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FEATURE ARTICLE
Treatment of Migraine from the View of Disease Diagnosis and Syndrome Differentiation in Combination
LI Tao ( Migraine is the most commonly encountered type of headache, a kind of cerebral vasomotor dysfunction basically of genetic background induced by disorders of multiple angioneurotic media, like 5-HT, epinephrine, prostaglandin, etc. Besides, its characteristics of protracted course with repeated attacks are closely related with the secondary inflammatory reaction(1). Though nonsteroid analgesics, ergotamine preparations, as well as the recently discovered 5-HT receptor activators represented by triptans showed effects in alleviating acute headache symptoms, the long-term medication for relapse prevention with antidepressants, receptor blocking agents, antiepileptics, calcium antagonists like Nimodipine and Flunarizine, all showed evident adverse effects with low effective rate and quickly reducing efcacy, which makes the control of migraine far from satisfactory(2,3). Chinese medicine (CM) is effective for treatment of migraine, the records on the disease and its therapy could be traced back to 2 000-odd years ago, and the retrieve of current literature showed that the often used therapeutic principles were dispelling wind and turbid-phlegm, abating Gan ()-depression, and removing blood stasis. The author's experience in treating migraine obtained in over 20 years' clinical practice is introduced in this paper. ) the long term. That is what is called "to alleviate symptoms in urgent condition and to cure the root in mitigated stage" in CM. Western medicines for stopping pain, such as nonsteroid anti-inammatory drugs, aspirin (especially the buffered form or solution form), ibuprofen, and naproxen could alleviate mild migraine; as for pain of moderate and severe degree, ergotamine, dihydroergotamine, and triptans might be administered. Generally, the effect of oral-taking drugs is often initiated slowly, but orally administering Sumatriptan 50-100 mg may show evident effect within one hour. For sudden and severe headache, subcutaneous injection of Sumatriptan may be chosen, and its nasal spraying form could also show efciency immediately, and therefore, it is used in acute attack. For the most severe cases, visiting special clinics is necessary to avoid the occurrence of this accident. The utilization of decoction form preparation is restrained in the stage of acute attacks of migraine due to its discommodious process of preparation, while the patent Chinese medicines are relatively convenient for use. The commonly used effective patent CM drugs in clinical practice are those developed on the basis of ancient recipe, such as Chuanxiong Chatiao Powder ( ), Tongtian Oral Liquid ( ), Chuanxiong Chatiao Granule ( ), Zhengtian Pill ( ), Composite Cavel Granule ( ), and Zhennaoning ( ), etc. They all help relieve migraine attacks in a certain degree and may be selected in clinical application according to CM syndrome differentiation. Tuina and acupuncture could alleviate headache, which are simple and convenient for implementation, especially useful to patients unsuitable or contraindicated to drug therapy, or under

To Stop Pain in Urgent Condition and To Cure the Root in Mitigated Stage
To stop the headache is necessary during the attack of migraine. At that time, headache in patients is always intensive, accompanied with nausea, vomiting, etc., so the cooperative use of CM and Western analgesics is eligible. Acupuncture and massage also show obvious effects in alleviating headache. Systematic CM therapy is necessary after that for resolving relapses in

Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing (100091), China Tel: 86-10-62835331, E-mail: lt0016@263.net DOI: 10.1007/s11655-009-251-4

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the condition when there is no ready contingent drug for use on the spot(4). The most frequently used acupoints in acupunctural treatment include Fengchi (GB20), Shuaigu (GB8), Hegu (Ll4), Zulinqi (GB41), Zhongdu (GB32), Yifeng (SJ17) and Lieque (LU7), etc., and they may be used in combination(5). The manipulation of acupuncture frequently applied on patients during acute attacks is the reducing method and, for those in the remission stage, the tonifying method.

Treatment Based on Syndrome Differentiation

This therapeutic principle of CM denotes the process of deducing the syndrome according to clinical manifestation of the disease and implementing the treatment with corresponding recipes and drugs selected depending on the differentiated syndrome, which implies that a certain drug could produce the best efficacy and the least adverse reaction in patients with CM syndromes, involving the concept of "selecting the best indication for the CM drug used." It is the specicity of CM in treating diseases.

is often induced by emotional disorder, which belongs to Gan-qi depressive accumulation syndrome. Therefore, its treatment should be recuperating Ganqi with the recipe of modied Sini Powder (), prescribed as thorowax root 15 g, white peony root 20 g, immature orange fruit 12 g, atractylodes rhizome 15 g, angelica root 10 g, and licorice root 6 g. It is a recipe of gentle nature, which could be applied on patients with constitution that tends to be of both cold and heat nature; the dosage applied on patients with weak constitution should be reduced properly. It is taken as the basic recipe for the treatment of migraine by the author.

The Cold-Heat Nature of Disease Should Be Resolved through Circumspective Inquiring

To resolve the cold-heat nature of migraine is the key link for treatment. Patients' usual constitution and the inducing factors of illness could provide important foundation for the resolution. Many patients display evident aversion to heat and preference for coolness, illustrating the inner heat constitution of patients. For them, Chinese medicines such as gastrodia rhizoma, uncaria stem with hooks, puncturevine fruit, prunella spike, and artemisia herb could be added in the recipe; while for patients of cold constitution with aversion to cold and preference for warmth, evodia fruit 6 g may be added in the recipe used, and prepared aconite root 6-10 g and cinnamon bark 3 g are indicated for severe cases.

