Journal of Ayurveda and Integrative Medicine 15 (2024) 100983

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Journal of Ayurveda and Integrative Medicine

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Case Report

Ayurveda management of migraine - a case report

Giramalla Patil a,* , Shivanand Patil b, Prateek Hosur c
a
All India Institute of Ayurveda, Sarita Vihar, New Delhi, 110076, India
b
All India Institute of Ayurveda, Dargalim, Goa, 403519, India
c
SGES’s Dr N A Magdum Ayurvedic Medical College, Ankali, Belgaum, Karnataka, 591213, India

A R T I C L E I N F O A B S T R A C T

Keywords: Migraine is one of the most prevalent causes of functional disability worldwide. Migraine patients experience
Ayurveda headaches of varying degrees, which are related with a higher level of disability and are triggered by psycho-
Ardhavabhedaka logical and physiological stressors. Migraine is estimated to affect 16.6% of the world’s population, with women
Migraine
being three times more likely to experience it than men. Despite considerable advancements in modern and
Rakthamokshana
traditional medicine, a complete cure remains uncertain. In Ayurvedic treatises, migraine headache is referred to
Siravyadha
Shirashoola as Ardhavabedhaka under the classification of Shiroroga (diseases related to the head region).
35-year-old Indian male police inspector, suffering from recurrent right hemi-cranial headaches once in three
days for the last three months, presented symptoms of Tridhoshaja Ardhvabhedaka (Migraine) associated with
Amlapitta (hyperacidity).
After a thorough assessment of the patient, the treatment was meticulously planned based on the patient’s
Dosha pradhanyatha and Vyadhi avastha (stage of disease). For the proper Samprapti vighatana, Nidana parivarjana
(abstinance from the eitiological factors), Deepana, Paachana, Siravyadha, Nasya and Dosha Shamana Chikitsa
principles were adopted. Further, the severity of the migraine was assessed by MIDAS and NPR score, which
subsequently decreased from 19 to 4, and the NPR scale decreased from 8 to 2 till completion of the therapeutic
intervention.
This case report unequivocally highlights the pivotal role of the Ayurveda treatment regimen in effectively
managing migraine. Overall, effective treatment of migraine cases requires the correct assessment of Dosha status
and Vyadhi avastha and the correct selection of the appropriate medicine and procedures like Siravyadha and
Nasya at that appropriate stage of the disease.

1. Introduction Patients with migraines experience acute pain, comparable to a blow

from a sharp object that pricks or splits, and when severe, it can affect
A migraine, a unilateral throbbing or pulsing headache, is a primary the functionality of the eye and ear [4,5]. Most people who suffer from
type of headache that can cause severe functional disability. In 2015, migraines have pain of varying intensities. Consequently, most patients
The Global Burden of Diseases study cited it as the seventh leading cause rely on a variety of painkillers both during acute attacks and to reduce
of disability worldwide. Migraine is estimated to affect 16.6% of the the frequency of migraine attacks to obtain relief from pain attacks.
world’s population, with women being three times more likely to Over time, many individuals with migraine headaches become
experience it than men. Most people experience migraine between the resistant to painkillers and other treatments, either due to harmful side
ages of 30 and 39, regardless of gender [1]. effects from taking the medicines for too long or a desire to avoid taking
Psychological and physiological stressors are known to trigger the drugs [6].
migraine episodes, which are associated with a greater degree of In Ayurvedic treatises, migraine headache is referred to as Ardhava-
disability [2]. Several intrinsic and extrinsic factors can trigger mi- bedhaka (Migraine) under the classification of Shiroroga (diseases related
graines, including a lack of sleep, poor eating habits, stress, and changes to the head region) [7]. Ardhavabedhaka is a Tridoshaja Shiroroga char-
in weather patterns [3]. acterised by recurrent attacks of headache, which are typically

Peer review under responsibility of Transdisciplinary University, Bangalore.

