针灸从肝胆论治偏头痛的理论探讨
摘要
为了更清楚的定义中医学的偏头痛诊断标准以及如何与西医的诊断相关,为中医学现代化发展以及更为广泛地在欧美国家被接受,本课题力图通过理论及临床资料的探讨与分析,明确偏头痛在中、西医两个医学体系中的临床标志性特征以及肝胆在其发病机理中所起的重要作用,为针灸临床诊断和治疗偏头痛提供坚实的中西医理论和临床依据。本课题的研究目的在于探讨以下问题：基于中医理论和临床观察基础上的偏头痛与和肝胆相关性的探讨；西医对偏头痛的理解及其与中医理论中肝、胆关系的探讨；针灸调理肝胆法治疗偏头痛的理论基础和临床依据探讨。
方法与内容
一.方法
本课题运用文献研究的方法,从中、西医角度分析、探讨肝胆与偏头痛病理生理及治疗之间的关系。
二.内容
1.从中医理论及临床角度探讨肝胆与偏头痛的关系
1.1偏头痛的中医发病机制
阳气的生理和病理在内经中是一个重要问题。综合来说,内经认为,脑为髓海,是人体手、足阳经及督脉会聚的地方,亦是人体精气会聚之处。五藏六腑之气血皆上注于头,正因如此,当阳气功能亢进或阴阳失调时,头部就很容易受到影响。比如,《黄帝内经·素问》曰：“故春气上于头”,这里的春气即指肝气。肝主疏泄,表现为肝气向上、向外的运动,其自然属性就是运行到人体的最高点,即头部。也就是说,一旦肝气的运动方式出现问题,就容易影响到头部功能,这对偏头痛来说是一个重发病因素的。
1.2正常的肝胆关系
肝胆之间通过它们各自所连属的经脉形成了表里关系,这使得二者之间不可能独立发挥各自的功能,二者在生理和病理方面均相互影响。中医理论中,肝的生理功能和特征有：储存血液、疏泄气机、主筋、其华在爪甲、开窍于目、主魂；胆的主要功能是储存和分泌由充盛的肝气所化生的胆汁,满足身体的需求。肝胆相表里,命门之火和胆共同协助肝脏行气。
1.3偏头痛与肝胆关系的临床研究
Blackwell、Facco等学者报道,临床上80%的偏头痛患者因肝阳上亢引发；Flaws、Sionneau、学者尹氏、刘氏等也认为,偏头痛患者常因肝阳上亢引发；Flaws和Sionneau的研究也认为,中医理论中,偏头痛通常由肝功能紊乱引起,尤其是肝阳上亢。学者陈氏、Coeytaux等人研究发现,46%的偏头痛患者存在肝血淤滞的情况；肝血淤滞引起的疼痛一般为固定痛,具体称为掣痛或烧灼痛；血淤型偏头痛发生的一般原因为头部经络之气的运行不畅,进而造成淤血,这种情况的产生多由于肝阳上亢后造成胆经之气血运行受阻,引发刺痛、掣痛等偏头痛特有的症状,这些疼痛一般位于眼后或太阳穴附近,由此可推断淤血发生在胆经及其旁络,也有可能涉及三焦经及其旁络；临床上,淤血一般是由于气滞逐渐加重引起,多引起于慢性偏头痛。
2.西医对于偏头痛的认识及与中医理论中肝胆的关系
2.1西医偏头痛的临床表现
典型的偏头痛表现为间断性发作的、严重的、跳动性的一侧头痛,常伴有神经系统功能障碍的表现如恶心、声音恐惧症(对噪音敏感)或畏光(对光线敏感)等。
2.2偏头痛发作时常见的疼痛部位
疼痛的部位通常沿三叉神经和颞区的上颈神经根附近分布；研究显示,疼痛更常出现的在颞区而不是巅顶或枕骨下区域；而从中医经络理论的角度来看,在大脑颞区(太阳穴)疼痛处,我们可看到三叉神经路径和胆经及其旁络之间的相互关系；胆经和三焦经之间的相互关系更解释了这一点,即二者都穿过太阳穴,与三叉神经的路径非常相似；肝经支络与目周围组织的联系与三叉神经在眼区的分布十分相似。
2.3偏头痛的病理生理学
偏头痛是一种复杂的脑部功能紊乱,一种其发病的病理生理学基础尚不十分清楚的血管神经性头痛。曾经,血管功能改变被认为是其发病的唯一原因,但目前,理论研究认为,偏头痛的发生原因与神经系统功能异常有关,并随之激活三叉神经血管系统,被激活的这个系统会增加神经肽的释放,并导致头部的疼痛,而脑血流量的变化本身并不会导致疼痛的产生。看来,导致偏头痛产生的主要原因是神经肽而不是血管管径的改变。这个有关偏头痛的发病机理的新理论推动了对偏头痛发病机理的认识。
科技的进步已经使得人们对理解脑血管收缩和扩张和由此产生的神经肽级联在偏头痛发病过程中所扮演的完整角色。有中医学者认为,血管直径的改变是受营气和卫气支配的,营卫之间的协调平衡共同调节着血管的管径。营主血管扩张,卫主血管收缩的过程与血管内皮有关,学者们把营气和卫气的功能分别等同于一氧化氮和降钙素基因相关肽。他们认为,经络气血郁滞引起偏头痛是源于营卫之气失衡。
