The Three Treasures - The Treatment of Headaches

Chronic headaches is one of the most common problems encountered in a Western clinic. The head was called in Chinese medicine the APalace of Yang@ because, superficially, it contains only Yang channels: in fact, arm Yang channels end on the head and leg Yang channels start on the head. Of course, Yin channels also reach the head: of the main channels only the Liver and Heart reach the head, while all the divergent Yin channels reach the head via their associated Yang channel (e.g. the Kidney channel reaches the head through its divergent channel joining up with the Bladder channel on the neck). The predominance of Yang channels on the head explains the frequency of headaches due to congestion of Yang on the head (e.g. Liver-Yang rising). However, broadly speaking, there are only four types of headache: 1) Headaches from Excess of Yang in the head (e.g. Liver-Yang rising, Liver-Fire) 2) Headaches from Deficiency of Yang in the head (e.g. Spleen-Qi deficiency, Kidney-Yang deficiency) 3) Headaches from Excess of Yin in the head (e.g. Dampness or Phlegm) 4) Headaches from Deficiency of Yin in the head (e.g. Kidney-Yin deficiency, Liver-Blood deficiency). DIAGNOSIS Headaches should be diagnosed according to the channel involved, the type of pain and the factors that ameliorate or aggravate them.

1. DIAGNOSIS ACCORDING TO CHANNELS

Top of the head The Liver channel reaches the top of the head internally and is the most frequent cause of headache there (Fig. 1). A headache at the top of the head is most often due to deficient Liver-Blood being unable to reach the area. It is dull in character and will improve if the patient lies down. In a few cases a headache in this area may be due to Liver-Yang rising in which case it will be sharp in character. There are also other causes of headache in this area not related to the Liver channel, such as deficient Qi and Blood unable to reach the top and Heart-Blood deficiency.

Fig. 1. Location of Terminal Yin (Jue Yin) headaches. Sides of the head This area corresponds to the Gall-Bladder channel and a headache here is most frequently due to LiverYang, Liver-Fire or Liver-Wind rising (Fig. 2). This headache is sharp and throbbing in character.

Fig. 2. Location of Lesser Yang (Shao Yang) headache. One side only This area also corresponds to the Gall-Bladder channel and a headache here is also due to either LiverYang or Liver-Fire rising. It is said in Chinese Medicine that a headache on the left side is more likely to result from a Deficiency and one on the right side to result from an Excess, but this is by no means a completely reliable rule. Temples This area also corresponds to the Gall-Bladder channel and a headache most frequently affects one side only. It is usually due to Liver-Yang, Liver-Fire or Liver-Wind rising and is throbbing in character (Fig. 3).

Fig. 3. Location of Gall-Bladder channel headache. Behind the eyes This is a very frequent location for migraine. The headache is due to Liver-Blood deficiency if the pain is dull, or to Liver-Yang rising if the pain is sharp and severe. Forehead Headaches in this area are usually related to the Stomach. They can indicate either Stomach deficiency if the pain is dull or Stomach-Heat if it is sharp. A very frequent cause of frontal headaches is either Dampness or Phlegm being retained in the head and preventing the clear Yang from ascending to the head to brighten the sense orifices. For this reason this type of headache is associated with a heavy sensation of the head, a muzzy feeling there, and a lack of concentration. If the headache is caused by Phlegm, the patient will also experience dizziness and blurred vision. In a few cases, frontal headaches can be due to a residual pathogenic factor, such as external Wind, which has not been expelled after an invasion of exterior Wind-Cold or Wind-Heat. Back of the head (occiput) Chronic headaches in this area are usually due to a Kidney deficiency manifesting on the Bladder channel. Acute headaches here are due to invasion of external Wind (usually Wind-Cold) and form a typical feature of the Greater Yang pattern within the 6-Stage pattern identification. This type of headache is accompanied by severe stiffness at the back of the neck. In a few cases, occipital headache can be associated with a Bladder pattern, such as Damp-Heat in the Bladder, in which case the pain will be sharp. All over the head Chronic headaches all over the head are due to Kidney-Essence deficiency. The Kidney-Essence nourishes the brain and when it is deficient the brain lacks nourishment. This can give rise to dull headaches all over the head accompanied by a feeling of emptiness.

Acute headaches affecting the whole head are due to invasion of external Wind (which can be either Wind-Cold or Wind-Heat). These are severe and sharp in character, sometimes accompanied by a pulling sensation.

