Migraine Headaches – A Review Of Current Western And Traditional Chinese Medical Approaches To Diagnosis And Treatment

PART 1 – MIGRAINE HEADACHE IN WESTERN MEDICINE

Introduction

Headache is the most commonly occurring neurological disorder, affecting 60-80% of the population at any one time. (Sahai-Srivastava & Ko, 2008) According to the International Headache Society (IHS), The International Classification of Headache Disorders, 2nd Edition (ICHD-II), headaches are divided into two basic categories: primary and secondary. The former are those without any organic or structural causes. These include migraine headache, trigeminal autonomic cephalalgias (including cluster headache), tension headache, and other primary headaches (i.e. hemicrania continua, new daily persistent headache, exertional headache, headache associated with sexual activity, etc.). Secondary headaches are those due to an underlying structural or organic disease. (HCSIHS, 2005)

Migraine Headache Clinical Presentations

Migraine headache (MH) is now ranked by the World Health Organization as number 19 among all diseases causing disability world-wide. MH may occur with or without an aura. Migraine without aura tends to be more common as well as more disabling than migraine with aura. In some patients there may be a premonitory phase, occurring hours or days before the headache, and/or a resolution phase, characterized by such symptoms as hyperactivity, hypoactivity, depression, craving for particular foods, repetitive yawning. (HCSIHS, 2005)

The ICHD-II criteria for migraine without aura are as follows:

“A.       At least 5 attacks1 fulfilling criteria B-D

B.        Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)

C.        Headache has at least two of the following characteristics:

1.         Unilateral location

2.         Pulsating quality

3.         Moderate or severe pain intensity

4.         Aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs)

D.        During headache at least one of the following:

1.         Nausea and/or vomiting

2.         Photophobia and phonophobia

E.        Not attributed to another disorder”

(HCSIHS, 2005)

Migraine with aura is the same as described above, with the addition of focal neurological symptoms that usually develop gradually over 5-20 minutes and last for less than 60 minutes. This subcategory includes hemiplegic and basilar-type migraine. The ICHD-II criteria for this type of migraine are as follows:

“A.       At least 2 attacks fulfilling criteria B–D

B.        Aura consisting of at least one of the following, but no motor weakness:

1. Fully reversible visual symptoms including positive features (e.g., flickering lights, spots or lines) and/or negative features (i.e., loss of vision)
2. Fully reversible sensory symptoms including positive features (i.e., pins and needles) and/or negative features (i.e., numbness)
3. Fully reversible dysphasic speech disturbance

C.        At least two of the following:

1.         Homonymous visual symptoms and/or unilateral sensory symptoms

2.         At least one aura symptom develops gradually over =/>5 minutes and/or different aura symptoms occur in succession over =/>5 minutes

3.         Each symptom lasts =/>5 and =/<60 minutes

D.        Headache fulfilling criteria B-D for 1.1 Migraine without aura begins during the aura or follows aura within 60 minutes

E.        Not attributed to another disorder”

(HCSIHS, 2005)

In addition there Hemiplegic-type and Basilar-type migraine. See Appendix 1 for detailed descriptions

The ICHD-II criteria for chronic migraine are: “MH occurring on 15 or more days per month for more than 3 months in the absence of medication overuse.” (HCSIHS, 2005)

Diagnostic Issues

Although standard medical texts conform to the ICHD-II criteria when describing the clinical features of migraine headache and its variants, (Goadsby & Raskin, 2009; Aminoff, 2009; Sahai-Srivastava & Ko, 2008; Chawla, 2008) the clinical diagnosis of migraine is fraught with difficulties. The Scottish Intercollegiate Guidelines Network (SIGN) reports that 50% of patients with migraine are misdiagnosed with another type of headache. There are several factors that contribute to this: a) up to 75% of migraine patients experience neck pain along with the attack; b) in up to 40% of patients a single ICDH-II criterion will be absent; c) pain is bilateral in 40% of patients; d) the pain is described as non-pulsating in 50%; e) vomiting occurs in less than 33%. Therefore, the recommendation is that: ‘Patients who present with a pattern of recurrent episodes of severe disabling headache associated with nausea and sensitivity to light, and who have a normal neurological examination, should be considered to have migraine.’ (SIGN, 2008).

