Western Diagnosis: Migraine
Medical History:
HPI: a 44 years old F. pt. seeks acupuncture treatment for her migraine today. her condition started when she was in 4th grade and has been treated by many doctors and modalities without satisfactory improvement. The patient denied her migraine associated with menstrual cycle or optical status but stress. Additionally, the pt. mentioned she would have a headache again if she skips meals a day. The pain primarily takes place on the left temp. area in a tense/consistent fashion, and could last form a few hours to 3 days, which affect concentration and feel exhaustion. She complaint ache and tension on the neck and shoulder areas, too.
Questioning exam: PMH: See Health Wellness Awareness sheets (HWA)
PSH: See HWA
FHx: nobody in her family has similar condition
SHx: alcohol occasionally
Meds: Ibuprofen and Masalt
Alllergy: NKDA
ROS: the pt. prefers stronger taste food such as spicy or salty food, otherwise, food is not much appeal to her. Her BM is regular once a day. Regular menses lasts 3 days per period. Cramping usually occurs the first. Crying easier before menses sometimes.
Cold hands and feet. Difficultly fall into sleep recently.
Pulse exam: PE: 110/78 mmHg, P 60
Pulses – slippery in general. Weak at “cun” and deep at “chi” bilaterally.
Liver pulse is significantly active.
Tongue exam: Thin and tender, slight pale with thin yellow coat
OM Diagnosis: Kd deficiency fails to nourish liver so that internal wind disterb the Shaoyang.
Treatment Principle: Supplement Kidney, soothe Liver Qi and relieve pain
Point Prescription: GB 20, Liv4, K3 bilaterally
GB4, Taiyang and St 7, left
25″ needling
Herbal Formula: Tian ma Qu Feng Zhi Teng Pian or
Bupluenum D & B Formuar
8×3/D
Lifestyle Prescription: stress management
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