Migranie

Chief Complaint: Headache

Western diagnosis: Migranie-(dx. 02/96)

Medical History: 55 year old male, reports frontal and temporal unilateral headache, daily in the am for an hour and then in the evening.H x reveals that he has suffered from this kind of pain for approx. 15 years. worse: with light, in the evening and with stress. better: "nothing, makes it better. but i am still taking Imitrex" reports patient. overall H&P unremarkable.

Questioning exam: Energy is low, feels cold often, has chronic dull lumbar pain, chronic alternating diarrhea and constipation; poor sleep (4-6 hours, restless); urination normal;

Pulse exam: Deep and soft in in cun and guan position; chi position tight; "knotted" kidney pulse (bilaterally); pain in back worse with palpation, tender to the touch;

Tongue exam: tongue body: deep purple center, pale on the top and deep reddish on the sides;scalloped; tongue coat: dirty gray fur, rooted;

OM Diagnosis: Spleen & Kidney vacuity-cold, low back pain, alt. loose stools, low energy slow deep pulse; General qi vacuity with blood stasis in the gall bladder meridian history, location and quality of pain;

Treatment Principle: Invigorate yang, fortify spleen, supplement qi to promote blood circulation and remove blood stasis to relieve pain.

Point Prescription: He Gu-drain counter clockwise
Tai Chong-drain counter clock wise
Zu San Li-reinforce
San Yin Jiao-reinforce
Yin tang-drain; retention 20 minutes

Herbal Formula: Bu Zhong Yi Qi Tang (Pine Mountain brand)3 TID;

Lifestyle prescription: Medical qigong on gallbladder meridian; encouraged patient to join a qigong class; had patient agree to eliminate wheat from diet; taught patient's wife to treat low back moxa-use 10-15 per day at mingmen area.

Results: after three treatments at intervals at once per week-migraines in the evenings stopped. patient reports that migraines in the am are manageable and does not "seem" to need western med. i informed him to consult with his MD first before making that kind of decision. rebound time 14 days ( i have now seen this patient for 60 days; he comes in every two weeks now.) when he is on wheat free diet his enegy increase and stools become normal.

Synopsis: will be advising patient to take up low intensity exercise like tai ji or pilates class.