lauramcgraw: April 29, 2019, 12:21am
Anyone with thoughts on this case? 16 year old girl with a chronic headache across forehead for 1 year, started
after getting pneumonia last april then a sinus infection. After that cleared up the headache appeared.They found an
archnoid cyst in an mri but didn’t think it was related. After many months they decided to remove it but no
headache relief. The H/A is achy in nature, worse with exercise(She’s a competitve swimmer) also happens with
jumping or running. when she starts exercising the headache gets sharp and has to stop, rest does not help. Tension
in back of neck, especially at GB20. She is very cold, thin with clammy hands,feet. Lips are very red and dry,
tongue is slightly red,moist and is puffy, pulse is slightly wiry on guan on both sides, more so on left side. Her
sweating seems normal with exercise does not get thirsty. She has no digestive problems, good appetite, normal
bowels. The first treatment I suppl heart as she is very cold, blue toes, icy cold with cold sweaty hands and feet. her
whole right side warmed up on the table so I suppl heart on the left also and she felt great, but no change in
headache. The second treatment I tried suppl lung as she is really thin with clammy hands and has these red dry
lips, no relief from headache. Then tried PC on the right side for GB head pain, no relief, I added the heart again
and it warmed her up but no change in headache.
Wondering if this just needs time to get relief from her headache? She is unwilling to take herbs at this point,
working on this!
Thanks for any insights.
michaelmax: April 10, 2019, 5:08pm
Hey @lauramcgraw that is a tough case.
The cold sounds rather pronounced, and she’s had some positive change with tonifying the heart. Maybe stick with
it for a couple of treatments in a row to see if it would help the HA.
Of course, watching for signs that she is not getting overheated.
I’m curious at the tension in the back of the head at GB20. Yes it’s the GB channel, but I’m still wondering about
some deep seated cold in the taiyang UB channel. And if that area loosens up, perhaps the front of the head would
relax as well.
KristinWisgirda: April 10, 2019, 6:21pm
Hi,
Thanks for the case. I am wondering if there any signs of Liver deficiency/SJ excess: Are her eyes bright? Any
light sensitivity? Is she pale?
My next thought is supplementing SI for pain. Is she very beautiful?
I would love to hear Toby’s take.26/01/2024, 12:25Year long headache – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/year-long-headache/72/print2/7
lauramcgraw: April 10, 2019, 7:22pm
Thanks for the idea to keep with the heart,Yes the cold is what sticks out for me, which makes sense with your
Taiyang cold bladder idea. I palpated the bladder channel at back of her neck and it doesn’t cause as much pain as
the GB channel.
lauramcgraw: April 10, 2019, 7:51pm
Thanks for the suggestions, I did think about liver. She does have some slight iron def from her blood panel and
she is a blood def gui zhi tang type although her tongue is puffy but not pale. She seems on the border of liver/SJ, I
didn’t get a big hit either direction, she’s not overly polite nor rude, cheeks can get rosy. She is not beautiful,I did
think about SI because of the duration of the pain although no blood stasis signs other than the blood stasis
symptoms being from cold. Trying Liver is a great suggestion.
KristinWisgirda: April 10, 2019, 8:43pm
Is she a hyperfocused overachiever type? That might point your more to SJ excess/liver deficiency too.
I hear competitive athlete and wonder about a strongly focused character.
KristinWisgirda: April 10, 2019, 8:50pm
I question trying heart again as it didn’t change her headache at all even when treated bilaterally. Treating it a
second time also made no change in the headache.
My understanding of Toby’s teaching is that treatment should made a definite change in the symptom for you to
repeat it. Please correct me if I misunderstand this.
lauramcgraw: April 10, 2019, 9:15pm
Good point on the heart. I will look again at the SJ/Liver.
Thanks
Ryan_Gallagher #9April 15, 2019, 5:28pm26/01/2024, 12:25Year long headache – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/year-long-headache/72/print3/7
I’m inclined toward supplementing LR. Headache worse with exercise + subjective cold tends to reflect blood
deficiency. Perhaps supplementing both LR and HT?
dcantor: April 15, 2019, 9:07pm
Regarding @KristinWisgirda’s last comment, this does sound similar to my process with the nausea/vomiting
case I posted – supplementing ST was well-received by the patient and seemed to fit with his sx, so it made sense to
me to try it again and weave in another channel. However, Toby was clear that if the chief complaint did not
change at all, don’t repeat that channel. If that is true, than it seems like you should try a different channel on its
own next and see what happens. Liver sounds like a good choice to me too, especially since pain is worse with
movement, but I’d also be curious about SI because of the poor circulation, red dry lips, wiry pulse, sharp pain…
Do you think her cold is coming from Blood deficiency or Qi stagnation? Or both?
lauramcgraw: April 16, 2019, 1:05am
Thanks for all the insights!! She really doesn’t have strong blood def symptoms from a Chinese medicine
perspective, just her western labs show slight iron def and according to the MD she is fine, the ND is saying she’s
on the low end of normal. She comes in tomorrow and will assess SJ/LV, she might be a bit awkward and socially
trying to get a hit on her, she’s not rude but not polite either. Good suggestion to not try heart again.
