Chief Complaint: Migraine Headache
Medical History: Ten year old male, complaining of migraine headaches which occur at any time of day. He had been having them since he was five years old. The H.A. would usually cause him to vomit. Prior to the onset of H.S he would see black spots, have ear ringing.
He would be very active while sleeping, kicking off the covers, tossing & turning. Red /purple color under the eyes (lower eyelid). He has a poor diet, very picky eater. Had problems in school.
Questioning exam: Headache that began behind the eyes and went back along the side of the head.
Tenderness at Lv3, Gb41,42, Lv14 and along the Gb channel on the head Gb 8-Gb20
Pulse exam: Pulse was weak & slow upon initial eval.
On the second eval the pulse was more wiry esp Sp & Lv but Ki was defecient.
Tongue exam: the body was pale except the tip & the right side which were red. There were also prickles evident.
OM Diagnosis: Lv yang rising due to Sp qi deficiency.
Treatment Principle: Tonify sp qi, sedate Lv yang, smooth Lv qi.
Point Prescription: Lv3,8, Sp 6, Sj5, Gb20,43
Herbal Formula: Formulae - Xiao Yao wan & Ba Zhen Wan
Lifestyle prescription: Dietary changes - eliminate chocolate, citrus fruit, tryamines.
Eat less junk food and more home amde foods.
Results: The patient has only had two H.A. since January when he statred treatment. Each time ti came on the heels of an illness. Otherwise the pt is free of H.A. and was doing much better in school, not even missing any days. He was initially treated twice weekly, then was stepped down to once a week. Then he stepped down to once a week and after April he was stepped down to once every other week. This is the current regimen.
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