| Introduction:Migraine headache is a chronic, and disabling neurovascular condition. The typical migraine presents as an episodic attack of severe, pulsating, one-sided headache often accompanied by dysfunction of the nervous system presenting as nausea, phonophobia (sensitivity to noise) or photophobia (sensitivity to light). Migraine is a very common condition. Population-based studies suggest that6%to7%of men and15%to18%of women experience migraine headache. The number of migraineurs in the US in1999was estimated to be27.9million. The incidence of migraine in China is9.85%and the annual incidence rate is79.97%. Based on a population of1.3billion this equates to103.6million people being affected by migraine headache. Migraine attacks can start at any age but the incidence of onset peaks in early to mid-adolescence.To more clearly define what the diagnosis of migraine signifies within Traditional Chinese Medicine (TCM) and how it relates to the diagnosis in Western Medicine we must examine the hallmark clinical features and pathogenesis in both systems of medicine. The majority of patients diagnosed with migraine in TCM are diagnosed with Liver Yang rising. However the rationale for this and the relationship with Western medicine has not been explored in depth in the English language.This study set out to explore the following:the relationship between migraine headache and the Liver and Gallbladder according to TCM theory and clinical observation, the Western medicine understanding of migraine headache and the relationship with the TCM theory of the Liver and Gallbladder, and the theoretical basis and clinical evidence of using acupuncture to treat migraine headache by regulating the Liver and Gallbladder.It is proposed that a multi-factorial relationship exists between:the Liver and Gallbladder and migraine headache, and the role of the Liver and Gallbladder and the Western construct of migraine headache. The primary sources of information for this study are journal articles and TCM reference and textbooks some of which are direct translations of Chinese sources. Only information published in English has been accessed.Chapter1-The Relationship Between Migraine Headache and the Liver and Gallbladder According to TCM Theory and Clinical Observation.Migraine Headache Disease Mechanisms in Chinese MedicineThe head is the juncture of all the Yang channels. These channels and the sea of marrow converge in the head. The Qi and Blood of the five Zang and six Fu organs all flow upward to the head. As a result the head is susceptible to harassment by Yang Qi that is unrestrained or out of its correct relationship with Yin. These factors are important to consider in all disorders involving the head including migraine.Because of the very specific symptomology of migraine headache in Western Medicine it is important to emphasize that not all patterns of disharmony underlying head pain (Tou Teng) are synonymous with migraine headache but that all migraine headaches are synonymous with head pain. Although there are different TCM patterns to which migraine headache is attributed we should be very clear about the headache presentation that is being referred to. Based on the information presented in this dissertation it is proposed that Liver Yang rising is the primary TCM pattern responsible for migraine headache. It is proposed that other TCM patterns are not synonymous with migraine headache but with headache. The only exception is Blood stasis and the role of Blood stasis in Liver Yang rising migraine headache will be discussed.The Relationship Between the Liver and Migraine HeadacheFlaws and Sionneau state that migraine headache most often originates from disorders of the function of the Liver, usually from hyperfunction of the Liver Yang. A study by Bowing et al concluded that the most common differential diagnoses in migraine headache are Liver Yang rising and Liver Qi stagnation.The pain of a migraine headache is associated with the attack phase of the migraine, and reflects the Liver Yang rising. There are three primary causes of Liver Yang rising in migraine headache:Liver Qi stagnation, Liver Blood deficiency, Yin deficiency of the Liver and/or Kidney Yin. The stagnation of Liver Qi can cause the development of Liver Blood deficiency, Liver Blood stasis, or Yin deficiency all of which can result in Liver Yang rising. However, Liver Blood deficiency and Yin deficiency can cause Liver Yang rising without Liver Qi stagnation as a precursor. Liver Qi stagnation is an excess cause of Liver Yang rising. Liver Blood and Yin deficiency are deficiency causes of Liver Yang rising. Liver Blood Stasis in Migraine HeadacheChen and Coeytaux reported that46%of migraine patients in their study had Blood stasis. Blood stasis occurs in more chronic migraines where Qi stagnation has become more severe. Hallmark features of Blood stasis in terms of pain are pain of a fixed location, and pain that is descried as stabbing or boring. Additional clinical signs of Blood in the tongue and pulse stasis will be evident between migraine attacks.A Possible Relationship Between Blood Stasis, Liver Yang Rising, Migraine and Cardiovascular DiseaseSeveral large studies have identified that patients with migraine have an increased risk of cardiovascular events due to a higher prevalence of risk factors and impaired endothelial function outside of the brain. In TCM migraine and cardiovascular disease are both intimately connected