffused and intense dull pain on the forehead and is accompanied by nausea, vomiting, sour regurgitation, a feeling of fullness of the epigastrium, a thick and sticky tongue coating and a Slippery pulse.


The headache from Blood deficiency (usually of the Liver or Heart, or both) is characterized by a dull ache, usually on the top of the head, and is accompanied by dizziness, blurred vision, insomnia, palpitations, a Pale tongue and a Choppy pulse.


The headache from Stomach- and Spleen-Qi deficiency is characterized by a dull frontal ache and is accompanied by tiredness, lassitude, weak limbs, loose stools, poor appetite, a Pale tongue and a Weak pulse.


The headache from Kidney deficiency (which could be Yin or Yang deficiency) is characterized by a dull headache all over the head, accompanied by a feeling of emptiness of the head, dizziness and tinnitus.


Stagnation of Cold in the Liver channel may cause a dull but intense, vertical headache associated with cold feet. However, this headache is rather rare.



Headaches of external origin


External headaches are due to invasion of Wind-Cold, Wind-Heat and Wind-Dampness and they all obviously have an acute onset.


The headache from Wind-Cold is characterized by a severe occipital ache and stiffness and is accompanied by pronounced aversion to cold, fever, sneezing and a Floating-Tight pulse.


The headache from Wind-Heat is characterized by a severe pain as if the head were being cracked open and is accompanied by aversion to cold, fever, sore throat, slight sweating and a Floating-Rapid pulse.


The headache from Wind-Dampness is characterized by a dull headache as if the head were wrapped up and is accompanied by a feeling of heaviness of the head, aversion to cold, fever, slight sweating, nausea and a Floating-Slippery pulse.


Figure 34.6 is a classification of headaches.



Case histories 34.1–34.5 illustrate some different patterns causing headache.



Case history 34.1


A 14-year-old girl had been suffering from recurring headaches since the age of 10 years. The headaches were severe and came approximately every 3 months. The headache was concentrated in the area behind the eyes, was throbbing in character and was accompanied by blurred vision, vomiting, and what she described as ‘fuzzy eyes’. Apart from the attacks of severe headaches every 3 months, she also experienced frequent, dull headaches in between.


On interrogation, she said she suffered from chronic tiredness and experienced some tingling of her limbs.


Her tongue was Pale, slightly Swollen and with a sticky coating; her pulse was slightly Slippery.


Diagnosis: The headaches are very clearly of the Liver-Yang type: this is confirmed by the throbbing character of the pain, the location behind the eyes and the vomiting. However, there are two other patterns which are evidenced by very few symptoms. First of all, there is some Liver-Blood deficiency, which is indicated by the chronic tiredness, the Pale tongue and the tingling; Liver-Blood deficiency is obviously the cause for the rising of Liver-Yang in this case. Secondly, there is also some Phlegm; this is evidenced mostly by the tongue (being Swollen and with a sticky coating) and pulse (being Slippery). The ‘fuzzy eyes’ could also be interpreted as a sign of Phlegm obstructing the eye orifices.


This is a good example of the importance of tongue and pulse as pointers to a certain pattern even in the absence of symptoms; for this reason, tongue and pulse pictures should never be discounted when they do not appear to accord with the presenting symptoms. For example, in this case of Liver-Blood deficiency with Liver-Yang rising, the tongue ‘should’ have been Pale and Thin and the pulse might have been Wiry on the left and Weak on the right. Why should the tongue and pulse show a certain pattern and the patient not show any signs of it? This often happens in young people when there is a certain pathogenic factor (in this case Phlegm) but, due to the young age of the person, it has not given rise to clinical manifestations as yet.


The treatment principle in this case should therefore be not only to nourish Liver-Blood and subdue Liver-Yang but also to resolve Phlegm.



Case history 34.2


A 28-year-old woman had been suffering from migraine since the age of 13. She was thin, quite tall and she walked with agility: her body shape was a typical Wood type (see Chapter 1). Her complexion was dull sallow, her hair was dry and her eyes had good shen.


The headaches were of a throbbing character and always occurred on the left side of the head, along the Gall-Bladder channel and behind the left eye; they occurred weekly and they were nearly always accompanied by nausea, vomiting and photophobia. The headache was not affected by posture or food intake and, although a headache always occurred with her period, she also suffered from headaches at other times. The headaches were aggravated by damp and windy weather and also by stress and fatigue. A striking feature of the headaches was that they were markedly better during two pregnancies and markedly worse soon after childbirth both times. She had two children, one 3 years old and one 6 months old. An EEG and CT scan revealed no abnormalities and drugs for migraine produced an aggravation.


