More painkillers, yet the headaches keep coming more often
Female, 42. Recurrent headaches for 6 years, worsening over the past 2 years. Prior care: neurology and pain clinics.
Attack frequency rose from once or twice a month to six to eight times, and painkillers were needed more than twelve days a month. The hard part of this case is not pain relief itself, but steadying the attack rhythm and easing the medication dependence together.
History and prior work-up
Recurrent episodic headache for 6 years, worsening year by year over the past 2: frequency increased from 1–2 attacks per month to 6–8 per month, each lasting 4–24 hours. Pain was mainly unilateral, pulsating, over the temple, sometimes spreading behind the eye, with nausea, photophobia, phonophobia, and occasional visual aura (flashing lights). Triggers clustered around the menstrual period, sleep loss, emotional stress, and alcohol.
Brain MRI, carotid ultrasound, blood count, and biochemistry showed no clear abnormality; secondary headache had been excluded by neurology. Acute treatment included ibuprofen, acetaminophen, and triptans; flunarizine was tried for prevention with limited effect and was stopped.
- Key issue: over the past 3 months, acute painkillers were used 12–15 days per month, meeting the risk threshold for 'medication-overuse headache (MOH)'. This needs co-management with neurology; we do not advise abrupt withdrawal on our own.
Examination and pattern differentiation
The pattern is mainly ascendant liver yang with blood stasis obstructing the collaterals, combined with liver constraint transforming into fire. The reasoning rests on three mutually confirming points: the location and timing of the pain, the link with mood and the menstrual cycle, and the tongue and pulse (wiry, thready, dark tongue). This corresponds to the textbook patterns of headache due to ascendant liver yang and blood stasis in Chinese internal medicine.
- Pain located at one temple, radiating to the vertex; pulse wiry and thready; tongue dark red with a thin white coat.
- Lusterless complexion; easily irritated, shallow sleep with many dreams; occasional bitter taste and dizziness; premenstrual breast distension.
Treatment pathway
- External treatment first: Fengchi (GB20), Taiyang (EX-HN5), Shuaigu (GB8), Baihui (GV20), Hegu (LI4), Taichong (LR3), Neiguan (PC6), plus ashi points at the most tender spots. Acupuncture is the mainstay; for severe pain, electroacupuncture (2 Hz) is added, alternating sides between sessions to avoid point fatigue. Twice weekly, 4 weeks per course.
- Herbal decoction as support: for ascendant liver yang, Tianma Gouteng Decoction with modifications (to settle the liver and subdue yang); for blood stasis obstructing the collaterals, Tongqiao Huoxue Decoction (decoction for orifices and blood flow) with modifications (to move blood, open the orifices, and relieve pain); where phlegm-damp predominates, we draw on Banxia Baizhu Tianma Decoction in combination. Dosage and modifications are set at the in-person consultation.
- Classical reference: Wang Qingren's Yi Lin Gai Cuo (Correcting Errors in the Forest of Medicine) used Tongqiao Huoxue Decoction for headache due to blood stasis.
- Concurrent management: review painkiller use frequency and agree a tapering pace with neurology (no abrupt self-directed stop); keep a headache diary (frequency, intensity, triggers, medication).
Re-evaluation
| Timepoint | Headache days | Painkiller use | Sleep / mood |
|---|---|---|---|
| Baseline at first visit | 8 days/month | 12 days/month | Shallow sleep, irritable |
| Week 4 review | ≤6 days/month | ≤8 days/month | Easier sleep onset |
| Week 8 review | ≤4 days/month | ≤4 days/month | Mood stable |
Follow-up and advice
The 4-week course is the review node. Goals are framed as 'reduce attack frequency, reduce severity, reduce reliance on painkillers' — we do not promise a cure. Avoid individual triggers (sleep deprivation, alcohol, cheese, and so on). If headaches keep worsening or new neurological signs appear, return to neurology for re-assessment.