2. DIAGNOSIS ACCORDING TO THE TYPE OF PAIN

Generally, a dull ache indicates an Empty condition, while a sharp pain indicates a Full condition. A sudden onset tends to indicate an exterior invasion, a gradual onset an interior one. Empty conditions causing dull headaches include deficiency of Qi and/or Blood, Liver-Blood deficiency and Kidney deficiency. Full conditions include Liver-Yang rising, Liver-Fire blazing, Liver-Wind, Phlegm, stasis of Blood and Stomach Heat. Dull A dull headache is due to one of the deficiencies outlined above. Feeling of heaviness This is characteristic of Dampness or Phlegm obstructing the head and preventing the clear Yang Qi from ascending to the head and the turbid Yin Qi from descending. The head typically feels heavy, muzzy and as if it were wrapped in a cloth. The patient also finds it difficult to concentrate and think, especially in the morning. While both Dampness and Phlegm may cause the above sensations, Phlegm is more obstructive and it clouds the "orifices" and sense organs, causing dizziness and blurred vision. These last two symptoms distinguish Phlegm from Dampness in the head. Distending pain This is a typical Chinese expression which will be seldom used by Western patients (or at least in AngloSaxon languages). The most frequently recurrent expressions used by Western patients describing this type of pain are "throbbing", "bursting" and "pulsating", all of which correspond to "distending". This sensation is typical of a Liver-related headache which could be from Liver-Yang or Liver-Fire. However, a distending pain can also be due to exterior Wind-Heat, in which case it will affect the whole head, whereas in the case of Liver-Yang or Liver-Fire it will most probably affect either or both sides of the head. Stiffness A pronounced stiffness of the occiput usually indicates an invasion of exterior Wind-Cold. A chronic headache with stiffness of the top of the shoulders and neck usually indicates Liver-Yang rising. Pulling A pulling type of sensation indicates internal Liver-Wind. Stabbing, boring This sensation is very intense and fixed in one place and it indicates Blood stasis. It occurs only in chronic headaches. A description also used in this context is "splitting headache". Feeling of emptiness A sensation of emptiness of the brain indicates deficiency of Kidney (Yin or Yang). We can summarize the different types of headaches according to patterns: Wind-Cold: severe occipital with pronounced stiffness Wind-Heat: severe, distending, in the whole head

Wind-Damp: feeling of heaviness as if the head were wrapped Liver-Yang, Liver-Fire: distending Liver-Wind: pulling Stasis of Blood: stabbing, splitting, boring Phlegm: heavy sensation as if the head were wrapped, dizziness Dampness: heavy sensation as if the head were wrapped Qi-Blood deficiency: dull Kidney deficiency: feeling of emptiness.

3. DIAGNOSIS ACCORDING TO AMELIORATION AND AGGRAVATION

The factors which make a headache better or worse may give an indication of the condition causing the headache. Time of day Chronic headaches which are worse in daytime indicate either deficiency of Qi/Yang or Dampness. Chronic headaches which are worse in the evening or at night indicate deficiency of Blood or Yin (which may be causing Yang rising). Activity/rest Headaches that get worse with activity are due to deficiency of Qi or Blood, whilst headaches that improve with light exercise may be due to Liver-Yang rising or Phlegm. Headaches that improve with rest and lying down are due to deficiency of Qi or Blood, whilst headaches that worsen lying down are due to Dampness or Phlegm. Weather Headaches that get worse with heat may be due to Liver-Yang or Liver-Fire rising, whilst headaches that get worse with cold may be due to deficiency of Yang. If they worsen with damp weather, it is a clear indication that they are due to Dampness or Phlegm. A headache that improves temporarily with the application of cold (for example, cold water) may be due to Liver-Yang or Liver-Fire. Emotions Headaches that worsen with anger are due to Liver-Yang or Liver-Fire. Headaches that get worse when a patient suddenly relaxes (the typical weekend headache) are due to Liver-Yang rising. Headaches that worsen with sudden excitement may be due to Liver-Yang rising. Sexual activity Chronic headaches that are aggravated after sexual activity (culminating in ejaculation for men or orgasm for women) clearly indicate a deficiency of the Kidneys. In rare cases, headaches may be ameliorated by sexual activity, which indicates Liver-Fire. Food Barring the vast subject of intolerance of certain foods, headaches that get worse after eating indicate Dampness, Phlegm, retention of food or Stomach-Heat. Headaches that get better with eating indicate deficiency of Qi or Blood. Headaches that are aggravated by the consumption of sour foods (such as oranges, grapefruit, vinegar, etc.) are due to Liver-Yang rising.

