Effective Integration of Traditional Chinese and Western Medicine Treatments for a 57-Year-Old Patient with Headaches Due to Liver-Yang Rising Syndrome

Headaches and dizziness can significantly impact daily life, especially when associated with chronic conditions like hypertension. This case highlights the successful treatment of a 57-year-old woman suffering from recurring headaches and dizziness for over a year. Despite stable blood pressure control through Western medication, her symptoms persisted. Upon further evaluation, she was diagnosed with hypertension and Liver-Yang Rising Syndrome, a common pattern in Traditional Chinese Medicine (TCM). By combining personalized TCM herbal therapy with standard antihypertensive treatment, the patient experienced significant relief from her symptoms and improved overall well-being.

Patient Overview

Patient: Female, 57 years oldDiagnosis: Headache – Liver-Yang Rising SyndromeHospital: First Affiliated Hospital of Nanchang UniversityVisit Date: December 2021Treatment: Integrated TCM and Western medicine, including a customized herbal formula and Amlodipine BesylateTreatment Duration: 15 days inpatient care, followed by 1 month outpatient follow-upOutcome: Significant improvement in headache and dizziness, stable blood pressure

Initial Consultation

The patient had a history of headaches and dizziness for over a year, previously diagnosed with hypertension and managed with Amlodipine Besylate. Despite treatment, she continued to experience intermittent symptoms, especially at the top of her head, often triggered by physical exertion. One week before admission, her symptoms worsened after an emotional outburst. She also experienced fatigue, palpitations, chest tightness, occasional nausea, and poor sleep quality. Her physical examination revealed a blood pressure of 170/110 mmHg and facial flushing. An ultrasound showed atherosclerotic plaque formation in the right common carotid artery and carotid bulb. Western diagnosis: Stage 2 Hypertension and carotid artery plaque. TCM diagnosis: Headache due to Liver-Yang Rising Syndrome.

Treatment Progress

First Evaluation

Based on TCM principles, the patient was diagnosed with Liver-Yang Rising Syndrome. Treatment focused on calming liver yang and resolving blood stasis. A customized herbal formula was prescribed, including Gastrodia, Uncaria, Achyranthes Root, Concha Margaritifera, Rehmannia Root, Polygonum Multiflorum Stem, Gardenia, Eucommia Bark, Scutellaria Root, Taxillus, Schisandra, Salvia, and Red Peony Root.

Second Evaluation (3 Days Later)

Her headache and head fullness improved slightly, and her sleep quality increased. However, her blood pressure remained high at 165/115 mmHg. Amlodipine Besylate was added to her regimen to better control her blood pressure, while continuing the herbal treatment.

Third Evaluation

Her dizziness and headache were nearly gone, and her blood pressure stabilized within the normal range. However, she developed poor appetite and persistent fatigue. Her tongue was dark red with tooth marks, and her pulse was thin. This indicated spleen deficiency with dampness retention. The treatment was adjusted to include Qi-tonifying and phlegm-resolving herbs such as Codonopsis Root, Poria, Atractylodes, Licorice Root, Astragalus, Chinese Yam, Amomum Fruit, Citrus Aurantium, and Eupatorium.

Fourth Evaluation

All symptoms had largely resolved. The patient no longer experienced headaches, her energy levels improved, and her appetite returned to normal.

Therapeutic Outcomes

The patient responded well to the combined treatment approach. Her headache and dizziness were significantly reduced, and her blood pressure remained stable throughout the follow-up period. The TCM approach focused on balancing liver function, resolving blood stasis with herbs like Salvia and Red Peony, which may help improve circulation and reduce vascular resistance. This holistic method complemented the Western medication, leading to a more comprehensive and lasting recovery.

Lifestyle and Preventive Measures

While the patient's condition improved, it is essential to recognize that hypertension can be influenced by various lifestyle factors. Excessive alcohol consumption, spicy foods, high-fat diets, and emotional stress can all contribute to liver dysfunction and elevated blood pressure. Patients are encouraged to adopt healthier habits, such as quitting smoking and alcohol, maintaining a low-fat diet, engaging in daily physical activity, and managing stress effectively. Herbal teas like chrysanthemum, Margarite shell, and corn silk can also support blood pressure regulation. Nutrient-rich foods like celery, seaweed, and potatoes are recommended, and steamed soft-shelled turtle can be used to calm liver yang.

Clinical Insights

Hypertension is increasingly affecting younger populations, emphasizing the importance of both symptom management and root cause treatment. This case demonstrates the value of integrating TCM and Western medicine to address not only the immediate symptoms but also the underlying imbalances. Emotional regulation, balanced work-rest schedules, and healthy eating habits are crucial for long-term blood pressure control. For patients struggling with persistent hypertension, early intervention with comprehensive, evidence-based treatment is essential to prevent serious cardiovascular complications.