To Dispel Evil Wind Is the First Task for Relieving Headache

Chinese medicines for dispelling evil wind could enhance the efficacy of treating migraine in the attacking stage. Most Chinese medicines of this kind have analgesic effect and are extensively applied in the treatment of migraine. The wellknown recipe Chuanxiong Chatiao Powder, a classic Chinese recipe for curing headache of wind-cold accumulation syndrome, consists of wind dispelling drugs as its main component. It is chiey applied on patients with cold-natured constitution. Moreover, the Wind dispelling drugs could not only be applied on headache induced by outer wind-cold invasion, but also be added in the prescription for treatment of the migraine caused by internal injury to speed up the control of headache.

Utilization of CM Drugs for Activating Blood Circulation to Remove Stasis Synchronously in Treating both the Supercial Symptoms and Root of Illness
Being a chronic disease, migraine is difficult for radical cure because its protracted illness course could last as short as several months and as long as many years. CM holds that long-term illness course must induce blood stasis, so while treating the superficial symptoms, the attached use of activating blood circulatin to remove stasis (ABCRS) and dredging-meridian drugs may be the sole path for winning long-term remission. ABCRS method has been widely applied in treatment of migraine, which holds an important position in current clinical reports concerning CM therapy on migraine. Xuefu Zhuyu Decoction () and Tongqiao Huoxue Decoction ( ) are the commonly used recipes. The author prefers to add drugs for activating

The Essence of Radical Therapy Is to Put Stress on Gan-Recuperation

Migraine is characterized by secund headache on the temporal region, namely, the location of Taiyang acupoint, which belongs to the running path of Shaoyang Gan-meridian. Patients suffering from migraine always show symptoms of impatience and bad temper before and/or after attack, and the attack

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blood circulation and dredging meridian to the abovementioned recipes, such as chuanxiong, cythula root, and orientvine stem, which could lead to good clinical efcacy in reducing frequency and severity of headache. Besides, Wuzhuyu Decoction () is effective for the treatment of Jueyin () headache, but this kind of migraine is rarely seen. Some papers have reported treatment of migraine from the view of phlegm.

Make Much of the Predisposing Cause to Prevent Relapse

In case that the predisposing cause of migraine in a patient is known, the respondent measures should be applied for relapse prevention. For example, to migraine induced by excessive sleeping, the relapse could be reduced just by timely getting up, and to others induced by certain foodstuff, like grape wine, overdose of coffee, and deteriorated cheese, abstaining from them could enhance the effect of prevention. Some medicines can not only cause attacks but also affect the efcacy of prevention, which may occur in combined use of analgesics, excessive ergotamine, excessive 5-HT 1B/1D receptor excitants, oral contraceptive, vascular dilators (nitroglycerin, nifedipine), etc. Therefore, the excessive medication of abovementioned remedies should be avoided. Besides, some approaches, like Taichi, qi-gong, and other relaxation therapy for relaxing muscles in head-neck region, could not only help avoid relapses but also help relieve headache symptoms in migraine patients during attacks.

Use Guide-Drug Depending upon Actual Situation

In some patients, the pain may spread to different positions. In this case, no matter what type the migraine is, administering of guide-drug depending upon the position of headache presented would be favorable to enhance therapeutic efficacy, for example, ligusticum rhizome and evodia fruit for headache on the top of the head; scullcap root and dahurian angelica for headache on the forehead supra-orbital region; kudzuvine root and notoperygium root for headache on occipital region; and thorowax and scullcap for headache on Taiyang acupoint or temporal region.

Use Effective Recipe Persistently to Ensure the Courses Long Enough

Since migraine is a chronic disease and could not be cured in a short time, a rather longer therapeutic course is necessary for reducing or preventing relapse. As to how long it should be lies in what recipe is used. It has been reported that the treatment on most patients should be applied persistently for about four weeks, while for those with frequent attacks it may be prolonged to three months. The author offered that for patients with frequent attacks (1-3 times in a month), treatment by CM remedy for about 3-4 weeks could obtain a rather long period of relief. Although adverse reaction of CM in treating migraine is rarely found, attention still should be paid to the safety in treating patients that take CM for a long time.
1. 2.

REFERENCES
Yu SY, Pu CQ. Translate. Mannul for diagnosis and treatment of migraine. Beijing: Scince Press; 2002:24-64. Silberstein SD. Evidence-based guidelines for migraine headache (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2000;55:754-762. 3. Pryse-Phillips WE, Dodick DW, Edmeads JG, Gawel MJ, Nelson RF, Purdy RA, et al. Guidelines for the diagnosis and management of migraine in clinical practice. Can Med Assoc J 1997;156:1273-1287. 4. Melchart D, Linde K, Fischer P, Berman B, White A, Vickers A, et al. Acupuncture for idiopathic headache. Cochrane Reviews 2001;1: CD001218. 5. Huang PX, Liu MC, ed. Clinical diagnosis and treatment on nervous system diseases with traditional Chinese medicine. 2nd ed. Beijing: People's Medical Publishing House; 2005:235. (Received February 18, 2009) Edited by GUO Yan