3.针灸调理肝胆法治疗偏头痛的理论基础及临床依据
3.1针灸穴位治疗效果观察
研究证实,针刺太冲穴15分钟后,鼻、颞侧睫状后短动脉阻力指数(P<0.05)比基线明显下降,研究者得出结论：针刺太冲穴对降钙素基因相关肽、一氧化氮以及神经源性血管扩张有效；从中医理论的角度来看,太冲穴可用于偏头痛引起的视觉功能异常的治疗,这项研究为中医理论的正确性作了充分的论证；针刺百会穴后,在安静的情况下,大脑中动脉、大脑前动脉的血流量显著升高,该研究显示针刺百会穴能有效提高脑血流量。从中医理论的角度来看,我们知道当人体阳气上升到顶点时就是人体的百会穴,百会也是人体内风上升后到达之处,同时,百会穴还有使胆经之气下降的功能。这项研究对百会穴在中医临床中常用于治疗相关症状的理论提供了有利的实验研究依据；针刺风池穴能有效调节人体的免疫系统及减轻血管内皮损伤。通过调节肝胆气机,风池穴在降低肝阳上亢型偏头痛患者的血清白细胞介素-6水平方面起重要作用；针刺合谷穴、太冲穴(四关穴)后,血一氧化氮升高；大脑额叶、枕骨脑叶、颞叶处的血流量均升高；该研究同时认为,太冲穴(四关穴)的作用机理在于,肝胆经均到达头部,而无论穴位在该经的哪个位置,这些穴位都可治疗该经运行路线上所有部位的症状,尽管选穴的位置离症状所在位置很远。具体表现在针灸理论中,就是远端取穴。总的来说,这些穴位能调节脑部血管的收缩和扩张、提高脑部血流量、调节炎症反应。
3.2针灸与西医药物治疗的临床疗效比较
某项研究将针灸的治疗效果与偏头痛的非处方药物的治疗效果进行了比较。针灸治疗组选用的穴位有：合谷、太冲、百会、率谷、风池、外关、足临泣、三阴交、印堂,治疗原则是疏理肝胆、平抑肝阳、止痛。统计结果显示,与西药治疗对照组比较,针灸治疗组每位患者的偏头痛的疼痛程度都比治疗前有明显下降(P<.014)；与西药治疗对照组比较,针灸治疗组患者偏头痛发生的平均频率均明显下降(P<0.006)；实验结果显示,针灸治疗对偏头痛效果显著,且无副作用。
结果
肝阳上亢是引起偏头痛的最常见的原因,而肝气郁结又是引起肝阳上亢的重要原因,二者也可同时引起偏头痛,肝血淤是引发偏头痛的第三个主要原因。情绪因素又是引发肝阳上亢的重要原因,愤怒、沮丧、长期担忧等都会造成肝气郁滞并进而演变成肝阳上亢。
西医中的偏头痛与中医中的肝阳上亢型偏头痛(疼痛沿胆经分布)最为接近,针灸调理肝胆法治疗偏头痛与西药、安慰剂等的疗效相比是十分成功的。
结论
一.偏头痛常见发病部位在胆经运行路线上,尤其是太阳穴附近,而很少发生在足厥阴肝经所属的巅顶。
二.偏头痛的发生与肝胆气机损伤有关。从偏头痛发作时疼痛的位置、性质、间隔时间、伴见症状等来看,都充分论证了肝胆及它们所属的经络在该病的发病原因中所起的重要作用。
三.针灸调理肝胆法治疗偏头痛的生理学研究能填补西医模型的不足,同时更好地解释中医理论。目前,中医对偏头痛的发病机制和治疗原则方面比西医有更完整和深入的理解。未来中西医在偏头痛的研究方面如果有更深入的研究和交流,将对肝胆在偏头痛发病中所扮演的角色及确立最佳的针灸治疗策略发挥更好的作用。
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 Medicine
The 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 Headache
Flaws 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 Headache
Chen 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 Disease
Several 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 Gallbladder
Published 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 Migraine
The 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.