Aggravating factors

In a person who already meets the criteria for migraine, particular factors may be associated with a relatively long-term (usually weeks to months) increase in the severity or frequency of attacks. Examples of commonly reported aggravating factors include: psychosocial stress, frequent intake of alcoholic beverages, other environmental factors. (HCSIHS, 2005)

Trigger factors (precipitating factors)

Trigger factors increase the probability of a migraine attack in the short term (usually less than 48 hours) in a person with migraine. Though some trigger factors have been reasonably well studied epidemiologically (e.g. menstruation) or in clinical trials (e.g. chocolate, aspartame), causal attribution in individual patients may be difficult. (HCSIHS, 2005) Common triggers include chocolate, aged cheeses and meats, wine and beer (possibly due to the presence of sulfites), and citrus fruits. (Chawla, 2008)

Aetiology and Pathogenesis

Although the precise mechanisms of MH are at present still unknown, previous theories, in particular the vascular theory, have been shown to be invalid and progressively more facts are accumulating allowing an increasingly clearer picture of the physiological events underlying MH. (Charles, 2009; Chawla, 2008; Sahai-Srivastava & Ko, 2008)

MH is now regarded as ‘an episodic disorder of brain excitability, akin to epilepsy and episodic movement disorders’ (Charles, 2009) Evoked potentials (EP) studies have shown ‘impaired habituation to repeated sensorial stimulation and this abnormality was confirmed across all sensorial modalities, making defective habituation a neurophysiological hallmark of the disease.’ (Brighina, Palermo, & Fierro, 2009)

The theory of cortical spreading depression (CSD), described by Leao, explains how changes in cellular excitability may trigger waves of altered brain function in the form of a slowly propagated wave of depolarization followed by inhibition of brain activity (Leao, 1944 in Charles, 2009) CSD begins with the release of potassium or glutamate from neural tissue. ‘This release depolarizes the adjacent tissue, which, in turn, releases more neurotransmitters, propagating the spreading depression.’ (Sahai-Srivastava & Ko, 2008) This may be the mechanism underlying the phenomenon of migraine aura. Thus, regional cerebral blood flow is decreased in the cortex corresponding to the clinically affected area, often also including an even wider area. (Charles, 2009; HCSIHS, 2005) However, regional cerebral blood flow shows no changes suggestive of CSD during attacks of migraine without aura. (HCSIHS, 2005)

Recent studies have shown that the premonitory symptoms, nausea, vertigo and autonomic symptoms in MH are due to activation of the hypothalamus and brain stem. (Charles, 2009) These areas of the brain may, in fact be the sites of origin of MH.  (Charles, 2009; Sahai-Srivastava & Ko, 2008; Chawla, 2008)  

Other researchers have found that magnesium deficiency may play an important role in altering cerebral cellular excitability. (Sun-Edelstein, & Mauskop, 2009; Sahai-Srivastava & Ko, 2008).

Treatments for Migraine

Treatment begins with identification of precipitating factors and the advice to avoid them. (Goadsby & Raskin, 2009) Pharmacological treatment involves separate treatments for the acute attack (in order to abort or alleviate it) and preventative treatments to minimize recurrence and reduce severity of subsequent attacks. Treatment approaches are stratified according to the intensity of the symptoms and the degree of disability experienced. (Chawla, 2008; Goadsby & Raskin, 2009; Aminoff, 2009) According to SIGN, ‘treatment begins with an analgesic and an anti-emetic if also required, escalating to a 5HT-1 agonist (i.e. triptan) as required’. A non-steroidal anti-inflammatory drug (NSAID) can be given following, or added to, a triptan for resistant attacks.’ (SIGN, 2008)

Preventative therapy may be instituted under the following conditions:

• ‘Two or more attacks each month with significant disability that lasts 3 or more days
• Contraindication to or ineffectiveness of symptomatic medications
• Use of abortive medications more than twice a week
• Migraine variants such as hemiplegic migraine or rare headache attacks producing profound disruption or risk of permanent neurological injury’

(Chawla, 2008)

Efficacy of Pharmacological Treatments

The NSAID’s (e.g. ibuprofen), aspirin and paracetomol are commonly available over the counter medicines, which have been the subject of RCT’s. Aspirin alone or ibuprofen alone gives effective pain relief for all grades of MH in about 50% of cases. A combination of paracetomol, aspirin and caffeine is effective in 84% of patients with mild to moderate MH. Paracetomol alone is effective in 57.8% of moderate (but not severe) cases; ketoprofen is effective in 62%. (SIGN, 2008)

For patients with moderate MH, the triptans provide effective pain relief in 51-59% of patients (i.e. freedom form pain after 2 hours). (SIGN, 2008)

It should be noted that the use of the above acute stage medications needs to be restricted to 2-3 days a week in order to prevent the development of a rebound headache phenomenon. (Aminoff, 2009; Chawler, 2008) See Appendix 2 for the clinical features of the rebound headache phenomenon.

