Diagnosis/Condition:

Discipline:
ICD-9 Codes:
ICD-10 Codes:
Origination Date:
Review/Revised Date:
Next Review Date:

Headache

Tension
Migraine
Stress
Cluster
LAc
784.0, 307.81, 346.0, 346.1, 346.2, 346.8,
307.81, 346.2
05/2012
05/2014

Headaches are generally classified as either primary or secondary and these classifications are
further divided into specific headache types. The primary headache disorders include migraine,
tension-type, and cluster headache. Secondary headache disorders are those attributed to an
underlying pathologic condition including any head pain of infectious, neoplastic, vascular, druginduced, or idiopathic origin.
The vast majority of patients who present with headache have one of the primary disorders, as
serious secondary causes for presentation with head pain are rare but potentially very serious. It is
necessary to differentiate primary and secondary headaches including differentiating migraine
headaches by TCM syndromes. This process will reveal the type of headache in Western
diagnostic terms, i.e. tension, migraine, hormonal, TMJ, etc.
The TCM view of headache has three primary etiological factors, each with unique pattern
diagnoses: 1) external pathogens (e.g. wind-damp-cold), 2) internal disharmony (e.g. liver Qi
disharmony), or 3) lifestyle imbalances (e.g. Qi deficiency). Headache pain, as a symptom,
indicates a stagnation in the movement of qi and blood. The specific pattern differentiation of
these imbalances is based on the nature and location of the pain, along with secondary symptoms
that may occur.
Acupuncture is widely used for the treatment of headache, but its effectiveness is controversial.
Overall, the existing evidence supports the value of acupuncture for the treatment of idiopathic
headaches.

Subjective Findings and History

History of Headache: initial onset and precipitating events

Intensity, character, location, radiation, and duration.
Frequency, timing, and onset.
Aggravating and alleviating factors.
Associated symptoms: aura, neurological changes, neck stiffness, etc
TCM ten questions: eyes, ears, digestion, urination, etc

Objective Findings

Pulse and tongue diagnosis

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Headache Clinical Pathway

Voice, general appearance, and complexion

Muscle tenderness, tender points

Assessment

TCM diagnosis
Pathogenic invasion (wind heat, wind cold, wind damp)
Channel invasion (taiyan, shoayang, yangming, tiying, shoayin, jueyin syndromes)
Yang excess, Stagnation, Deficiency syndromes
Western diagnosis (migraine, tension, cluster, sinus, scalp neuritis, etc)

Plan

Passive Care
Acupuncture: points selected according to diagnosis and location
Chinese Herbs selected according to Chinese diagnosis

Length of Treatment

Estimated duration of treatment: initially 2-3 times per week for 2-3 weeks then 1
treatment every 2 weeks, then 1 treatment per month.
Patient should experience at least 50-60% improvement in duration, intensity, frequency,
or severity within specified number of treatments. Patients with severe symptoms may
need more frequent and/or intense treatment.
The presence of recent stressors may require more treatment.

Referral Criteria

New onset headaches should be referred to primary physician for definitive Western
diagnosis and workup.
If patient has signs of neurological damage (e.g. weakness) or hypertension then the
patient should be immediately referred to primary care physician during the initial course
of treatment.
If patient worsens or the nature of the pain changes then the patient should be referred to
primary care physician.
Cervical spine joint dysfunction and migraine headaches should be referred for
manipulation and adjunct therapy. Acute onset of intense pain should be referred to
emergency services.

References

Cummings, T. M Abstract of Acupuncture for recurrent headaches: a systematic review of

randomized controlled trials. FACT 2000; Vol. 5 Issue 2 pp. 120-121.
Diagnosis and treatment of headache. Institute for Clinical Systems Improvement - Private
Nonprofit Organization. 1998 Aug (revised 2004 Nov).
Acupuncture. NIH Consensus Statement National Institutes of Health. November 3 - 5,
1997.
Audette JF and Blinder RA. Acupuncture in the management of myofascial pain and headache.
Curr Pain Headache Rep 2003;7:395-401.
Baischer W. Acupuncture in migraine: Long-term outcome and predicting factors. Headache
1995;35:472-474.
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Headache Clinical Pathway