Pathophysiology
Once 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 System
The 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 Inflammation
Activation 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 Depression
Cortical 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 Triggers
People 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 Gallbladder
A 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 Strategy
During 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 Points
Point 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 Gallbladder
The Physiology of Acupuncture Points
With 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 Medication
A 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 Strategy
Based 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.
Conclusion
This 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.
方法与内容
一.方法
本课题运用文献研究的方法,从中、西医角度分析、探讨肝胆与偏头痛病理生理及治疗之间的关系。
二.内容
1.从中医理论及临床角度探讨肝胆与偏头痛的关系
1.1偏头痛的中医发病机制
阳气的生理和病理在内经中是一个重要问题。综合来说,内经认为,脑为髓海,是人体手、足阳经及督脉会聚的地方,亦是人体精气会聚之处。五藏六腑之气血皆上注于头,正因如此,当阳气功能亢进或阴阳失调时,头部就很容易受到影响。比如,《黄帝内经·素问》曰：“故春气上于头”,这里的春气即指肝气。肝主疏泄,表现为肝气向上、向外的运动,其自然属性就是运行到人体的最高点,即头部。也就是说,一旦肝气的运动方式出现问题,就容易影响到头部功能,这对偏头痛来说是一个重发病因素的。
1.2正常的肝胆关系
肝胆之间通过它们各自所连属的经脉形成了表里关系,这使得二者之间不可能独立发挥各自的功能,二者在生理和病理方面均相互影响。中医理论中,肝的生理功能和特征有：储存血液、疏泄气机、主筋、其华在爪甲、开窍于目、主魂；胆的主要功能是储存和分泌由充盛的肝气所化生的胆汁,满足身体的需求。肝胆相表里,命门之火和胆共同协助肝脏行气。
1.3偏头痛与肝胆关系的临床研究
Blackwell、Facco等学者报道,临床上80%的偏头痛患者因肝阳上亢引发；Flaws、Sionneau、学者尹氏、刘氏等也认为,偏头痛患者常因肝阳上亢引发；Flaws和Sionneau的研究也认为,中医理论中,偏头痛通常由肝功能紊乱引起,尤其是肝阳上亢。学者陈氏、Coeytaux等人研究发现,46%的偏头痛患者存在肝血淤滞的情况；肝血淤滞引起的疼痛一般为固定痛,具体称为掣痛或烧灼痛；血淤型偏头痛发生的一般原因为头部经络之气的运行不畅,进而造成淤血,这种情况的产生多由于肝阳上亢后造成胆经之气血运行受阻,引发刺痛、掣痛等偏头痛特有的症状,这些疼痛一般位于眼后或太阳穴附近,由此可推断淤血发生在胆经及其旁络,也有可能涉及三焦经及其旁络；临床上,淤血一般是由于气滞逐渐加重引起,多引起于慢性偏头痛。
2.西医对于偏头痛的认识及与中医理论中肝胆的关系
2.1西医偏头痛的临床表现
典型的偏头痛表现为间断性发作的、严重的、跳动性的一侧头痛,常伴有神经系统功能障碍的表现如恶心、声音恐惧症(对噪音敏感)或畏光(对光线敏感)等。
2.2偏头痛发作时常见的疼痛部位
疼痛的部位通常沿三叉神经和颞区的上颈神经根附近分布；研究显示,疼痛更常出现的在颞区而不是巅顶或枕骨下区域；而从中医经络理论的角度来看,在大脑颞区(太阳穴)疼痛处,我们可看到三叉神经路径和胆经及其旁络之间的相互关系；胆经和三焦经之间的相互关系更解释了这一点,即二者都穿过太阳穴,与三叉神经的路径非常相似；肝经支络与目周围组织的联系与三叉神经在眼区的分布十分相似。
2.3偏头痛的病理生理学
偏头痛是一种复杂的脑部功能紊乱,一种其发病的病理生理学基础尚不十分清楚的血管神经性头痛。曾经,血管功能改变被认为是其发病的唯一原因,但目前,理论研究认为,偏头痛的发生原因与神经系统功能异常有关,并随之激活三叉神经血管系统,被激活的这个系统会增加神经肽的释放,并导致头部的疼痛,而脑血流量的变化本身并不会导致疼痛的产生。看来,导致偏头痛产生的主要原因是神经肽而不是血管管径的改变。这个有关偏头痛的发病机理的新理论推动了对偏头痛发病机理的认识。
科技的进步已经使得人们对理解脑血管收缩和扩张和由此产生的神经肽级联在偏头痛发病过程中所扮演的完整角色。有中医学者认为,血管直径的改变是受营气和卫气支配的,营卫之间的协调平衡共同调节着血管的管径。营主血管扩张,卫主血管收缩的过程与血管内皮有关,学者们把营气和卫气的功能分别等同于一氧化氮和降钙素基因相关肽。他们认为,经络气血郁滞引起偏头痛是源于营卫之气失衡。
3.针灸调理肝胆法治疗偏头痛的理论基础及临床依据
3.1针灸穴位治疗效果观察