* Corresponding author.
E-mail address: [email protected] (G. Patil).

https://doi.org/10.1016/j.jaim.2024.100983
Received 15 March 2023; Received in revised form 17 May 2024; Accepted 17 May 2024
Available online 24 October 2024
0975-9476/© 2024 The Authors. Published by Elsevier B.V. on behalf of Institute of Transdisciplinary Health Sciences and Technology and World Ayurveda
Foundation This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
G. Patil et al. Journal of Ayurveda and Integrative Medicine 15 (2024) 100983

unilateral and often associated with Bhrama (feeling dizzy), Aruchi 5. Diagnostic assessment
(tastelessness), Prakasha Asahatwa (photophobia), and Shabda Asahatwa
(sound intolerance) [8]. Patient appeared to be of Vata pittaja prakruti, mamsasara purusha.
The line of management for Ardhavabhedaka includes different His astasthana pariksha revealed that Nadi is Vata Pitta, Jivha is uplipta
Shodhana methods and Shamanaushadhis. Typically, patients are treated (Coated), Akruthi (built) Madhyama (moderate), the rest of pareeksha
with Snehana (internal oleation), Swedana (sudation), Virechana (ther- like Mala (Feaces), Mutra (urine), Shabdha (sound), Sparsha (touch), and
apeutic purgation) [9], and Nasya (nasal installations), along with the Druk (vision) were prakrutha (normal).
oral intake of various herbal and herbomineral medications. If the pa- The findings of routine blood investigations were found to be
tient does not respond to the above line of treatments, the Rakthamok- normal, as listed in Table 1, and radiological investigations like CT and
shana (bloodletting) procedure may be adopted [10]. MRI also showed no abnormality.
The systemic symptoms of migraine are also related to the symptoms Based on the patient’s etiological factors, presented symptoms, and
of Amlapitta (a state of hyperacidity). In the case of Amlapitta, patients clinical examinations, it was diagnosed as Tridoshaja Ardhavabhedhaka
experience symptoms such as nausea, vomiting, giddiness, headache. (TA), which can be correlated to Migraine disease (8A80-ICD11) asso-
Hence, the management line used to treat hyperacidity and the measures ciated with amla pitta (hyperacidity).
for correcting the digestive fire will also aid in managing migraine cases
[8]. Overall, effective treatment of migraine cases requires the correct 6. Therapeutic intervention
assessment of Dosha status and Vyadhi avastha (stage of disease) and the
correct selection of the appropriate medicine at that stage of the disease. After a thorough assessment of the patient, the treatment was
meticulously planned based on the patient’s Dosha pradhanyatha and
2. Patient Information Vyadhi avastha. For the proper Samprapti vighatana, Nidana parivarjana
(abstinance from the eitiological factors), Deepana, Paachana, Siravyadha,
A 35-year-old Indian male, police inspector by profession, appeared and dosha Shaman chikitsa principles were adopted.
with complaints of right hemi- cranial headache once every three days During the first visit, the headache was associated with the
for the last three months, associated with nausea and vomiting. His pain Amlodgara (sour belching) and Daha (epigastric burning sensation) and
was throbbing in nature, severe in intensity (7/10 on a numeric pain Jivha liptata (coated tongue). After carefully assessing the causative
rating scale), and lasted 1–2 hours, exacerbated by sunlight and loud factors, Nidana Parivarjan (abstinence from Etiological factors) was
noises. The patient also presented an epigastric burning sensation and advised. Bilvadi gulika was prescribed for Agni deepana and Ama pachana
sour belching. It was discovered that the patient follows a specific diet and for Kosta shuddhi preferably for Pitta rechana, Avipattikar churna was
and lifestyle routine that involves consuming mostly spicy and sour prescribed. During the second visit, there was subsequent relief from the
foods. They also have irregular eating habits and take mid-day naps associated symptoms, but the intensity of the headache remained un-
while staying awake late at night. The patient reported feeling anxious changed. Tab Dologran and Nasya (nasal instillation) with Anutaila was
due to job-related stress and experiencing difficulty sleeping because of prescribed on second visit. Siravyadha was planned for the second visit,
their work schedule. but because of the hectic schedule of the patient, it was rescheduled for
The patient had visited an allopathic doctor and was given a pre- the third visit. During third visit the Siravyadha was performed as briefed
scription of NSAIDs and Antacids. Initially, taking the recommended below.
medications helped to alleviate the symptoms. However, within the last Siravyadha (Vein puncture): a. Poorva Karma (pre-operative pro-
two months, the frequency of episodes has increased to 4–5 days per cedure) - The patient was advised to take Grithayukta Mudga Yusha
week, with heightened intensity (9/10 on a numeric pain rating scale) (ghee-added green gram soup) Orally for three days before siravyadha.
and resistance to the prescribed drugs. The headache episodes have
become extremely severe (10/10 on the numeric pain rating scale) since
the prior week. The frequency has also gone up to two episodes per day, Table 1
lasting for 1–2 hours and being continuous and unresponsive to NSAIDs. Laboratory investigations.
Past history: The patient had no history of hypertension, diabetes TEST OBSERVED VALUE
mellitus, heart disease, eye/ENT diseases or any other respiratory ill- RBC count 5.54 × 106 ml
nesses. Although the patient consumes alcohol, he does not report any WBC count 9500/cumm
history of smoking. There is a family history of migraine to the patient’s PCV 45.7%
father and Paternal grandfather. Hb 15.0 g%
Neutrophils 52%
Basophills 0
3. Clinical findings Esionophills 4%
Lymphocytes 30%
General Examination: The patient’s physical examination revealed Monocytes 5%
Platelet count 3.61 Lakhs/cumm
no contributing findings, such as fever, pallor, icterus, or aberrant skin
Bleeding Time 3.12 min
pigmentation. His vitals were BP 130/80, HR 80, and Respiratory rate Clotting Time 5 min
17 per minute. Blood Glucose-Random 90 mg/dl
Local Examination: There were no palpable lymph nodes, and the Serum Urea 21 mg%
neurological and musculoskeletal examination results were also nega- Bilirubin Total 1.10 mg%
Bilirubin Direct 0.10 mg%
tive. The far and close visual acuity was determined to be within normal
SGOT 39 units/lts
ranges, and the intraocular pressure was confirmed to be normal. SGPT 43 units/lts
However, no significant contributing finding was elucidated in thorough Alkaline Phosphatase 62 units/lts
systemic and local examinations. Total Proteins 7.7 g/dl
Albumin 4.8 g/dl
The assessment scales used were the Numerical Pain Rating Scale
Globulin 2.9 g/dl
(NPR) [11] and the Migraine disability assessment test (MIDAS) [12]. AG Ratio 1.66
Total Cholesterol 180 mg/dl
4. Timeline LDL 70 mg/dl
HDL 80 mg/dl
Triglycerides 140 mg/dl
Details of the therapeutic timeline and outcome are listed in Table 2.

