Clinical Case #2

History and Symptoms

The patient has been experiencing migraine headaches for over 30 years, starting from the age of six. The headache intensifies with physical labor, fatigue, or prolonged cognitive activity. Additionally, the pain exacerbates every month during her menstrual cycle, which is often accompanied by heavy flow, dizziness, and forces her to remain in bed for two to three days. Other symptoms include vertigo, palpitations, poor memory, withered complexion, pale appearance of lips and nails, fatigue, and aversion to talking.

Diagnosis

To diagnose the chief complaint of headache, nine syndromes should be taken into account (refer to the link to headaches). The symptoms in boldface should be checked against those listed under each syndrome.

1. Wind-cold syndrome (2)

• Dizziness (1)
• Headache with dizziness (1)

2. Wind-heat syndrome (2)

• Dizziness (1)
• Headache with dizziness (1)

3. Wind-dampness syndrome (0)

• None

4. Liver yang upsurging syndrome (8)

• Dizziness (1)
• Headache (1)
• Headache in women (1)
• Migraine headache (5)

5. Dampness-sputum syndrome (5)

• Dizziness (1)
• Headache with dizziness (3)
• Prolonged dizziness (1)

6. Energy deficiency syndrome (6)

• Dizziness (1)
• Fatigued eyes and spirits (fatigue) (1)
• Headache occurring after labor and fatigue (2)
• Prolonged headache (2)

7. Blood deficiency syndrome (5)

• Dizziness (1)
• Fatigue (1)
• Headache with dizziness (3)

8. Kidney energy deficiency syndrome (3)

• Dizziness (1)
• Fatigue (1)
• Prolonged dizziness (1)

9. Blood coagulation syndrome (0)

• None

Conclusions

Based on the symptoms, the diagnosis is Liver Yang upsurging syndrome, which has a score of 8.