Preventative medications include beta blockers, anti-epileptics, and antidepressants. According to Chawler, ‘most preventive medications have modest efficacies and have therapeutic gains less than 50% when compared to placebo.’  (Chawler, 2008) In addition most have unpleasant side effects, e.g.

• Beta blockers: impotence (males), 
• Anti-epileptics: weight loss and dysesthesia, polycystic ovary disease (Sahai-Srivastava & Ko, 2008)
• Antidepressants, e.g. amiptryptiline (AMT), venlafaxine (VLF).  AMT: hypersomnia, difficulty in concentration, orthostatic hypotension; VLF: nausea and vomiting. (Bulut, Berilgen, Baran, Tekatas, Atmaca, Mungen, 2004).

Appendix 1:

Hemiplegic migraine

Hemiplegic migraine is as described above for migraine with aura with the addition of fully reversible motor weakness. Basilar-type migraine is as described above for migraine with aura with the addition of at least two of the following fully reversible symptoms, but no motor weakness:

• dysarthria
• vertigo
• tinnitus
• hypacusia
• diplopia
• visual symptoms simultaneously in both temporal and nasal fields of both eyes
• ataxia
• decreased level of consciousness
• simultaneously bilateral paraesthesias

(HCSIHS, 2005)

Appendix 2:

Analgesic rebound headache

The following are the clinical features of analgesic rebound headache:

• Headache occurs daily or near daily
• Occurs in a patient with primary headache disorder who uses immediate relief medications very frequently, often in excessive quantities
• Headache varies in intensity, type, severity, and location from time to time
• Slight physical or intellectual effort bring on headaches; threshold for pain low
• Headache accompanied by asthenia, nausea and other GI symptoms, restlessness, anxiety, irritability, memory problems, difficulty in intellectual concentration, and depression
• Drug-dependent rhythmicity of headaches
• Evidence of tolerance to analgesics over a period of time
• Withdrawal symptoms when taken off the medications abruptly
• Spontaneous improvement of headache on discontinuing the medications

(Chawler, 2008)

PART 2 – MIGRAINE HEADACHE IN TCM

Introduction

Traditionally, headaches have been categorized according to exopathic cause or endopathic cause, particularly in regard to herbal treatment. (Shi, 2003, p.191; Bo, 2000, p.333; Wang, 1996, p.240-241; Maciocia, 1994, p.12, 19-52; Scott, 1984) In addition, headaches are categorized according to location of the pain. (Scott, 1984; Blackwell, 1991; Wang, 1996, p.240; Deadman, Al-Khafaji & Baker, 1998; Flaws & Sionneau, 2001, p.347-351; Shi, 2003, pp.192, 198) Although not a distinct subcategory of headache in the classical literature, MH has recently been defined and categorized according to TCM principles. However, there is much divergence amongst various authors and it is apparent that the understanding of MH in TCM is still evolving.

Definitions of MH and its Aetiology

Generally, MH is categorized as tou feng (Wind in the head) and pian tou tong (pain in one half of the head), and is mainly due to internal injury brought about by emotional factors leading to Liver Yang hyperactivity (Flaws & Sionneau, 2001, p.346; Yin & Liu, 2000, p.370; Blackwell, 1991) Some authors note that the disease causes may also include dietary factors, hormone fluctuations during the menstrual cycle as well as the effects of ageing. (Flaws & Sionneau, 2001, p.346) In addition, it has been noted that exterior Wind-Cold may be a trigger factor in cases where MH is brought on as a result of allergic factors, neck injury or contraction of the common cold. (Jiang, 2004)