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G. Patil et al. Journal of Ayurveda and Integrative Medicine 15 (2024) 100983

Table 2
Therapeutic intervention with timeline and outcome.
No. of Visits Medicines/Procedure Observations/outcome MIDAS NPR score

First Visit 1.Avipattikara Churna [15] 5g Orally at Observations on first day of OPD visit MIDAS Score- NPR score-
(February 10, bedtime with lukewarm water. Right hemi cranial headache once every three days for the last three months, 19 10/10
2022) 2. Bilwadi Gulika [16] 1 tab BD Orally associated with nausea and vomiting
before food with lukewarm water.
Second Visit 1.Tab Dologran 1 tab BD Orally After food Associated symptoms like hyperacidity (amlodgar), nausea, vomiting MIDAS score- NPR score-
(February 17, with lukewarm water. reduced. 19 10/10
2022) 2. Anu Taila [17] Nasya, 6 drops (3 drops No improvement in the intensity of headache.
in each nostril) Administration in
Morning.
Third Visit (March 1.Raktamokshana (bloodletting). Hyperacidity, Nausea and vomiting reduced considerably. Before Before
06, 2022) 2.Sootashekara Rasa [18]1 Tab BD orally No improvement in the intensity of headache. Siravyadha Siravyadha
before food with lukewarm water. MIDAS score- NPR score- 8/
3. Shira shooladi vajra rasa [19] 1 Tab BD 14 10
orally after food Soon After Soon After
With lukewarm water. Siravyadha Siravyadha
MIDAS score - NPR Score-5/
14 10
Fourth Visit Kalyanaka Gritha [20] 10g OD orally After siravyadha Symptoms like Photophobia, burning sensation reduced MIDAS score- NPR score- 4/
(March 21, before food in morning with lukewarm significantly, the migraine attack was reduced in frequency, but complained 12 10
2022) water. of Occasional sleep disturbances.

Fifth Visit (April Kalyanaka Gritha 10g OD orally before Patient relieved with the accompanied symptoms and significantly reduced MIDAS score- NPR score- 3/
05, 2022) food in morning with Lukewarm water intensity in Headache during migraine attacks, frequency of migraine attack 12 10
reduced to once in last 15 days.
Sixth Visit (May Kalyanaka Gritha 10g OD orally before Significant reduction in all the symptoms, encountered 2 episodes of MIDAS score - NPR score- 3/
04, 2022) food in morning with Lukewarm water migraine attacks with reduced headache intensity. 10 10

Seventh Visit Kalyanaka Gritha 10g OD orally fefore Only one episode of migraine attack since last one month. MIDAS score - NPR score - 2
(June 05, 2022) food in morning with Lukewarm water 4