Posture If a headache improves when the patient is lying down it is due to a Deficiency; if it worsens when lying down (and improves when sitting) it is due to an Excess. For example, severe headaches from Liver-Yang rising usually get better sitting up and the patient dislikes lying down. Menstruation Many types of headaches are closely affected by the menstrual function. Headaches that precede the onset of the period are usually due to Liver-Yang rising. If they worsen during the period, they may be due to Liver-Fire or stasis of Blood. If they occur towards the end of the period, they indicate Blood Deficiency. Pressure If the patient dislikes pressure on the part of the head where the headache occurs, it indicates an Excess condition. Conversely, if the headache improves with pressure, it indicates a Deficiency condition.

REMEDIES
INTRODUCTION
The three main remedies for chronic headaches with their respective patterns are: Clear Yang: Liver-Yang rising and Phlegm Bend Bamboo: Liver-Yang rising from Liver-Blood deficiency Brighten the Eyes: Liver-Blood deficiency. Apart from these three, which will be discussed first, many other remedies can be used for chronic headaches: these are listed below in alphabetical order with their respective patterns. Break into a Smile: Liver-Qi stagnation Calm the Spirit: Liver- and Heart-Blood deficiency Clear the Soul: Phlegm-Heat in the head Drain Fields: Dampness Drain Fire: Liver-Fire Ease the Muscles: Damp-Heat Expel Wind-Cold: external Wind-Cold Expel Wind-Heat: external Wind-Heat Freeing the Moon: pre-menstrual Liver-Qi stagnation Limpid Sea: Phlegm in the head Nourish the Root: Kidney-Yin deficiency Penetrating Vessel: rebellious Qi of the Penetrating Vessel Red Stirring: Blood stasis Release Constraint: Liver-Qi stagnation Strengthen the Root: Kidney-Yang deficiency Tonify Qi and Ease the Muscles: Qi deficiency and some Dampness Welcome Fragrance: Damp-Heat head and sinuses

An important classification of remedies for headaches is that between remedies for Full-type and those for Empty-type of headaches:

EXCESS

Liver-Yang rising: Brighten the Eyes, Bend Bamboo, Clear Yang. Liver-Fire: Drain Fire Rebellious Qi: Penetrating Vessel Dampness: Drain Fields, Ease the Muscles, Welcome Fragrance Phlegm: Limpid Sea, Clear the Soul Liver-Qi stagnation: Freeing the Moon, Break into a Smile, Release Constraint Blood stasis: Red Stirring External Wind: Expel Wind-Cold, Expel Wind-Heat DEFICIENCY Qi deficiency: Tonify Qi and Ease the Muscles Blood deficiency: Brighten the Eyes, Calm the Spirit Yang deficiency: Strengthen the Root Yin deficiency: Nourish the Root Table 1 summarizes the remedies for headaches according to pattern and character and location of pain. PATTERN Liver-Yang rising FORMULA Clear Yang, Bend Bamboo, CHARACTER Throbbing, in the temples, at sides of the head or behind the eyes, dizziness Throbbing, intense, behind the eyes or temples Throbbing at top of the head Dull, on forehead

Liver-Fire

Drain Fire

Rebellious Qi Dampness

Penetrating Vessel Drain Fields, Ease the Muscles, Welcome Fragrance Limpid Sea, Clear the Soul Freeing the Moon, Break into a Smile, Release Constraint Red Stirring Expel Wind-Cold, Expel Wind-Heat

Phlegm

Dull, on forehead or all over head, muzziness, dizziness Intense, all over head

Liver-Qi stagnation

Blood stasis External Wind

Stabbing, fixed in one place Severe, moving

Qi deficiency Blood deficiency Yang deficiency Yin deficiency

Tonify Qi and Ease the Muscles Brighten the Eyes, Calm the Spirit Strengthen the Root Nourish the Root

Dull, all over head Dull, on top or behind eyes Dull, all over head Dull, all over head, feeling of emptiness of the head