Laura
michaelmax #12April 16, 2019, 1:44am
Keep us posted, curious to see what shakes out with her
lauramcgraw: April 17, 2019, 7:24pm
She’s an overachiever, straight A student, swimmer, doesn’t like public speaking so I suppl liver on the right side
and her right leg started to get warm a few minutes in, her headache stayed the same. After 5 minutes no change to
her headache, not much effect, she didn’t feel bad but it wasn’t the right channel so I took out those needles and
tried sm. Intestine. Again she felt warmth coming up her right leg about a minute, her right foot was much warmer
than her left objectively and subjectively to the touch, again no relief for the headache. Feeling unsure what to do at
this point. Her toes are really cold and purple, she is quite clammy. I have tried Heart, lung, PC, and Liver and now
Sm. Int with no change. I just recieved her blood work from a year ago and she has very low ferritin and borderline
low T4. I asked her to redo her blood work and see where she is at with that, she did take an iron supplement but
hasn’t lately. My thought is the low ferritin is causing the headaches and with exercise making it worse points to
the ferritin def.26/01/2024, 12:25Year long headache – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/year-long-headache/72/print4/7
KristinWisgirda: April 17, 2019, 10:07pm
Hi @lauramcgraw,
Thanks for the update. I am wondering what would have happened if you left the Liver supplementing needles in
for 20 minutes. Rereading her case along with the new info you gave, Liver supplementing sounds like the best
prospect. I’ve heard Toby mention that he gives Heart supplementing treatments more time before evaluating their
effect because cold situations respond more slowly. So even though H didn’t work for the headache, I wonder if the
overall cold presentation might make her respond to the treatment more slowly on the table.
Besides the leg getting warm, were there any other signs that she was getting some benefit from the Liver
treatment? Toby emphasizes watches changes on the face as an indicator for better or worse. The complexion
should even out, the face relax, etc. Of course that deep dropping in is the clearest sign of benefit.
After all of these treatments I can understand a sense of urgency arising about making some change. Indications
that her whole system was at least relaxing would at least be show that the treatment was worth giving more time
to.
Did you have her take 3 deep belly breaths- inhale, pause, slow exhale- before reevaluating? I am finding that it
really enhances the treatment effect more quickly.
Interested to hear your thoughts. The hard cases are the best learning opportunities. Though frustration can be part
of the price to pay for the lesson.
lauramcgraw: April 18, 2019, 12:54am
Thanks for the thoughts on this case and taking the time. I did have her take 3 deep breaths, her face didn’t look
relaxed, she just stares at me and shrugs her shoulders when I ask if there is any change, and says no. I probably
left the liver in a bit longer than 5 minutes and she didn’t look relaxed or stressed, I usually can tell when it’s right,
the patient has that deep dropping sign even when the symptoms is still there, suppl the liver for her just felt empty
if that makes sense.? I agree that the liver seems like a good fit but I would say the heart treatment seemed like the
best fit when I put in the needles- she did look relaxed but the headache didn’t change. Curious what Toby thinks
on how long before I should see results, I was under the impression that if it didn’t resolve the condtition to not
treat that channel a second time. Toby also mentioned that if there is not a noticable change or dropping into
relaxation within the first 5 minutes you can take those out and try your second idea. Really wish I could help her
as she is quite miserable.
KristinWisgirda: April 18, 2019, 1:43am
She is thin and clammy with no gi problems. What does her belly look like-flat, pudgy, or distended?
lauramcgraw #17April 18, 2019, 1:47am26/01/2024, 12:25Year long headache – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/year-long-headache/72/print5/7
Flat, like a gui zhi tang type body, tight rectus, ticklish. Liver makes so much sense on paper. Appetite good,
bowels good, no bloating. She is willing to take tablets so will put her on Gui Zhi tang, really would like to modify
it.
KristinWisgirda: April 18, 2019, 2:23am
I’ve noticed that Olympic swimmers are much softer looking than other athletes, like there is a layer of fluid or fat
just under their skin. Does your patient have a soft layer just under her skin, even though she is thin and her rectus
is tight? I am wondering if there is more damp below the surface than you would otherwise think.