B. Pradhana karma (operative procedure)- Following a Mukha

Abhyanga (face massage) with Bala Taila and Baspha Sweda (steam
sudation) with cold packs over the eyes, the patient was instructed to sit
in a chair with their neck flexed forward and supported by their fists
under their chin. Using their index and middle fingers, they were
advised to gently occlude their external jugular vein while a crepe
bandage stabilized their position, as shown in Fig 1. The area was
sterilized with a spirit swab before selecting a prominent vein on the
right temporal area. A sterile needle (22 G) was inserted and approxi-
mately 65 ml of blood was collected as illustrated in Fig 2.
C. Paschat Karma (Post-operative procedure) - Following the

Fig 2. Complete Cessation of Blood flow.

complete cessation of blood flow, the needle was carefully extracted,

and the puncture site was dressed with gauze infused with Betadine. The
patient was advised to take rest. Later, Kalyanaka Gritha was advised on
subsequent visits for 2 months.

7. Outcome

During the patient’s first and second visits, patient reported a

decrease in associated symptoms and amlapitta. However, the intensity
and frequency of migraines remained unchanged. After undergoing
Fig 1. Position of siravyadha.

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G. Patil et al. Journal of Ayurveda and Integrative Medicine 15 (2024) 100983

Siravyadha, there was a notable improvement in the intensity and digestion (Pachana), and balances Pachaka Pitta and Samana Vayu
recurrence. The patient’s MIDAS score decreased from 19 to 14, and the without any adverse effects.
NPR scale decreased from 8 to 5 shortly after the procedure. Further- Anu Taila [19] Nasya (nasal instillation), is advised along with
more, during subsequent visits, the MIDAS score decreased to 4 and the Dologran tablet, because of its Sthanika Dosha Nirharana (pacification of
NPR scale reduced to 2 after the administration of Kalyanaka Gritha. local humours) properties by virtue of shodhana effect, as it is indicated
in various diseases of head and neck [20]. Nasya is a bio-purification
8. Discussion method that involves administering medication through the nasal pas-
sage. This method allows the medication to reach the brain directly and
Shirashoola, commonly known as headache, is a multifaceted ailment distribute throughout the body. When applied, the herbal potency rea-
that is identified both as an independent disease and a manifestation of ches the shringataka, a vital point at the base of the nose, and then ex-
various disorders in Ayurvedic literature. The condition is categorized tends to the head, eyes, ears, and throat, assisting in expelling harmful
into different groups based on the doshas implicated and the nature of doshas from the head. This may be attributed to its stimulating effect on
the pain. Proper identification of the underlying cause is imperative for the brain through olfactory and respiratory pathways. The nasal
creating an efficient treatment regimen [7]. epithelium is a highly permeable monolayer, and the submucosa has
The patient indulged in various Aharaja nidana (dietary eitiological extensive vasculature, enabling rapid absorption and direct entry of the
factors), i.e., Katu, amla rasa Pradhana Ahara and Madyapana, and drug into the systemic circulation, bypassing hepatic metabolism.
Viharaja nidhana (lifestyle related eitiology) includes Ratri jagarana, Intranasal drug delivery through olfactory and respiratory pathways
Akala ahara Sevana, and Manasika nidhana, which includes Chinta, holds promise for delivering medication to the central nervous system.
which are responsible for the vitiation of Agni and Tridosha, which Lipid-based drugs with a lower molecular weight, less than 400–600 Da
subsequently vitiated Rasa and Rakthavaha srothas , and gets lodged in (Dalton), and a positive charge have a greater ability to cross the
Ardha siras, causing symptoms of TA. As the patient is continuously blood-brain barrier [17].
involved in Pitta and Vata vriddhikar ahara (food) and Vihara (lifestyle), After the previous treatment, the patient approached with the
which are accountable for the aggravation of Vata and Pitta Dosha and persistent migraine episodes along with symptoms of Rakta Dusti,
the generation of Amlapitta in koshta, which further intensifies headache characterised by photophobia and a burning sensation in the eyes. As a
episodes of TA [13]. result, the patient underwent Siravyadha, a bloodletting procedure that
In this case, the therapeutic strategy includes three main components involved removing 65 ml of blood using Siravyadha (phlebotomy)
- Nidana Parivarjana, Siravyadha, and Shamana Chikitsa. Nidana Par- following standard operating procedures. The Siravyadha treatment
ivarjana refers to avoiding the causative factors that led to the issue in effectively relieved the patient’s photophobia and burning sensation in
