Case Study: Chronic Headache in Traditional Chinese Medicine

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Case Study: Chronic Headache in Traditional Chinese Medicine

Introduction: This case study discusses the diagnosis and treatment of a 52-year-old female presenting with chronic headaches lasting approximately five years. The primary TCM diagnosis of Qi deficiency informs the treatment approach, emphasizing the strengthening of the Lungs and Spleen, tonifying Qi, and alleviating headache symptoms. A comparison is made between conventional TCM and Saam Acupuncture diagnostic and treatment approaches, highlighting different theoretical frameworks and acupuncture strategies.

Case History:

Patient Information:

Age: 52-year-old female

Primary Complaint: Chronic headaches for five years

Symptoms: Dull, intermittent headaches worsened by fatigue, exertion, cold exposure, and end-of-day fatigue. Pain is poorly localized, sometimes frontal. Reports a sensation of coldness in the head, relieved by wearing a scarf or hat. Weak neck muscles contribute to forward head posture.

Objective Findings:

Vital Signs: Blood Pressure: 123/78 mmHg, Heart Rate: 61 bpm

Tongue: Pale, swollen, scalloped with a thin white coating

Pulse: Weak and fine

Digestive Symptoms: Loose stools, pale-colored urine

Sleep: 9 hours per night, with established healthy sleep habits

TCM Diagnosis:

Primary Diagnosis: Qi deficiency, with symptoms indicating deficiencies in the Spleen and Lungs.

Treatment Principle: Strengthen the Lungs and Spleen, tonify Qi and Yang, raise Yang Qi to the head, and alleviate headaches.

Treatment Plan:

Acupuncture Prescription:

DU-20 (Baihui): Lifts Yang Qi, clears the head, and alleviates headache symptoms.

ST-36 (Zusanli): Tonifies Qi and Blood, enhances digestive function, and boosts overall vitality.

SP-6 (Sanyinjiao): Regulates the Spleen, Liver, and Kidneys, and supports fluid metabolism.

ST-40 (Fenglong): Resolves phlegm and dampness, harmonizes the Stomach and Spleen.

LV-3 (Taichong): Regulates Liver Qi and Blood, alleviates stress.

GB-41 (Zulinqi): Regulates the Gallbladder and Liver, clears Heat and Dampness.

(Initial Presentation:The patient, a 52-year-old female, presented with a chronic headache persisting for several months. She described the pain as a dull, continuous pressure located primarily in the frontal and temporal regions, often exacerbated by stress and lack of sleep. Previous treatments, including over-the-counter pain relievers, provided minimal relief.

First Treatment Session:During the initial consultation, the patient's pulse was assessed and found to be wiry, and her tongue appeared with a thin white coating, indicating internal imbalances consistent with liver qi stagnation. The treatment focused on relieving stress and promoting the smooth flow of liver qi. Acupoints used included LR3 (Taichong), GB20 (Fengchi), and LI4 (Hegu). Post-treatment, the patient reported a slight decrease in headache intensity, though the pain persisted.

Second Treatment Session:In the follow-up session, the patient mentioned that while the headaches continued, they were less intense and occurred with less frequency. A deeper assessment revealed tension in the neck and shoulders, contributing to the discomfort. The treatment was adjusted to address these musculoskeletal issues, including acupuncture points such as GB21 (Jianjing) and BL10 (Tianzhu), in addition to the points used previously. Following this session, the patient experienced notable relief, describing her headaches as "less bothersome" and reporting improved sleep quality.

Third Treatment Session:By the third session, the patient reported significant improvement, with headaches occurring only sporadically and with reduced intensity. The treatment was focused on consolidating the progress and preventing recurrence. Points used included ST8 (Touwei) for frontal headaches and SP6 (Sanyinjiao) to further balance the body's qi. The patient expressed satisfaction with the treatment outcome, noting that her overall quality of life had improved.