The periods were quite normal, coming regularly, with normal amount and colour but rather painful on the first 2 days. Her general health was good with no abnormalities in urination or defecation or sleep.


Diagnosis: Observation of her body type indicates that she is a Wood type: her agile walk accords with this, which is a good sign. As mentioned in the chapter on observation, each Five-Element body type has a characteristic walk and a deviation from this is not a good sign. For example, the Wood type should walk in an agile way and if they walked stiffly it would not be a good sign. Her dull complexion and dry hair suggest Blood deficiency; the normal sparkle of her eyes suggested that she did not suffer from any deep emotional problem.


The marked amelioration during pregnancy and aggravation after childbirth strongly suggests a deficiency of the Kidneys and the disharmony of the Penetrating and Directing Vessels: this is confirmed also by the onset of the headaches soon after menarche (which occurred when she was aged 12½.


We therefore need to confirm the presence of Blood deficiency and Kidney deficiency with further questioning. To confirm or exclude Blood deficiency, we ask about numbness and tingling of the limbs, dizziness, poor memory, insomnia, blurred vision: she did suffer from tingling of her limbs but from none of the other symptoms. However, we can conclude that there is some Blood deficiency from the tingling of her limbs, the dull complexion and the dry hair. As for Kidney deficiency, she had no symptoms of it apart from lower backache, but this symptom together with the onset of the headaches at menarche, the amelioration during pregnancy and the aggravation after childbirth confirms the presence of a Kidney deficiency and the disharmony of the Penetrating and Directing Vessels.


Her tongue was very slightly Pale but Red on the sides, Swollen and with a sticky coating and there was a small, peeled patch on the left side in the breast area; her pulse was generally Weak and Empty at the deep level.


The Pale colour of the tongue and the weakness and emptiness of the pulse confirm Blood deficiency and Kidney deficiency. However, the swelling of the tongue body and the sticky coating point to Phlegm, something that was not apparent from observation nor interrogation: her thin body indicates a tendency to Blood and Yin deficiency whereas Phlegm usually manifests with a tendency to being overweight. Furthermore, she had no other symptoms of Phlegm: there was no dizziness, no blurred vision, no feeling of heaviness of the head, no dull headaches, no expectoration of phlegm. However, in these cases, I never discount the tongue signs and I concluded that, although she had no other symptoms of Phlegm, the tongue signs were clear enough to confirm the presence of Phlegm; this is confirmed by the aggravation of the headaches in damp weather. The simultaneous presence of Liver-Yang rising and Phlegm is a very common cause of chronic headaches.


The character of her headaches points very clearly to Liver-Yang rising: this is confirmed by the throbbing nature of the pain, the nausea and vomiting, the sensitivity to light and the location of the headache on the Gall-Bladder channel. We can therefore conclude that the causes of the rising of Liver-Yang are the Blood and the Kidney deficiency: the former constitutes the Manifestation (Biao) and the latter the Root (Ben). From the point of view of Deficiency and Excess, the former consists of the Blood deficiency, Kidney deficiency and also Spleen-Qi deficiency, while the latter consists of Liver-Yang rising and Phlegm. We can deduce the presence of Spleen-Qi deficiency from the presence of Phlegm and from the Weak pulse.


The Pale colour of her tongue body can be attributed to any or all of her deficiencies, that is, Blood-Kidney- and Spleen-Qi deficiency. The redness of the sides confirms the rising of Liver-Yang and the swelling of the tongue body and the sticky coating indicate Phlegm. The last aspect of her tongue to interpret is the peeled patch on the left side in what may, under certain circumstances, be the breast area. There are two ways of interpreting the significance of this peeled patch: it could indicate either the very beginning of Yin deficiency (which may develop from Blood deficiency) or a problem in the left breast. This could be a problem in the left breast (such as mastitis) developed after childbirth; however, the patient said that this was not the case. The other possible explanation is that the peeled patch may indicate a more serious potential problem in the left breast such as a malignant lump.


In this case we need to treat both the Root and Manifestation simultaneously: the Root by nourishing Blood, tonifying Spleen and Kidneys and strengthening the Penetrating and Directing Vessels, and the Manifestation by subduing Liver-Yang and resolving Phlegm.

Related posts:

  1. OBSERVATION OF THE GENITALIA
  2. MENSTRUAL SYMPTOMS
  3. DIAGNOSIS BY HEARING
  4. MENTAL AND EMOTIONAL SYMPTOMS

Stay updated, free articles. Join our Telegram channel
Tags:
Apr 15, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on HEAD

Full access? Get Clinical Tree
Get Clinical Tree app for offline access