Table 1. Remedies for headaches according to pattern

THE REMEDIES
Clear Yang, Bend Bamboo and Brighten the Eyes will be discussed first because they are the three main remedies for headaches; the others are discussed in alphabetical order. CLEAR YANG This is the main remedy for chronic headaches deriving from a combination of Liver-Yang rising and Phlegm. This combination is a frequent cause of chronic headaches as the rising of Liver-Yang carries Phlegm to the head. Indeed, the combination of these two factors is probably the most common cause of chronic headaches in adults. Typically, a person suffering from these two patterns will experience frequent, chronic headaches of a dull nature together with a feeling of heaviness and muzziness in the head and dizziness (caused by Phlegm), punctuated by attacks of severe, throbbing headaches caused by rising Liver-Yang. Clear Yang also nourishes Blood to help to subdue Liver-Yang and tonifies Kidney-Yang to help to resolve Phlegm. If Liver-Blood deficiency is pronounced, the patient can combine Clear Yang with Brighten the Eyes, taking the former in the morning and the latter in the afternoon. If Kidney-Yang deficiency is pronounced, the patient can combine Clear Yang with Strengthen the Root, taking the former in the afternoon and the latter in the morning. If instead of Kidney-Yang deficiency there is a Kidney-Yin deficiency, Clear Yang should be combined with Nourish the Root, taking the former in the morning and the latter in the evening. If there is a pronounced deficiency of Spleen-Qi, the patient should combine Clear Yang with Soothe the Centre, taking the former in the afternoon and the latter in the morning. Clear Yang is also the prime remedy for chronic dizziness, which often affects the elderly. BEND BAMBOO Bend Bamboo is the main remedy for chronic headaches from Liver-Yang rising occurring against a background of Liver-Blood deficiency: this situation is particularly common in women. This type of headache is throbbing in nature and occurs on the sides of the head, temples or behind the eyes. It may be unilateral or bilateral and it often changes side. It is frequently accompanied by nausea, vomiting and visual disturbances. If the rising Liver-Yang originates from a Kidney deficiency, Bend Bamboo may be associated either with Strengthen the Root in case of Kidney-Yang deficiency or with Nourish the Root, in case of Kidney-Yin deficiency. If Bend Bamboo is combined with Strengthen the Root, the patient can take the former in the evening (say, 4 tablets) and the latter in the morning (also 4 tablets). If the Blood deficiency is very pronounced and extra tonification of Blood is called for, Bend Bamboo should be combined with Brighten the Eyes, taking the former in the afternoon and the latter in morning.

If the headaches occur in conjunction with the menstrual period, and the rising of Liver-Yang stems from a Kidney deficiency, a different protocol can be followed. The woman could take Bend Bamboo for about two weeks before and during the period (6 tablets a day) and Strengthen the Root or Nourish the Root (depending on whether there is Kidney-Yang or Kidney-Yin deficiency respectively) for about two weeks after the period (6 tablets a day). If there is a pronounced deficiency of Blood, the woman could take Brighten the Eyes for about two weeks after the period and Bend Bamboo for about two weeks before and during the period. BRIGHTEN THE EYES Although this remedy is specific for eye problems, it is well suited to treat chronic headaches deriving from Liver-Blood deficiency. Chronic headaches from Liver-Blokd deficiency are dull in character and occur either on the forehead or at the top of the head. They are alleviated by rest. In women, they worsen after a menstrual period. Like Bend Bamboo, Brighten the Eyes also subdues Liver-Yang: the ingredients Ju Hua Flos Chrysanthemi, Man Jing Zi Fructus Viticis, Mi Meng Hua Flos Buddleiae and Bai Ji Li Fructus Tribuli all subdue Liver-Yang, although they are included in the remedy primarily for their property of affecting the eyes. Thus, there is an overlap between Bend Bamboo and Brighten the Eyes in so far as both nourish Liver-Blood and subdue Liver-Yang: however, Bend Bamboo=s main impact is to subdue Liver-Yang (and therefore treat the Manifestation Biao) while Brighten the Eyes=s main impact is to nourish LiverBlood and its Liver-Yang subduing action is weaker (and it therefore treats the Root Ben). For this reason, both Bend Bamboo and Brighten the Eyes may be used for chronic headaches from Liver-Yang rising and Liver-Blood deficiency: the former would be used when the acute attacks are frequent and the pain severe; the latter when the acute attacks are very infrequent and the pain much less severe. Apart from this, Brighten the Eyes may also be used for headaches deriving purely from Liver-Blood deficiency, without any Liver-Yang rising. BREAK INTO A SMILE Break into a Smile, a variation of Chai Hu Shu Gan Tang Bupleurum Soothing the Liver Decoction, pacifies the Liver, eliminates stagnation of Qi and stops pain. It can be used to treat headaches deriving from stagnation of Qi affecting the head. This type of headache is distending in character and it occurs on the forehead. It is elicited either by emotional stress or by dietary indiscretions. CALM THE SPIRIT Calm the Spirit, a variation of Gui Pi Tang Tonifying the Spleen Decoction, tonifies Spleen-Qi and nourishes Spleen- and Heart-Blood. It is suitable to treat headaches from deficiency of Heart- and LiverBlood. Such headaches are dull in character and occur either on the forehead or at the top of the head. They are more common in women and may be associated with menstruation, often coming during and after the period. Another situation in which this remedy may be used is for headaches in children deriving from shock. Pre-natal or post-natal shock may affect children causing Heart-Blood deficiency. The ancient Chinese thought that an evil spirit could enter the Heart and displace Blood causing Heart-Blood deficiency. Other doctors sceptical of the evil spirits as a cause of disease thought that the opposite was true, i.e. it was the Heart-Blood deficiency that created a Avacuum@ in the Heart and allowed evil spirits to enter. In any case, in modern medicine, the effect of shock is somewhat equivalent to the ancient evil spirits and it may induce a Heart-Blood deficiency. In this case the child will suffer from dull headaches at the top of the head and will sleep poorly; young children may wake up crying several times during the night. Shock in children may also manifest with a bluish tinge on the forehead.