研究证实,针刺太冲穴15分钟后,鼻、颞侧睫状后短动脉阻力指数(P<0.05)比基线明显下降,研究者得出结论：针刺太冲穴对降钙素基因相关肽、一氧化氮以及神经源性血管扩张有效；从中医理论的角度来看,太冲穴可用于偏头痛引起的视觉功能异常的治疗,这项研究为中医理论的正确性作了充分的论证；针刺百会穴后,在安静的情况下,大脑中动脉、大脑前动脉的血流量显著升高,该研究显示针刺百会穴能有效提高脑血流量。从中医理论的角度来看,我们知道当人体阳气上升到顶点时就是人体的百会穴,百会也是人体内风上升后到达之处,同时,百会穴还有使胆经之气下降的功能。这项研究对百会穴在中医临床中常用于治疗相关症状的理论提供了有利的实验研究依据；针刺风池穴能有效调节人体的免疫系统及减轻血管内皮损伤。通过调节肝胆气机,风池穴在降低肝阳上亢型偏头痛患者的血清白细胞介素-6水平方面起重要作用；针刺合谷穴、太冲穴(四关穴)后,血一氧化氮升高；大脑额叶、枕骨脑叶、颞叶处的血流量均升高；该研究同时认为,太冲穴(四关穴)的作用机理在于,肝胆经均到达头部,而无论穴位在该经的哪个位置,这些穴位都可治疗该经运行路线上所有部位的症状,尽管选穴的位置离症状所在位置很远。具体表现在针灸理论中,就是远端取穴。总的来说,这些穴位能调节脑部血管的收缩和扩张、提高脑部血流量、调节炎症反应。
3.2针灸与西医药物治疗的临床疗效比较
某项研究将针灸的治疗效果与偏头痛的非处方药物的治疗效果进行了比较。针灸治疗组选用的穴位有：合谷、太冲、百会、率谷、风池、外关、足临泣、三阴交、印堂,治疗原则是疏理肝胆、平抑肝阳、止痛。统计结果显示,与西药治疗对照组比较,针灸治疗组每位患者的偏头痛的疼痛程度都比治疗前有明显下降(P<.014)；与西药治疗对照组比较,针灸治疗组患者偏头痛发生的平均频率均明显下降(P<0.006)；实验结果显示,针灸治疗对偏头痛效果显著,且无副作用。
结果
肝阳上亢是引起偏头痛的最常见的原因,而肝气郁结又是引起肝阳上亢的重要原因,二者也可同时引起偏头痛,肝血淤是引发偏头痛的第三个主要原因。情绪因素又是引发肝阳上亢的重要原因,愤怒、沮丧、长期担忧等都会造成肝气郁滞并进而演变成肝阳上亢。
西医中的偏头痛与中医中的肝阳上亢型偏头痛(疼痛沿胆经分布)最为接近,针灸调理肝胆法治疗偏头痛与西药、安慰剂等的疗效相比是十分成功的。
结论
一.偏头痛常见发病部位在胆经运行路线上,尤其是太阳穴附近,而很少发生在足厥阴肝经所属的巅顶。
二.偏头痛的发生与肝胆气机损伤有关。从偏头痛发作时疼痛的位置、性质、间隔时间、伴见症状等来看,都充分论证了肝胆及它们所属的经络在该病的发病原因中所起的重要作用。
三.针灸调理肝胆法治疗偏头痛的生理学研究能填补西医模型的不足,同时更好地解释中医理论。目前,中医对偏头痛的发病机制和治疗原则方面比西医有更完整和深入的理解。未来中西医在偏头痛的研究方面如果有更深入的研究和交流,将对肝胆在偏头痛发病中所扮演的角色及确立最佳的针灸治疗策略发挥更好的作用。
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 Medicine
The 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 Headache
Flaws 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 Headache
Chen 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 Disease
Several 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 Gallbladder
Published 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 Migraine
The 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.
Pathophysiology
Once 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 System
The 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 Inflammation
Activation 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 Depression
Cortical 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 Triggers
People 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 Gallbladder
A 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 Strategy
During 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 Points
Point 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 Gallbladder
The Physiology of Acupuncture Points
With 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 Medication
A 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 Strategy
Based 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.
Conclusion
This 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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