Head and Neck Pain Lecture Notes

Pain Due to Cancer - Prognosis and TCM Integration

General Assessment and Staging:
- When pain due to cancer occurs, the cancer is usually at the medium or later stage.
- There is often a mixture of different pathogenic factors involved.
Treatment Objectives:
- Treatment must be adapted to identify the primary and secondary causes of pain.
- Sedation of cancer pain aims to address primary and secondary causes simultaneously.
- In many cases, good results can be quickly achieved, and painkillers or morphine doses can be reduced.
Integrative TCM Treatment:
- Traditional Chinese Medicine (TCM) can be administered during conservative treatment, surgical intervention, chemotherapy, and radiation.
- TCM treatment helps improve accompanying symptoms, including:
  - Fatigue
  - Nausea and vomiting
  - Poor appetite
  - Insomnia and restlessness
  - Diarrhea
  - Headache
  - Anxiety and over-worry
  - Secondary head and neck pain

Anatomy: Muscles of the Head and Neck

Principal Muscle Groups:
- The head's principal muscles are categorized into those of facial expression and those of mastication (chewing).
Muscles of Facial Expression:
- Orbicularis Muscles: Ring-shaped muscles surrounding the eyes and lips.
  - Orbicularis Oculi: Surrounds the eye.
  - Orbicularis Oris: The muscle of the lips.
- Antagonists:
  - Levator Palpebrae Superioris: Known as the "lifter of the upper eyelid"; it serves as the antagonist for the orbicularis oculi.
  - Antagonists of the orbicularis oris are responsible for producing smiles, sneers, or grimaces.
- Buccinator: One of the largest muscles of expression, forming the fleshy part of the cheek. It is often referred to as the "trumpeter's muscle" because it is used for whistling or blowing.
- Other Expression Muscles: Several muscles are responsible for lifting eyebrows or drawing them together for a frown.
Muscles of Mastication:
- There are four pairs of mastication muscles that all insert on and move the mandible.
- Temporalis: The largest mastication muscle, located superior to the ear.
- Masseter: Located at the angle of the jaw.
Tongue Muscles:
- The tongue possesses two main muscle groups:
  - Intrinsic Muscles: Located entirely within the tongue.
  - Extrinsic Muscles: Originate outside the tongue.
- The complexity of these muscles allows for flexibility and functions such as speaking, chewing, and swallowing.
Summary Table of Head and Neck Muscles:

Name	Location	Function
Orbicularis Oculi	Encircles eyelid	Closes eye
Levator palpebrae superioris	Posterior orbit to upper eyelid	Opens eye
Orbicularis oris	Encircles mouth	Closes lip
Buccinator	Fleshy part of the cheek	Flattens cheek; helps in eating, whistling, and blowing wind instruments
Temporalis	Above and near ear	Closes jaw
Masseter	At angle of jaw	Closes jaw
Sternocleidomastoid	Along lateral neck to mastoid process	Flexes head, rotates head toward opposite side from muscle

Introduction to Headaches

Clinical Prevalence:
- Headaches are one of the most common conditions in clinical practice.
- Up to $50\%$ (half) of the adult population will experience at least one headache in a year.
- They affect people across all ages, races, social levels, and geographical locations.
Impact on Life:
- Frequency and intensity can range from mild/occasional to debilitating.
- They significantly damage quality of life.
Presentation:
- Headaches can be unilateral (one side), bilateral (both sides), or occur over the whole head area.
- They are usually subjective symptoms experienced at different levels of intensity.