CLEAR THE SOUL Clear the Soul resolves Phlegm-Heat and calms the Mind: it is a variation of Wen Dan Tang Warming the Gall-Bladder Decoction. It can be used to treat headaches from Phlegm stagnating in the head and obfuscating the clear orifices. This type of headache is dull in character and accompanied by dizziness, blurred vision and a feeling of muzziness and heaviness of the head. Such headaches are worse in the morning. DRAIN FIELDS Drain Fields resolves Dampness and may be used to treat headaches from Dampness stagnating in the head. This type of headache is dull and occurs on the forehead. It is accompanied by a sensation of heaviness in the head, which feels as if wrapped in cotton-wool. The headaches from Phlegm and Dampness are similar and the following table highlights the similarities and differences: Headache from Phlegm Headache from Dampness Character Feeling of heaviness Location Dizziness Blurred vision Poor memory DRAIN FIRE Drain Fire is a variation of Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction (without Mu Tong) and may be used to treat headaches from Liver-Fire. In character these headaches are very similar to those deriving from the rising of Liver-Yang and they occur in the same areas. The main difference from Liver-Yang rising lies in the accompanying symptoms: with Liver-Fire there is more intense heat, more feeling of heat and thirst, more dryness and more mental restlessness. Hence additional symptoms that might differentiate Liver-Fire from Liver-Yang rising are intense thirst, a feeling of heat, a red face and eyes, a bitter taste, dry stools, mental restlessness and irritability, a red tongue with a thick-dry-darkyellow coating and a wiry and rapid pulse. EASE THE MUSCLES Ease the Muscles resolves Damp-Heat from the Stomach and Spleen and from the muscles and it is specific for post-viral fatigue syndrome. However, it may also be used for chronic headaches from DampHeat in the Stomach. This headache is dull but intense and occurs primarily on the forehead. EXPEL WIND-COLD Expel Wind-Cold releases the Exterior and expels external Wind-Cold. The symptoms of an exterior invasion of Wind-Cold include aversion to cold, shivering, possibly fever, occipital stiffness and ache and a Floating pulse. The occipital stiffness is a typical symptom of the Greater-Yang pattern which appears Dull Yes Forehead No No No Dull Yes Throughout the head Yes Yes Yes