with the Liver. For example hypertension and migraine headaches can be caused by Liver Qi stagnation with Liver Yang rising. In addition it is been established that migraine headache commonly has an element of Blood stasis and cardiovascular disease often presents as Blood stasis patterns. It is very possible that people that experience migraine headache are on a continuum to develop CVD. Acupuncture and Chinese herbal medicine to subdue the Yang, course the Liver and invigorate Blood might not only treat the migraine headaches but prevent or minimize the onset of CVD. It is recognized that this is an oversimplification of the many relationships but further research in the relationship of the Liver with migraine headache and CVD from a theoretical, clinical, and research perspective is warranted.The Location of Migraine Pain and the Relationship with the GallbladderPublished studies agree that the head pain during a migraine is significantly more common in the temporal region than the vertex or suboccipital areas. The mechanisms by which the excess Liver Yang energy affects the Qi and Blood flow in the Gallbladder channels can be explained through the interior-exterior relationship of the Liver and Gallbladder and their primary channels but even more importantly, through the Divergent channels, and to a lesser degree the Luo channels.The Relationship Between the Gallbladder, Shao Yang Stage Disorder, and Migraine Headache.According to Shang Han Lun (Discourse on Cold Injury) Shao Yang disease is a disorder of externally contracted febrile disease occurring when a pathogen invades the body. The pathogen can follow the movement of Yang Qi or attack the Shao Yang level directly. It is a stage of the six-channel pattern identification. In modern practice there are doctors that follow the classic diagnostic and treatment principles of Zhang Zhong Jing. However others use concepts of this classical theory to explain and classify modern disorders. Dr. Yitian Ni proposes that a deficiency of Righteous Qi allows multiple disorders to attack the Shao Yang stage directly, it does not have to be invasion of an external cold pathogen In this model it is proposed that the Righteous Qi is depleted by mental and emotional stress, immune deficiencies, and poor lifestyle choices. Young states that the pathomechanism of Shao Yang disease is stagnation of Qi of the Gallbladder and San Jiao transforming into Fire and disturbing the pivotal mechanism of the Shao Yang.It is recognized that this theory does not exactly reflect the writing of the Shan Han Lun, but it is a valid theoretical way of supporting the relationship of the Gallbladder and migraine headache.Chapter2-The Western Medicine Understanding of Migraine Headache and the Relationship with the TCM Theory of the Liver and Gallbladder.Clinical Manifestations of MigraineThe simplified diagnostic criteria from the International Classification of Headache Disorders (ICHD-II) stipulate repeated attacks lasting4-72hours that have the following components:normal physical examination, no other reasonable cause for the headache. There must be at least two of:unilateral pain, throbbing pain, aggravation of pain by movement, moderate or severe intensity of pain. Finally, there must be at least one of: nausea or vomiting, photophobia or phonophobia.PathophysiologyOnce considered to be caused purely by vascular changes, current theories suggest that the initiation of a migraine involves a primary nervous system dysfunction which in turn activates the trigeminovascular system.The Trigeminal SystemThe trigeminovascular system is considered an important generator of the sensory input leading to migraine. It is hypothesized that migraine specific triggers cause Cortical Spreading Depression (CSD) and or primary brain stem dysfunction which causes dilation of cranial blood vessels.Changes in cerebral blood flow alone do not cause changes in pain. It appears that it is the effects of the neuropeptides not the change in blood vessel diameter that are partly responsible for migraine pain.Neuropeptides and Neurogenic InflammationActivation of the trigeminovascular system causes the release of neuropeptides from trigeminal nerve endings within the brain causing neurogenic inflammation. The main neuropeptides involved in this cascade are Substance P, Calcitonin Gene Related Peptide (CGRP), and nitric oxide (NO).Release of these neuropeptides from trigeminal sensory afferents causes neurogenic inflammation characterized by vasodilation, leakage of blood vessels, endothelial changes, platelet aggregation, and degranulation of mast cells.It is suggested by He and Lin that the change in diameter of the blood vessels is controlled by the interaction of the Defense Qi and Nutrient Qi. They equate the actions of Nutrient Qi and Defense Qi to NO and ET respectively.Cortical Spreading DepressionCortical Spreading Depression (CSD) is a slowly propagating wave (2-6mm/minute) of continuous neuronal depolarization across the cortex, followed by a strong, relatively long lasting neural depression. It is intimately connected with migraine triggers and pain.Migraine TriggersPeople with migraines have a low "migraine threshold" because they have a hyper-excitable cortex. This means they are more susceptible to outside influences. This hyper-excitable resting state of the cortex can be likened to the presence of Liver Qi stagnation. The more pronounced the degree of ’resting’ Liver Qi stagnation