Conclusion:Over three sessions, the patient's chronic headache was effectively managed through a combination of acupuncture points aimed at relieving liver qi stagnation, addressing musculoskeletal tension, and promoting overall qi balance. The patient's feedback indicated a positive trajectory, with marked improvement in symptoms and daily functioning.)

Dietary and Lifestyle Recommendations:

Stay hydrated, maintain regular sleep patterns, manage stress, limit caffeine and alcohol, eat regular meals, exercise regularly, check posture, limit screen time, avoid headache triggers, and consider acupuncture or massage

Assignment (2000 words 10%) 20% of your course mark Learning Outcome assessed by this assignment is:

4. Compare and contrast different diagnostic theories used in traditional Chinese medicine diagnosis.

For this assignment, you need to choose one (1) real clinical case (non- musculoskeletal condition) from your clinical practices. Then compare and contrast different diagnostic theories and their application to this case. You need to fulfil the following criteria:

1. You will need to provide a short outline of the main complaint/presenting condition, age, gender and occupation, medical and surgical history and a summary of the relevant areas of the case history which informed your diagnosis (including subjective and objective findings). 2. The initial theory you present will be the one you applied when you diagnosed and treated the client within the clinic. This diagnostic theory will come from the previous TCMT courses. These include Eight Principles, Five Phases/Elements, Cause of Disease, Fundamental Substances, Zang Fu, Jing Luo (channel theory), Shang Han Lun, Wen Bing, San Jiao, etc. 3. Provide the treatment plan, including treatment principles, methods, point prescription and rationale, and dietary & lifestyle advice (if applicable) that you actually used within the clinical setting. 4. Next you should explore a new diagnostic theory from within Chinese Medicine that you have researched yourself. Some examples include but not limit to Dr. Tan's Balance Method, Master Tung's Acupuncture, Saam Acupuncture, Japanese Acupuncture (including Yoshio Manaka, Kiiko Matsumoto), Abdominal Acupuncture, Scalp Acupuncture, and so on. 5. You explore the same case from the theoretical perspective using the new diagnostic theory that you have researched, including the diagnosis with rationales, treatment principles and treatment plan. Instructions 1. This assignment is to be submitted electronically in your Moodle classroom. 2. You are asked to submit your assignment to both the assignment activity and the Turnitin activity that you will find created for you

Assignment formatting

Margins are 25mm each from the top, bottom, left, and right borders of the A4 paper. 2. Font size 12 (Times New Roman or Calibri) and 1.5 line spaced The referencing style is Vancouver. Below are two guides we recommend https://guides.library.uq.edu.au/referencing/vancouver/introduction https://www.cite.auckland.ac.nz/2_6.html ALL references must be of academic standard, such as a journal article, textbook, textbook chapter or suitable medical or governmental website. Please note the quality of content in web sources needs to be assessed very carefully. In general, website references (including Wikipedia and acupuncture practitioners websites) are unlikely to provide reliable information suitable for this assignment. Quotes must be in quotation marks and the in-text citation must include the page number. It is expected that you will use at least six reference sources. Your references need to include required or recommended readings from your course and sources you have located yourself. Please note these references do not include your lecture or power point notes, as the written information contained in your course notes may not be academic sources. If course notes are used, they are additional to the minimal references required and need to be referenced appropriately. https://guides.library.uq.edu.au/referencing/vancouver/lecture-notes Verbal information from your teacher is also additional to minimal references required and needs to be referenced in the body of your essay only as personal communication. https://guides.library.uq.edu.au/referencing/vancouver/personal-communication Please read the marking rubric (below and in your Moodle classroom) carefully. This explains how your assignment marks will be awarded. Please ensure your assignment covers all the criteria that will be marked

. Turnitin NZSATCM uses Turnitin software to monitor plagiarism. You are asked to submit your assignment to the Turnitin activity on Moodle that has been created to this essay. The similarly figure created is then placed on your title page.

(different diagnostic IS SAAM acupuncture)