Western Medicine: Types and Classification of Headaches

Primary Headaches:
- Includes Migraine, Tension, and Cluster headaches.
- Tension Headache: The most frequently occurring type. While the cause is unknown, physical or emotional stress are possible factors.
Secondary Headaches:
- Caused by underlying structural problems in the head or neck.
- Examples include cerebral bleeding, tumors, meningitis, and encephalitis.
- Some secondary headaches can be potentially life-threatening.
Cranial Neuralgias and Facial Pain:
- Headaches due to inflammation of nerves in the head and upper neck.
Western Medical Diagnosis:
- Established via medical history, symptoms, physical exams, and tests.
- Tests include blood work, CT scans, or MRI of the head.
Red Flag Symptoms (High Risk):
- Very severe headache.
- Persistent nausea and vomiting.
- Aggravation by exertion, coughing, or bending over.
- Association with fever, stiff neck, seizure, or recent head trauma/falls.
- Changes in vision, speech, or behavior.
- Weakness or changes in sensation.
Common Medications and Side Effects:
- Aspirin/Ibuprofen: Irritating to the stomach; may cause bleeding.
- Acetaminophen (Paracetamol): Large amounts can cause liver damage or failure.
Specific Western Causes:
- Nasosinusitis
- Trigeminal neuralgia
- Neurosis
- Cluster/Migraine headaches
- Sequela of brain concussion
- Hypertension, Cephalitis, Glaucoma, and Tumors

Traditional Chinese Medicine (TCM) Theory of Headaches

Channel Distribution:
- All six Yang channels traverse the head area.
- The $Du$ channel and Liver channel also connect to or distribute through the head.
- The head is where all Yang channels of the hand and foot meet.
- $Qi$ and Blood from the five $Zang$ and six $Fu$ organs flow upward to the head.
Organ Roles in Head Health:
- Kidney: Most important organ for producing Marrow. The Brain is considered the "Sea of Marrow."
- Spleen: Transforms Food Essence into $Qi$ and Blood to nourish the brain.
- Lung: Disperses $Qi$ to all parts of the body, including the head.
- Heart: Dominates blood circulation and mental activity.
- Blood: Acts as the basic source of energy for the brain.

TCM Etiology: Exogenous (External) Factors

Wind (The Primary Pathogen):
- Exists in every season and often combines with Cold, Heat, or Damp.
- Wind-Cold: Characterized by contraction. Causes physical contraction of channels, muscles, and tendons, resulting in disordered $Qi$ and Blood circulation. Results in a "contracting sensation."
- Wind-Heat: Common in late spring and summer. Attacks the Upper- $jiao$ through the mouth and nose. Causes fever and red face.
- Toxic Fire: Occurs in hot weather (late spring/summer) or from insect bites. A strong Yang factor that damages blood channels and can lead to swollen red nodules or erosions on the head.
- Wind-Damp: Characterized by viscosity and heaviness. Blocks the ascent of clear Yang- $Qi$ and the descent of turbid $Qi$ . Causes a "heavy sensation" as if the head is wrapped in a cloth.

TCM Etiology: Endogenous (Internal) Factors

Liver Dysfunction:
- One of the most common causes of endogenous headache.
- The Liver coordinates $Qi$ circulation (physically and emotionally).
- Pathology: Bad mood/anger $\rightarrow$ Liver- $Qi$ Stagnation $\rightarrow$ Liver-Fire $\rightarrow$ Hyperactivity of Liver-Yang.
Dietary Factors:
- Heat/Fire: Spicy food or alcohol causes Heat/Fire in the Stomach, which burns Stomach- $Yin$ and induces headaches (often on the forehead).
- Damp-Phlegm: Fatty, sweet, or salty food damages Spleen function. Phlegm blocks the channels.
Deficiencies:
- $Qi$ and Blood Deficiency: Caused by chronic illness, overwork, or excessive bleeding (menstruation/trauma). Brain is not sufficiently nourished.
- Kidney-Essence Deficiency: Caused by heredity, excessive sex, multiple births, or chronic sickness. Leads to an "empty" feeling in the brain.
Physical Trauma:
- Accidents, falls, or strokes direct damage channels and muscles, leading to Blood Stasis.
- Blood Stasis headache is fixed in location and stabbing in nature.