Chinese publications before 2004 (the year that the IHS revised the classification of headaches) as well as some Western publications use the terms ‘vascular headache’ and ‘migraine’ interchangeably. (Bo, 2000, pp. 335-337; Maciocia, 1994, p.54; Sahai-Srivastava & Ko, 2008) Moreover, some Chinese publications fail to distinguish between the various types of headache and other localized head pain. (e.g. Shi, 2003, pp.191-198, Wang, 1996, pp.240-247)

Pathogenesis

Flaws and Sionneau provide a succinct description of the disease mechanisms in migraine; the state of the Liver being the most important factor. Liver constraint due to emotional strain leads to stagnation of the Qi; due to the Yang nature of Qi, the main areas affected are in the upper body, either along the course of the Liver channel to the eyes and vertex or in the Shao Yang channel to cause pain in the temporal region. Additionally, the Liver Qi may invade the Stomach, causing nausea and vomiting. Stagnant Qi tends to develop Heat, which may further transform into Fire, and Fire may provoke interior Wind. All of these pathogens tend to rise upwards in the body, congesting within the confines of the cranium, causing pain. In women, the cyclic fluctuations of the menstrual cycle may compound the pathologies described above. At mid-cycle, when Yang predominates, the ministerial Fire becomes exuberant and may cause or worsen the development of Fire from the stagnant Liver Qi, thus precipitating migraine attacks. Additionally, the premenstrual movement of Blood into the uterus may lead to Blood deficiency in the Liver, which will lead to the development or worsening of the Liver constraint – Qi stagnation, setting in train the sequence of pathological events described above. The relative condition of Yin-Blood deficiency immediately after menstrual bleeding may cause or aggravate Liver Blood deficiency and/or Liver Yin deficiency. The former may lead to Liver constraint-Qi stagnation and the latter to Liver Yang hyperactivity, both of which may underlie migraine attacks. With advancing age, as a woman approaches the menopause, Liver Blood and Kidney Yin are generally in a state of decline. Thus, women may be more predisposed to migraines during this time due to the increased tendency towards Liver constraint-Qi stagnation and Liver Yang hyperactivity, arising as a result of the age-related depletion of the Yin and Blood.

A vicious cycle may develop, leading to a chronic condition: Liver constraint-Qi stagnation tends to affect the Spleen, leading to Spleen Qi deficiency. This, in turn, leads to Blood deficiency because of the diminished production of Qi and Blood by the Spleen, thus worsening the condition of the Liver. Moreover, Spleen deficiency may lead to the retention of Phlegm-Damp. These pathogens may also become involved in the development or worsening of migraines. The normal Qi movements of the middle Jiao may become disrupted due to congestion by Phlegm-Damp, which subsequently rise up to the head and cause stagnation of the Qi and Blood and blocking the clear orifices, thus leading to MH. These events are most likely to occur against a background of Liver Qi stagnation, internally generated Fire and interior Wind. In cases with severe pain, the headache is caused by Blood stasis within the network vessels, which has developed due to prolonged or recurrent Qi stagnation. (Flaws & Sionneau, 2001, p.346-347)

Commonly seen Clinical Syndrome-Patterns

Yin and Liu describe two major syndrome-patterns underlying MH: Hyperactivity of the Liver Yang; and Kidney Yin deficiency. (Yin & Liu, 2000, p.370) Bo includes stagnation of Phlegm (or Wind-Phlegm) as well as Wind-Heat (Bo, 2000, pp. 335,337). Hou describes two main syndrome-patterns: Obstruction of the Channels and Collaterals by Wind and Phlegm and Blood Stasis, Flaring-up of Wind-Fire. (Hou, 1996, pp. 80-82) Flaws describes five patterns: Liver depression-Qi and Blood vacuity; ascendant Liver Yang hyperactivity; Cold reversal; Phlegm reversal; Blood stasis obstructing the Network Vessels. (Flaws & Sionneau, 2001, p.346-347)

Based the above description of the pathogenesis of migraine, we can divide the syndrome-patterns into ben (underlying causes or chronic co-existing pathologies) and biao (symptom manifestations or immediate causes of symptomatology) in the following way:

Ben:

• Kidney Yin deficiency (or Kidney and Liver Yin deficiency)
• Qi and Blood deficiency
• Liver constraint, Qi stagnation

Biao:

• Hyperactivity of the Liver Yang
• Liver Fire
• Obstruction of the Channels and Collaterals (by one or more of: Wind, Phlegm, Cold, Blood Stasis)
• Flaring-up of Wind-Fire

Migraines generally develop with the progression of one or more of the ben syndromes to develop one or more of the biao syndromes. Treatments should be divided into two phases: a) preventative treatment between attacks and b) treatment during the acute episodes. (Flaws & Sionneau, 2001, p.351) In addition, the biao factors include differentiation of the affected Channels, based upon the location of the pain. (Scott, 1984; Blackwell, 1991; Wang, 1996, pp.240-241; Deadman, Al-Khafaji & Baker, 1998; Flaws & Sionneau, 2001, p.347-351; Shi, 2003, pp.192, 198)

Clinical Outcomes

There are two recent systematic reviews, which have concluded that acupuncture is an effective treatment for MH prophylaxis, at least as effective as current pharmacological interventions and without side effects. (Linde, Allias, Brinkhaus, Manheimer, Vickers, et al., 2009; Sun & Gan, 2008) Moreover, acupuncture has been shown to also be superior to medication therapy in improving headache intensity, frequency, and response rate. (Sun & Gan, 2008) In addition, there are several well conducted clinical trials that have recently demonstrated the efficacy of acupuncture treatments for MH, showing considerably better outcomes than pharmacological interventions. (Zhong, Li, Luo, Wang, Wu, Zhou, et al., 2009; Faco, Liguori, Petti, Zanette, Coluzzi, De Nardin, et al., 2008)

Evidence for the effectiveness of herbal medicines also quite good. The TCM formula Wu Zhu Yu Tang appears to be of comparable effectiveness in selected populations to pharmacological intervention for prevention of MH. (Odaguchi, Wakasugi, Ito, Shoda, Gono, Sakai, et al., 2006). Xiao Yao San, administered as nasal drops shows a high degree of effectiveness in aborting MH (Hu, Zhou & Wang, 2006) Chinese herbal medicine administered according to TCM principles was shown to be effective in MH patients who responded poorly to pharmaceuticals. (Melchart, Hager, Liao, Weidenhammer, Linde, 2004)

ACUTE STAGE TREATMENTS ACCORDING TO TCM SYNDROME-PATTERNS

The pathodynamics underlying any particular clinical case is likely to be complex. As pain is the single most important clinical feature, Blood stasis should be addressed in all cases. Thus, one of the formulas described under the subheading of Blood Stasis will be included in all acute stage treatments. In addition, Interior Wind is also a common feature, and this often occurs due to Liver Fire or stagnant Heat in the Liver. In some cases, there is also Phlegm, which binds with Wind to exacerbate the symptoms. In such cases several appropriate formulas will be prescribed together in order to cover each aspect of the patient’s pathology.

The common clinical presentations are given below together with key diagnostic features and suggested TCM herbal and acupuncture treatments.

Liver Yang rising with Interior Wind

(visual aura or other visual disturbance, dizziness, tinnitus, irritability, red tongue, wiry pulse)

Ping Gan Xi Feng Tou Tong Wan (Gastrodia & Vitex Formula) [a.k.a. HEADACHE RELIEF FORMULA]

Acupuncture: LR-3; LR-8; Sp-6; SJ-5; GB-20; M-HN-9 (taiyang); plus local points according to the site of pain and distant points according to the Channel

Liver Fire

(red face and eyes, bitter taste in the mouth, thirst, dark and scanty urine, constipation with dry stools, red tongue with a yellow coat, rapid pulse)

Long Dan Xie Gan Tang (Gentiana Fomula) [ANTI-INFLAMMFORMULA]

Acupuncture: LR-2; SP-6; SJ-5; GB-38; GB-20; M-HN-9 (taiyang); plus local points according to the site of pain and distant points according to the Channel

Liver constraint, Qi stagnation

(history or stress or emotional strain, distending sensation in the hypochondrium, wiry pulse)

a) Deficiency syndrome-pattern (Liver Blood deficiency)

Xiao Yao San (Bupleurum and Dang-gui Formula) [a.k.a. STRESS RELIEF 2 FORMULA]

OR

Jia Wei Xiao Yao San (Bupleurum & Peony Formula) [a.k.a. STRESS RELIEF 1 FORMULA]

b) Excess syndrome-pattern with Blood stasis

Chai Hu Shu Gan Tang (Bupleurum & Cyperus Combination) [a.k.a QI MOVER FORMULA]