KristinWisgirda: April 18, 2019, 6:42pm
I’ve seen Toby treat lots of very thin patients with flat abdomens for internal dampness by supplementing LI or St.
He noted that the quality of the flesh can be significant. He calls the appearance of a soft, puffy layer under the skin
“fog”- a sign of dampness. Given that the onset of this patient’s headache occurred after what must have been a
significant Earth/Metal disharmony(pneumonia), and that she spends lots of time submerged in water, and that her
skin is quite damp, I am curious about the damp/dry balance in her body and wonder if she has that “fog” under her
skin, or a puffy face or any other signs of damp.
A side note Toby says edema can be an internal or external damp sign- there is no hard and fast rule about it.
If dampness if her issue, then this would explain why the warming aspect of the bilateral Heart treatment didn’t
stick.
An aside: Regarding another element that this case brings up, I found a note that Toby will wait as long as 20
minutes before evaluating pain symptoms when supplementing the Heart, because cold can be slower to respond.
Just something else to consider as we are trying to determine if needles should be left in or not. It sounds like
@lauramcgraw gave the initial Heart treatment the full time to work.
KristinWisgirda: April 18, 2019, 11:45pm
I created a new topic, Evaluating treatment effect on the table, after asking Toby some questions that came up in
our discussion. It is worth checking out. More fuel for the fire!
michaelmax: April 22, 2019, 1:04am
KristinWisgirda:26/01/2024, 12:25Year long headache – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/year-long-headache/72/print6/7
I’ve seen Toby treat lots of very thin patients with flat abdomens for internal dampness by supplementing LI or
St. He noted that the quality of the flesh can be significant. He calls the appearance of a soft, puffy layer under
the skin “fog”- a sign of dampness.
This is one of the things I love about the medicine we practice. There are some basic principles, which on the
surface can look simplistic. And yet as we learn to better observe we an see aspects of nuance that is not available
on first glance.
It’s easy to see someone who is thin and think… dry. But we all know that dampness that can be a tricky thing. And
dampness in a “thin” person will express differently than dampness in a more fleshy patient.
That “fog” is a keen observation.
My suspicion is that as we practice this system, especially if we can manage to stick to basics, it will teach us to
make these kinds of nuanced observations.
Donley: April 30, 2019, 1:56pm
I understand that this thread may have run its course, but after listening to the last Crowdcast again I have a
question about Moxa. It sounds like this patient needs heat. The treatments were working, but just not quite getting
her over the hump. I think adding moxa (be it needle top, rice grain, or moxa box) would not add confusion to the
body as to what the Sa’am treatment is correcting, but I do not have much experience at all yet. What do you with
more experience think of adding Moxibustion to Sa’am?
I’m thinking if moxa were added to the liver it may warm and dry a bit of the coolness and moisture or the Lv or
other organ systems. It would be extreme to add it the fire + fire heart, but if that fire is just not strong enough
(especially due to being doused everyday with cold water) moxabustion may be the tender necessary to get the fire
burning brightly…
michaelmax: April 30, 2019, 3:18pm
@Donley these are really good questions and I’m looking forward to seeing what @Tobydaly1 has to say about
this.
I’ll probably sound like a broken record here, but it’s worth repeating. At the beginning it is best to simply use the
system as it is.
Why?
Because that way you will get very clear and direct feedback on your treatment. If you start adding in moxa, then
you might not see the power of tonifying the HT to bring heat to the body. Often when beginning to learn a new
system we kind of “hedge our bets” by throwing in things we already know just to “be sure.”26/01/2024, 12:25Year long headache – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/year-long-headache/72/print7/7
I encourage you to use the system on its own and see first what it has to say to you.
Tobydaly1: April 30, 2019, 7:42pm
Donley:
What do you with more experience think of adding Moxibustion to Sa’am?
Other modalities (moxa, gua sha, etc) and even other acupuncture points are compatible with the Saam system, just
make sure you need them. Also, consider the view point of this New Yorker article – The Heroism of Incremental
Care (https://www.newyorker.com/magazine/2017/01/23/the-heroism-of-incremental-care) and remember that
we can’t always cure everything immediately and sometimes we do harm when we try.
Donley: May 1, 2019, 2:12pm
Thanks @michaelmax and @Tobydaly1 for your comments. Also thank you Toby for sharing the article. It was
quite an interesting read. I had just read about out crumbling infrastructure, and this article’s message was basically
the same. Priorities!