the more easily emotional stressors such as anger, grief, resentment, and worry trigger a pathological reaction e.g. a Liver Yang rising migraine.Chapter3-The Theoretical Basis and Clinical Evidence of Using Acupuncture to Treat Migraine Headache by Regulating the Liver and GallbladderA study of literature from the Pre-Qin Dynasty through the end of the Qing Dynasty found acupoints on the Gallbladder channel were used most often followed by points on the Liver and San Jiao channels in the treatment of headache[29]. A review of modern publications and articles in English found that the acupoints most commonly used in current practice to treat migraine are from these same three channels. Acupoints from the San Jiao channel are chosen because of the pathway of the channel on the head, the intersection points with the Gallbladder channel, the Divergent channel connections, and six-channel theory.Traditional Treatment StrategyDuring a migraine attack the head pain and the accompanying symptoms are the Biao reflecting Liver Yang rising. Traditionally the treatment strategy for migraine is to provide immediate relief of head pain during the attack. This is done by anchoring the Liver Yang and dispersing Liver Qi stagnation. If Blood stasis is present and an additional source of pain the treatment should also invigorate Blood to disperse Blood stasis. This is treatment of the Biao.To treat the Ben or root cause(s) of Liver Yang rising the TCM patterns must be identified. In migraine they are usually:Liver Qi stagnation, Liver Blood deficiency, or Yin deficiency. The treatment strategy therefore aims to free course the Liver Qi and nourish Blood and/or Yin of the Liver or Kidney or both. Liver Qi stagnation is an excess cause of Liver Yang rising. Blood and Yin deficiency are deficiency causes of Liver Yang rising. Because of the emotional component associated with Liver Qi stagnation and Liver Yang rising in migraine acupuncture points to calm the Shen should be used during the migraine attack and between the migraine attacks. Calming the Shen should be included in the Ben and Biao treatment strategy.Commonly Used Acupuncture PointsPoint prescriptions for the treatment of Liver Yang Rising migraine headache suggested by authors of eight textbooks commonly used in the acupuncture curriculum in schools and in clinics in the US were researched. Twenty-six acupuncture points were recommended. These points are divided into two categories:Points that drain the excess to anchor Liver Yang (Biao) and points that supplement deficiency (Ben). These categories are further divided into local and distal points.Local acupuncture points recommended to drain excess on the Gallbladder channel are: Hanyan (GB4), Xuanlu (GB5), Shuaigu (GB8), Yangbai (GB14), Fengchi (GB20), and Jianjing (GB21).Local acupuncture points recommended to drain excess on the San Jiao channel are: Yifeng (SJ17), Jiaosun (SJ20).Additional local points recommended to drain excess are:Baihui (DU20), Taiyang (M-HN-9), and Yintang (M-HN-3).Distal Acupuncture Points recommended to drain excess on the Gallbladder Channel are:Yanglingquan (GB34), Yangfu (GB38), Xuanzhong (GB39), Zulinqi (GB41), and Xiaxi (GB43).Distal Acupuncture Points recommended to drain excess on the San Jiao Channel are: Yemen (SJ2),Zhongzhu (SJ3), and Waiguan (SJ5). Distal Acupuncture Points recommended to drain excess on the Liver Channel are: Xingjian (Liv2), Taichong (Liv3), Qimen (Liv14).Acupuncture Points Recommended to Supplement Deficiency are all distal points: Ququan (Liv8), Rangu (kd2), Taixi (Kd3), Sanyinjiao (SP6). The theoretical basis for the use of these points in the regulation of Liver Yang rising is explored.The Relationship between TCM Theory and Clinical Evidence in the Regulation of the Liver and GallbladderThe Physiology of Acupuncture PointsWith advances in technology one approach that is being increasingly used to better understand the influence of acupuncture on migraine headache and inadvertently the role of regulation of the Liver and Gallbladder is the evaluation of specific point function. By using biochemical markers and imaging techniques it is hoped that a better understanding of the mechanism(s) of action of acupuncture and the effectiveness of specific acupuncture points and point combinations will be better understood. The main areas of research are: neurogenic inflammation, cerebral blood flow, ocular blood flow, endothelial function, vasoactive substances, and the functional organization of brain networks. Only points and point combinations specific to regulation of the Liver and Gallbladder are examined in this study:Qiuxu (GB40), Fengchi (GB20), Baihui (DU20), Taichong (Liv3), Si Guan (Four Gates).The Effectiveness of Acupuncture Compared to Prescription Medication One way to examine the effectiveness of acupuncture in the treatment of migraine is to compare it with a proven medication. An extensive literature review discovered that acupoint combinations used in these clinical trials are reflective of acupuncture treatment to regulate the Liver and Gallbladder even when a TCM diagnosis is not specified. The acupuncture point combinations and their rationale are examined in detail. Acupuncture points are most commonly chosen from the Gallbladder, Liver, and San Jiao channels.The literature revealed that only acupuncture points to regulate the Liver and Gallbladder are researched in studies on migraine headache. Although other patterns are