Acupuncture: LR-3; Sp-6; GB-34; LI-4; ST-36; Du-24; M-HN-9 (taiyang); plus local points according to the site of pain and distant points according to the Channel

Wind Phlegm

(excessive sputum, nausea, fullness of the chest and/or epigastrium, greasy tongue coat)

1. With Heat (red tongue with a  yellow coat)

Wen Dan Tang (Bamboo & Hoelen Formula) [a.k.a. CLEAR THE PHLEGM FORMULA]

OR

b) With Cold (pale tongue with a white coat)

Er Chen Wan (Citrus & Pinellia Combination)

Acupuncture: ST-40; LI-4; LU-7; Du-20; ST-8; plus local points according to the site of pain and distant points according to the Channel

Stasis of Blood

(fixed pain)

Tao Hong Si Wu Wan ((Persica, Carthamus & Dang-gui Combination) [a.k.a. BLOOD MOVING 2 FORMULA]

OR

Xue Fu Zhu Yu Tang (Persica & Cnidium Combination) [a.k.a. BLOOD MOVING FORMULA]

Acupuncture: LI-4; LI-11; SP-6; LR-3; plus local points according to the site of pain and distant points according to the Channel

ACUPUNCTURE TREATMENTS ACCORDING TO THE SITE OF PAIN

(Sourced from: Scott, 1984; Blackwell, 1991; Maciocia, 1994, pp.7-10; Deadman, Al-Khafaji & Baker, 1998; Flaws & Sionneau, 2001, p.347-351; Shi, 2003, pp.192, 198)

Vertex (i.e. the area round Baihui Du-20)

Channel/s: Jue-yin; Liver, Du mai

Local points: DU-20, Du-21

Distant points: LR-3; BL-67; LR-2; GB-34; SI-3

Temporal area

Channel/s: Shao-yang; GallBladdder, Liver; San-jiao

Local points: GB-4; GB-5; GB-8; M-HN-9 (taiyang); GB-20

Distant points: SJ-3, SJ-4, SJ-5, GB-34, GB-41, LU-7

Frontal area (i.e. forehead)

Channel/s: Yang-ming; Stomach, Large Intestine

Local points: ST-8, DU-23, GB-14; BL-2;

Distant points: LI-4, ST-44.

Back – (across the occiput)

Channel/s: Tai-yang; Bladder, Du mai

Local points: BL-9; BL-10; DU-19; DU-15, DU-16; DU-14; BL-11.

Distant points: SI-3; BL-60; SI-6; SI-1

REFERENCES

Aminoff, M. (2009). “Chapter 24. Nervous System Disorders” (Chapter). McPhee, S., Papadakis, M., Tierney, L.: CURRENT Medical Diagnosis & Treatment: http://www.accessmedicine.com/content.aspx?aID=12507.

Blackwell, R. (1991). The Treatment of Headache and Migraine by Acupuncture. JCM;(35):20-26

Bo, P. (chief ed.). (2000). Traditional Chinese Internal Medicine. Beijing: People’s Medical Publishing House.

Brighina, F., Palermo, A., Fierro, B. (2009). Cortical inhibition and habituation to evoked potentials: relevance for pathophysiology of migraine. J Headache Pain; 10(2):77-84.

Bulut, S., Berilgen, M., Baran, A., Tekatas, A., Atmaca, M., Mungen, B. (2004). Venlafaxine versus amitriptyline in the prophylactic treatment of migraine: randomized, double-blind, crossover study. Clin Neurol and Neurosurg; 107 (2004) 44–48

Charles, A. (2009). Advances in the Basic and Clinical Science of Migraine. Ann Neurol. 65(5): 491-8

Chawla, J. (2008). Migraine Headache. In eMedicine Specialties, Neurology, Headache and Pain. Retrieved 1st August, 2009 from: http://emedicine.medscape.com/article/1142556-overview

Deadman, P., Al-Khafaji, M., Baker, K. (1998). Some Acupuncture Points Which Treat Headache. JCM 58: 5-18

Faco, E., Liguori, A., Petti, F., Zanette, G., Coluzzi, F., De Nardin, M., Mattia, C. (2008). Traditional acupuncture in migraine: a controlled, randomized study. Headache.;48(3):398-407