Clinical Differentiation of Headaches

Onset and Quality:
- Sudden onset: Exterior condition.
- Gradual onset: Interior condition.
- Dull pain: Deficiency of $Qi$ and Blood or Kidney-Essence.
- Sharp/Stabbing pain: Liver- $Qi$ stagnation, Liver-Fire, or Blood Stasis.
- Heaviness/Muzzy: Accumulation of Damp-Phlegm; head feels wrapped in cloth.
- Distension/Throbbing/Bursting: Liver disorder (Fire or Yang hyperactivity) or Stomach-Fire.
- Pulling sensation: Formation of Liver Wind.
- Hollow/Empty sensation: Deficiency of Kidney-Essence.
Location-Based Differentiation:
- Top of Head (Vertex): Liver channel. Dull (Blood deficiency); Sharp (Yang hyperactivity). If external, it involves the Bladder channel.
- Back of Head (Occiput): Acute (Wind-Cold-Damp in Bladder channel); Chronic (Damp-Phlegm, Kidney deficiency, or Liver-Yang hyperactivity).
- Sides of Head (Temples): Gallbladder and Liver disorders. Includes stagnation, fire, stones, or external factors.
- Forehead: Stomach or Gallbladder channels. Dull (Stomach- $Qi$ deficiency); Sharp (Stomach-Fire); Heavy (Damp-Phlegm).
- Behind the Eyes: Liver disorders (Blood def, $Qi$ stagnation, Fire, or Yang hyperactivity).
Environmental and Lifestyle Aggravations:
- Weather: Heat (Liver/Stomach Fire); Cold (Yang/Blood deficiency); Humidity (Damp-Phlegm).
- Emotions: Stress (Liver- $Qi$ stagnation); Anger (Liver-Fire/Yang); Fear (Kidney deficiency); Worry (Spleen deficiency).
- Sexual Activity: Worsens after (Kidney-Essence deficiency); Alleviated after (Liver- $Qi$ /Fire stagnation).
- Posture: Alleviated by lying down (Deficiency); Worsens lying down (Excess).
- Menstruation: Aggravated before/during (Liver/Blood stagnation); Aggravated after (Blood/Kidney deficiency).
- Pressure: Alleviated by pressure (Deficiency); Worsens with pressure (Excess).

Acupuncture Treatment: Exogenous Syndromes

Invasion of Wind-Cold:
- Symptoms: Contracting headache, aversion to cold/wind, stiff neck, no sweat, thin white coating, superficial tense pulse.
- Principles: Dispel Wind, Eliminate Cold, Relieve headache.
- Points: $LU-7$ (Luo), $LI-4$ (Yuan), $SJ-5$ (Luo), $GB-20$ , $GB-21$ , $UB-10$ , $Ah\,Shi$ .
- Modifications: Fever (add $Du-14$ ); Stiff neck (add $SI-3$ , $UB-62$ , $LI-20$ , $Du-23$ ).
Invasion of Wind-Heat:
- Symptoms: Distending/burning headache, red face/eyes, thirst, sore throat, yellow discharge, superficial rapid pulse.
- Principles: Dispel Wind, Clear Heat, Relieve headache.
- Points: $ST-8$ , $Taiyang$ , $Du-23$ , $GB-14$ , $GB-20$ , $LI-4$ (Yuan), $LI-2$ (Ying-spring), $LI-11$ (He-sea), $SJ-5$ (Luo).
- Modifications: Thirst (add $SP-6$ ); Sore throat (add $LU-10$ ); Constipation (add $ST-25$ ).
Invasion of Wind-Damp:
- Symptoms: Heavy sensation, wrapped head, lassitude, poor appetite, slippery superficial pulse.
- Principles: Dispel Wind, Eliminate Damp, Relieve headache.
- Points: $LU-7$ , $SJ-4$ (Yuan), $SJ-6$ , $LI-4$ , $GB-20$ , $SP-6$ , $SP-9$ , $Ah\,Shi$ .
- Modifications: Fullness in chest (add $PC-6$ , $Ren-17$ ); Diarrhea (add $ST-25$ ).
Attack of Toxic Fire:
- Symptoms: Sharp/burning pain, high fever, irritability/coma, stiff neck, delirium, dark reddish purple tongue, rapid pulse.
- Principles: Clear Heat, Reduce fever, Remove Toxin, Cool Blood.
- Points: $Du-20$ , $GB-20$ , $GB-8$ , $GB-21$ , $LI-4$ , $LI-11$ , $SJ-6$ , $SP-6$ , $SP-10$ , $LV-2$ , $GB-43$ , $HT-3$ , $UB-17$ .
- Modifications: Coma (add $Du-26$ , $KD-1$ ); Restlessness (add $PC-8$ ).