the first place. Siravyadha refers to the removal of venous blood which the eyes by removing Sthanika Dosha from the blood and aiding in the
helps to remove any accumulated toxins or impurities from the body. relief of Vata Avarana.
Finally, Shamana Chikitsa refers to the palliative treatment, which aims Siravyadha (Vein puncture) procedure helps remove inflammatory
to alleviate the symptoms and provide relief. All these three components agents and chemical mediators present in large amounts, such as bra-
are necessary because both the Shakha and the Koshta (the gut) have dykinin, histamine, serotonin, substance P, and leukocytes. Previous
undergone Dosha Prakopa, which refers to the aggravation of the three research has shown that the blood detoxification theory, in which
Doshas (Vata, Pitta, and Kapha). removing old red blood cells and obstruction from the blood promotes
In the initial line of treatment Nidana Parivarjana was given top the removal of toxins, improves the nutrition status, and boosts the
priority hence, the patient was advised not to take Amla, Katu, Vidahi metabolic process by providing good blood circulation. According to
Ahara and asked to avoid alcohol consumption and advised to avoid Acharya Sushruta, VP is described as Ardhachikitsa, which emphasizes
Raatrijagarana and diwaswapna. It not only prevented the further its action on various neurological and vascular pathologies [21–23].
aggravation of dosha (prakopa) but also severity of the symptoms. After the Siravyadha the patient was advised to take palliative drugs
The next step in the treatment plan involves using Bilwadi Gulika such as Soothashekar Rasa [24] and Shirashooladi Vajra Rasa [25] to
[14], known for its digestive stimulant and digestant qualities, which prevent further blood vitiation and to balance the Tridoshas. Sootha-
will help with the successful digestion of Ama Dosha and prevent the shekara Rasa is known for its Pitta Shamaka properties, which help to
formation of rasadushti. It also possesses ushna veerya (hot potency), balance the pH of the gut [26]. Shirashooladi Vajra rasa also reduces the
Kturasa (pungent taste), katahara (Mitigating Kapha and Vata), Soo- severity of headaches by performing Tridosha Shamana. The patient’s
laghna (Analgesic),Dahashamana (calms down burning sensation), condition improved significantly as assessed with the MIDAS and NPR
Shophaghna (anti-inflammatory), Vnaropaka (Wound healing), and scale, as shown in Table 2.
Gashaka (papule resolving) properties [15]. Kalyanaka Gritha [27]was prescribed in this case owing to its efficacy
After achieving proper Amapachana, Koshta Shodan (Mrudu Vir- in managing various types of pain, whether originating from peripheral
echana) with Avipattikara churna [16] was carried out to remove Dosha nerves, the brain, or the spinal cord. Pain affects various aspects of one’s
(humours) from the body, especially pitha dosha as the patient had Pitta life, including physical, behavioural, cognitive, emotional, spiritual, and
vruddi Lakshna at that phase and avipattikar choorna is also known for its interpersonal elements [28].Along with other causative agents, stress is
capacity to increase digestive fire and neutralizing gastric acid. After one of the primary contributing factors; hence Kalyanaka Gritha has
achieving koshta shuddhi the subsequently administered medication will been recommended for 60 days for its commendable ability to harmo-
result in greater efficacy and improved metabolism [8,17]. Further, the nize the three doshas, Agnideepana properties to enhance physical
constituents of Avipattikar churna have been found to possess antiulcer prowess and establish mental equilibrium. This, in turn, aids in the
properties. Haritaki, Maricha, and Pippali have demonstrated cytopro- alleviation of all Manasika Nidanas, which might otherwise lead to Dosha
tective effects on the gastric mucosa. Shunthi has been observed to Prakopa and ultimately result in the Rasa and Rakta Dusti. At the time of
reduce gastric secretion, enhance mucosal resistance, and potentiate the the last follow-up evaluation, the patient’s NPR score was two, and
defensive factors of the gastric mucosa. Additionally, Lavanga has been MIDAS score was 4, indicating a No or Little disability range and
shown to play a role in maintaining basal gastric mucosal blood flow and improvement in overall well-being.
increasing mucus secretion [18].
In the following session, the patient received an oral dose of 9. Conclusion
Dologran tablet containing Patyadi Kwatha extract (250mg), Shira-
shooladi Vajra Ras (120mg), Godanti Bhasma (100mg), and Lagu Soota- The management involves first avoiding nidan (etiology/triggers),
shekara Ras (100mg). This tablet aids in reducing Pitta Vriddhi, improves Siravyadha followed by administering appropriate medications and

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G. Patil et al. Journal of Ayurveda and Integrative Medicine 15 (2024) 100983

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