Flaws, B. & Sionneau, P. (2001). The Treatment of Modern Western Diseases With Chinese Medicine: A Textbook & Clinical Manual. Boulder, CO: Blue Poppy Press

Goadsby, P., Raskin, N. (2009). “Chapter 15. Headache” (Chapter). Fauci, A., Braunwald, E., Kasper, D., Hauser, S., Longo, D, Jameson, J., Loscalzo, J: Harrison’s Principles of Internal Medicine, 17e: retrieved August 21, 2009 from: http://www.accessmedicine.com/content.aspx?aID=2890365.

Guerra, M., Volpe, S., Mao, J. (2009). Therapeutic uses of magnesium. Am Fam Physician. 80(2):157-62

Headache Classification Subcommittee of the International Headache Society (HCSIHS) (2005). The International Classification of Headache Disorders, 2nd Edition, 1st revision. Retrieved 1st August, 2009 from: http://ihs-classification.org/en/0_downloads/

Hou, J (chief ed.) (1996). Traditional Chinese Treatment for Psychogenic and Neurogenic Diseases. Beijing: Academy Press

Hu, H., Zhou, Y., Wang, X. (2006). Clinical study on effect of Xiaoyao Nose Drops in stopping episode of migraine. Chin J Integr Med.;12(2):112-7

Jiang, D. (2004). Management of Migraine using Traditional Chinese Medicine. JCM; (76):40-44

Leao, A., (1944). Spreading Depression of Activity in the Cerebral Cortex. J Neurophysiol; 359-390

Linde, K., Allias, G., Brinkhaus, B., Manheimer, E., Vickers, A., White, A. (2009). Acupuncture for migraine prophylaxis. Cochrane Database Syst Rev.;(1):CD001218

Maciocia, G. (1994). The Practice of Chinese Medicine. The Treatment of Diseases with Acupuncture and Chinese Herbs. Edinburgh: Churchill Livingstone

Melchart, D., Hager, S., Liao, J., Weidenhammer, W., Linde, K. (2004).Treatment of patients with chronic headaches in a hospital for traditional Chinese medicine in Germany. A randomised, waiting list controlled trial. Complement Ther Med.;12(2-3):71-8

Odaguchi, H., Wakasugi, A., Ito, H., Shoda, H., Gono, Y., Sakai, F., Hanawa, T. (2006). The efficacy of goshuyuto, a typical Kampo (Japanese herbal medicine) formula, in preventing episodes of headache. Curr Med Res Opin.; 22(8):1587-97

Sahai-Srivastava, S., Ko, D. (2008). Pathophysiology and Treatment of Migraine and Related Headache. From eMedicine Specialties, Neurology, Headache and Pain. Retrieved 1st August, 2009 from: http://emedicine.medscape.com/article/1144656-overview

Scott, J. (1984). The Diagnosis and Treatment of Headaches by Acupuncture. JCM (15):5-29

Scottish Intercollegiate Guidelines Network (2008). Diagnosis and Management of Headache in Adults – A national clinical guideline. Edinburgh: Scottish Intercollegiate Guidelines Network. Retrieved 1st August, 2009 from: http://www.sign.ac.uk/guidelines/fulltext/107/index.html

Shi, A. (2003). Essentials of Chinese Medicine: Internal Medicine. California: Bridge Publishing Group

Sun, Y., Gan, T. (2008). Acupuncture for the management of chronic headache: a systematic review. Anesth Analg.;107(6):2038-47

Sun-Edelstein, C., Mauskop, A. (2009). Role of magnesium in the pathogenesis and treatment of migraine. Expert Rev Neurother; 9(3):369-79

Wang, S. (1996). Advanced Textbook on Traditional Chinese Medicine and Pharmacology, Vol. III. Beijing: New World Press.

Yin, G., Liu, Z. (chief eds.) (2000). Advanced Modern Chinese Acupuncture Therapy. Beijing: New World Press

Zhong, G., Li, W., Luo, Y., Wang, S., Wu, Q, Zhou, B., Chen, J, Liu, B. (2009) Acupuncture at points of the liver and gallbladder meridians for treatment of migraine: a multi-center randomized and controlled study. Zhonguo Zhen Jiu.;29(4):259-63