Acupuncture Treatment: Endogenous Syndromes

Liver-Qi Stagnation:
- Symptoms: Stress-related, depression, dizzy, hypochondriac pain, wiry pulse.
- Points: $Du-20$ , $Sishencong$ , $LV-3$ (Yuan), $PC-6$ , $HT-3$ , $LI-4$ , $SP-6$ .
- Modifications: Irregular menstruation (add $SP-8$ ); Nervous loose stools (add $LV-13$ , $SP-3$ ).
Blood Stasis:
- Symptoms: Stabbing, fixed location, worse at night/menstruation, purplish tongue, thready/choppy pulse.
- Points: $LI-4$ , $LV-3$ , $SP-6$ , $UB-17$ (Blood influential), $GB-20$ , $GB-14$ , $GB-15$ , $PC-6$ , $LV-5$ (Luo).
- Modifications: Painful spots (add $Ah\,Shi$ ); Poor memory (add $Sishencong$ ).
Hyperactivity of Liver-Yang:
- Symptoms: Shaking of head/hands, vertigo, wiry pulse.
- Points: $GB-20$ , $Du-20$ , $Taiyang$ , $SP-6$ , $LI-4$ , $GB-43$ , $KD-2$ , $LV-2$ (Ying-spring), $LV-8$ (Water), $HT-8$ .
Accumulation of Heat in Yangming (Stomach/Large Intestine):
- Symptoms: Forehead pain, sweat, bad breath, painful gums, forceful pulse.
- Points: $LI-2$ , $LI-4$ , $SJ-6$ , $ST-8$ , $ST-40$ , $ST-44$ (Ying-spring), $Ren-12$ (Front-mu), $GB-20$ .
Accumulation of Damp-Phlegm:
- Symptoms: Dizziness, nausea, greasy coating, slippery pulse.
- Points: $GB-20$ , $ST-8$ , $Ren-12$ , $LI-4$ , $SP-6$ , $SP-9$ , $Yintang$ , $Ah\,Shi$ .
Deficiency of Qi:
- Symptoms: Pale face, tiredness, shortness of breath, toothmarks on tongue.
- Points: $UB-20$ (Spleen-shu), $UB-21$ (Stomach-shu), $ST-36$ (He-sea), $ST-42$ (Yuan), $SP-3$ , $SP-6$ , $ST-8$ .
Deficiency of Blood:
- Symptoms: Poor vision, palpitations, listlessness, hair loss, thin/weak pulse.
- Points: $Du-20$ , $HT-5$ (Luo), $PC-6$ , $ST-36$ , $SP-6$ , $Ren-4$ , $Ren-6$ , $KD-3$ , $GB-39$ (Marrow influential).
Deficiency of Kidney-Essence:
- Symptoms: Tinnitus, loose teeth, weak knees, thready/weak pulse.
- Points: $KD-3$ , $SP-6$ , $UB-11$ (Bone influential), $GB-39$ , $LV-3$ , $ST-36$ , $UB-23$ (Kidney-shu), $Du-20$ , $Taiyang$ , $Yintang$ .

Prognosis and Clinical Notes

Treatment Efficacy:
- Acupuncture yields high success for both exogenous and endogenous headaches.
- TCM is noted to have better therapeutic results than Western drugs for chronic cases, with no side effects.
- Timeframes: Blood Stasis headaches or Migraines require a longer duration of treatment.
Clinical Priorities:
- Head points and $Ah\,Shi$ points provide quick symptomatic relief by harmonizing local collaterals.
- Symptomatic treatment must be combined with addressing the underlying cause for long-term results.
- Prevention is a crucial element of management.