Duo X. 100 cases of intractable migraine treated by acupuncture and cupping. J Tradit Chin Med
1999;19:205-206.
Hu J. Acupuncture treatment of migraine in Germany. J Tradit Chin Med 1998;18:99-101.
Lee WC. Acupuncture Treatment for Migraine: Clinical Observations. Med Acupunct 1998;10:3334.
Linde K, Scholz M, Melchart D, et al. Should systematic reviews include non-randomized and
uncontrolled studies? The case of acupuncture for chronic headache. J Clin Epidemiol 2002;55:7785.
Linde K, Allais G, Brinkhaus B, Mannheimer E, Vickers A, White A. Acupuncture for tension-type
headache. Cochrane Pain group 2010
Linde K, Allais G, Brinkhaus B, Mannheimer E, Vickers A, White A. Acupuncture for migraine
prophylaxis. Cochrane Pain group July 2011
Manias P, Tagaris G, Karageorgiou K. Acupuncture in headache: a critical review. Clin J Pain
2000;16:334-339.
Melchart D, Linde K, Fischer P, et al. Acupuncture for idiopathic headache. Cochrane Database
Syst Rev 2001;CD001218Melchart D, Linde K, Fischer P, et al. Acupuncture for recurrent headaches: a systematic review of
randomized controlled trials. Cephalalgia 1999;19:779-786.
Vickers AJ, Rees RW, Zollman CE, et al. Acupuncture for chronic headache in primary care: large,
pragmatic, randomised trial. BMJ 2004;328:744.
Wonderling D, Vickers AJ, Grieve R, et al. Cost effectiveness analysis of a randomised trial of
acupuncture for chronic headache in primary care. BMJ 2004;328:747.
Melchart D et. al. Acupuncture for idiopathic headacheThe Cochrane Database of Systematic
Reviews 2007 Issue 1. (Accessed at http://www.cochrane.org/reviews/en/ab001218.html)
Martin V, Elkind A. Diagnosis and classification of primary headache disorders. In: Standards of
care for headache diagnosis and treatment. Chicago (IL): National Headache Foundation; 2004.
(Accessed at http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=6111&nbr=3966)
Rossi P,Faroni J,Malpezzi MG, Cesarino F, Nappi G. Headache 2006 Apr 46 (4):622-31
Diener HC. Acupuncture for the treatment of headaches: more than sticking needles into
humans? Cephalgia. 2008.
Linde K. NK, & Meissner K. Are sham acupuncture interventions more effective than (other)
placebos? A re-analysis of data from the Cochrane Review on placebo effects. Forsch
Komplementmed 2010;17(5):259-264
Soderberg EI, Carlsson JY, Stener-Victorin E, Dahlof C. Subjective well-being in patients with
chronic tension type headache: effects of acupuncture, physical training, and relaxations training.
Clin J Pain, June 201127)5:448-456
Alais G, Romoli M, Rolando S, Castagnoli Gabellari I, Benedetto C. Ear acupuncture in unilateral
migraine pain. Neurol Sci. June 2012;31 Suppl 1:S185-187
Yang CP, Chang MH, Liu PE, et al. Acupuncture vs. topiramate in chronic migraine prophylaxis: a
randomized clinical trial. Cephalgia. Nov 2011;31(15):1510-1521
Wang LP, Zhang XZ, Guo j, et al. Efficacy of acupuncture for migraine prophylaxis: a single
blinded, double-dummy, randomized controlled trial. Pain. May 24 2011
Zhao l< Guo Y, Wang W, Yan LJ. Systematic review on random controlled clinical trials of
acupuncture therapy for neurovascular headache. Chin J Integ Med Apr 26 2011
Linde K, Allais G, Brinkhaus B, Mannheimer E, Vickers A, White AR. Acupuncture for tension
type headache. Conchrone Database Sys Rev. 2009; Jan21(1):CD007587

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Headache Clinical Pathway

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CHP desires to keep our clinical pathways customarily updated. If you wish to provide additional
input, please use the e-mail address listed below and identify which clinical pathway you are
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Chuck Simpson, DC, CHP Medical Director: csimpson@chpgroup.com

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Headache Clinical Pathway