in invasions of external Wind-Cold. Occasionally, if the external pathogenic factor is particularly strong, the occipital headache may be very intense and occur along the Great-Yang channels of the back of the neck and head. By definition, this is only an acute headache. EXPEL WIND-HEAT Expel Wind-Heat releases the Exterior and expels Wind-Heat. The symptoms of an exterior invasion of Wind-Heat include a slight aversion to cold, fever and a Floating-Rapid pulse. An invasion of Wind-Heat can be accompanied by a headache which may be very intense: it occurs on the occiput but is often also felt throughout the head. By definition, this is only an acute headache. FREEING THE MOON Freeing the Moon treats pre-menstrual tension by pacifying the Liver, moving Qi, eliminating stagnation and calming the Mind. It can treat pre-menstrual headaches from stagnation of Liver-Qi. This type of headache occurs before the period and it affects the forehead: the ache is accompanied by a feeling of distension. LIMPID SEA Phlegm in the head is a frequent cause of headaches. Limpid Sea resolves Phlegm, primarily DampPhlegm: it is a variation of Er Chen Tang Two Old Decoction. Headache of this type are dull in character and usually occur on the forehead. They are accompanied by feelings of muzziness and heaviness of the head, a sensation as if the head were wrapped, dizziness and blurred vision. In chronic headaches, Phlegm is often combined with Liver-Yang rising. The former causes frequent dull headaches and the latter severe, throbbing headaches. In such cases, if the Phlegm predominates, Limpid Sea can be combined with Bend Bamboo; otherwise Clear Yang is suitable since it specifically treats chronic headaches from Liver-Yang rising and Phlegm. NOURISH THE ROOT Nourish the Root nourishes Kidney-Yin. Kidney-Yin deficiency can cause headaches of a dull nature occurring inside the head and often accompanied by a feeling of emptiness there. PENETRATING VESSEL The remedy Penetrating Vessel harmonizes the Penetrating Vessel by tonifying the Kidneys, nourishing Blood, strengthening the Uterus and subduing rebellious Qi. Rebellious Qi of the Penetrating Vessel may cause symptoms all along the pathway of the vessel in the abdomen, chest, throat and face: for example, the patient may suffer abdominal distension and fullness, umbilical distension, epigastric pain, a tightness or a feeling of oppression of the chest, palpitations, a sensation of a lump in the throat and a feeling of heat in the face. Of course, not all these symptoms are necessary to diagnose a disharmony of the Penetrating Vessel. One of the symptoms of rebellious Qi in the Penetrating Vessel can be headaches caused by Qi rebelling towards the head which is usually related to the Liver channel. This type of headache is more common in women and it often occurs in conjunction with the period, usually before or after. It is intense in character, it may affect the forehead or the whole head and it is associated with a feeling of heat of the face and with anxiety. The pulse associated with this type of headache is Weak on both Kidney positions and relatively Overflowing on both cun positions. RED STIRRING Red Stirring invigorates Heart-Blood and is specific for Blood stasis in the chest. However, as it affects the whole Upper Burner in general, it can be used for headaches from Blood stasis. This type of headache is stabbing in character and fixed in one small area of the head: it starts during the night or worsens at

night. RELEASE CONSTRAINT Release Constraint pacifies the Liver, moves Qi, eliminates stagnation, calms the Mind and settles the Ethereal Soul: it is for Liver-Qi stagnation arising by itself (i.e. without a background of Liver-Blood deficiency) from emotional stress. It is specific for mental depression from Liver-Qi stagnation. This type of Liver-Qi stagnation frequently causes dull but intense headaches on the forehead with a distending character. The headaches are typically worse when under stress. An essential sign to prescribe this remedy is a pulse that is Wiry in all positions. STRENGTHEN THE ROOT Strengthen the Root tonifies Kidney-Yang. Kidney-Yang deficiency may cause dull headaches all over the head which are aggravated by overwork and excessive sexual activity and ameliorated by rest. TONIFY QI AND EASE THE MUSCLES Tonify Qi and Ease the Muscles is a variation of the formula Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction which tonifies and lifts Spleen-Qi. Deficiency and sinking of Qi may cause dull headaches because clear Qi is not reaching the head: this type of headache is dull, occurs on the forehead, and is aggravated by work and ameliorated by rest. There is also a slight feeling of muzziness deriving not from Dampness or Phlegm in the head, but by the failure of the deficient and sinking Qi to rise to the head to clear the upper orifices. WELCOME FRAGRANCE Welcome Fragrance resolves Damp-Heat and Toxic Heat from the nose and is specific for sinusitis. It is ideal for frontal and facial headaches deriving from chronic sinusitis: this type of headache is dull, occurs on the forehead and in the face and is accompanied by a feeling of heaviness of the head and by nasal obstruction or discharge. DOSAGE AND PROTOCOL In chronic headaches, the average dosage is 6 tablets per day, usually taken as 2 tablets three times a day. As the remedy needs to reach the head, it should be taken at least 1 hour after meals. The dosage of some remedies can be adjusted according to time of day. For example, in headaches from Deficiency, it is better to use a higher dose in the morning, e.g. 4 tablets in the morning and 2 in the afternoon. In headaches from Blood deficiency it is better to take a higher dose in the afternoon, e.g. 2 tablets in the morning and 4 in the afternoon. For headaches from Yin deficiency it is better to take a higher dose in the evening, e.g. 4 tablets in the evening and 2 in the afternoon.