published in reference books as causes of migraine they do not appear to have significant clinical value. Based on the theoretical evidence and clinical evidence (demonstrated by clinical trials) migraine headache as they are defined in Western Medicine most closely correspond to the differential diagnosis of Liver Yang rising with pain the Gallbladder channel. Acupuncture to regulate the Liver and Gallbladder is successful in treating migraine headache as compared to medication, sham, and placebo acupuncture. The Effectiveness of Acupuncture Compared to Nonprescription MedicationA clinical trial to compare the effectiveness of acupuncture to nonprescription migraine western medication for the treatment of migraine headache was carried out by this author. The acupuncture points used were:Hegu (LI4), Taichong (Liv3), Baihui (DU20), Shuaigu (GB8), Fengchi (GB20), Waigun (SJ5), Zulinqi (GB41), Sanyinjiao (SP6), and Yintang (M-HN-3). The therapeutic principles were to anchor the Liver Yang, course the Liver, and eliminate pain the Gallbladder channel. The secondary aim of treatment was to nourish Blood and clam the Shen.Statistical analysis shows that there are larger reductions from baseline in the average number of migraines in the treatment group compared to the control group (P<.014). In addition, there are larger reductions from baseline in the average intensity of migraines in the treatment group compared to the control group (P<.006). The results indicate that in this group of patients acupuncture significantly reduced the number of migraine headaches and the intensity of migraine headaches more effectively than nonprescription medication.Proposed Treatment StrategyBased on theory, clinical observation, clinical findings, and research findings it is proposed that treatment of migraine headache due to Liver Yang rising should adhere to the traditional principles of treating the Ben and Biao with slight modification. It is proposed that treatment should consider the Ben and Biao but should occur in three phases depending on intensity and frequency of migraine attack and include address the Shen.ConclusionThis study set out to explore the relationship between migraine headache and the Liver and Gallbladder according to TCM theory and clinical observation. It identified from theoretical, clinical, and research based sources that migraine headaches are most commonly caused by pathomechanisms of the Liver particularly Liver Yang rising. Liver Qi stagnation is a frequent precursor of Liver Yang rising and may occur simultaneously. Liver Blood stasis is a third Liver related pattern that is commonly diagnosed in migraine headache. The most common factor contributing to Liver Yang rising migraine headache is emotional. Anger, frustration, resentment, and worry accumulate over time and cause Liver Qi stagnation which in transforms into Liver Yang rising.It has been determined from theoretical and clinical sources that the most common location of pain during a migraine headache is the temporal region of the head corresponding to the Gallbladder channel. The multi-faceted methods of communication between the interiorly-exteriorly paired Zang Fu such as the Divergent and Luo channel connections explain this hallmark migraine symptom.The study has also sought to understand the Western medicine pathogenesis of migraine headache and the relationship with the TCM theory of the Liver and Gallbladder. Migraine is a neurovascular headache and involves a primary nervous system dysfunction that activates the trigeminovascular system. Stimulation of this system causes a release of neuropeptides from the afferents of the trigeminal nerve afferents causing head pain. We see relationships between the Western Medicine and TCM systems in terms of explanation of migraine signs and symptoms.This study set out to investigate is the theoretical basis and clinical evidence of using acupuncture to treat migraine headache by regulating the Liver and Gallbladder. The theoretical literature recommends the use of points primarily located on the Liver and Gallbladder channels to treat Liver Yang rising Migraine headache. Additionally, points on the San Jiao channel are commonly recommended. Theoretically, the point functions of the most commonly recommended points subdue the Liver Yang and free course the Liver Qi. Supplemental functions are aimed at nourishing Blood and Yin to further restrain the Yang. An important point function seen across categories is to calm the Shen acknowledging the emotional component of the disorder. Review of publications and journal articles suggest the physiological mechanisms by which acupuncture regulates the Liver and Gallbladder in patients with migraines include modulating neurogenic inflammation, cerebral blood flow, vasoactive substances, and the functional organization of brain networks.The theoretical implications of the study suggest that the involvement of Zang Fu other than the Liver and Gallbladder and their role in migraine headache should be re-examined. The location of pain, the nature of pain, the intermittent presentation of pain plus the additional symptoms that accompanying migraine overwhelmingly support the Liver and Gallbladder as the primary organs and channels involved. The main Liver disharmony being Liver Yang rising.It is recognized that a limiting factor of this study is the use solely of publications in English. |
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