A Case of Migraine Without Aura That Was Successfully Treated With an Herbal Medicine

Introduction

Migraine is a common disabling condition that affects about 10% of the population and has a high socioeconomic cost. ¹ It consists of two major clinical subtypes: migraine with or without aura. Two percent of the population has frequent migraine attacks. ¹ All patients with migraine require acute treatment for each attack, and some require prophylactic pharmacotherapy. There are two types of regimen for the acute treatment of migraine: nonspecific treatments, such as analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs), and disease-specific treatments, such as ergotamine and 5-HT1B/D agonists (triptans). Among these acute therapies, triptans are thought to be the most effective agents. However, recurrence, triptan-specific adverse effects, and cardiovascular safety are major shortcomings of these treatments. ²

In the preventive treatment of migraine, β-blockers and antiepileptic drugs are among the most widely used and well-studied nonspecific prophylactics. However, these prophylactic drugs achieve a therapeutic gain of only approximately 25%, and all have significant adverse effects. ³ Therefore, better pharmaceutical treatments against migraine are needed.

In Japan, a variety of herbal products, which mainly consist of herbal extract formulations, have been available under the Japanese National Health Insurance System since 1976. Accordingly, herbal medicines have been widely used to treat a variety of headaches, including migraines, especially when the standard therapies are not effective or cannot be continued because of their adverse effects. However, there appear to be few English-language reports concerning the treatment of migraine with herbal medicines. ^{4 –6}

This report describes the case of a 49-year-old woman who had frequent episodes of migraine without aura. Despite the administration of antiepileptic drugs as prophylaxis, she experienced severe migraines almost three times a week and had to take 100 mg of sumatriptan orally for each attack. Because the pain-relieving effect of sumatriptan was unstable and the patient did not want to take this drug any more in order to avoid overuse, we decided to treat her with a traditional Japanese/Chinese herbal medicine, sanno-shashin-to extract, instead of sumatriptan. Soon after she started taking this herbal medicine, the intensity of her headaches was markedly decreased, to the extent that she no longer needed triptans. The findings suggest that sanno-shashin-to extract might be a novel option for the treatment of migraine.

Patient

A 49-year-old married woman who had a son and a daughter and worked part-time in the medical profession had developed trigeminal neuralgia at age 33 and had experienced frequent headaches ever since. At first, her headaches occurred once a week, but she was able to control acute attacks by taking NSAIDs. However, her headaches gradually intensified, and the frequency of the attacks also gradually increased. In the end, NSAIDs no longer worked as painkillers. Thus, she consulted the headache center of a university hospital at age 47.

The results of physical and neurologic examinations were unremarkable, and magnetic resonance imaging of her head showed no abnormalities. Migraine without aura was diagnosed, and she was treated with per oral sumatriptan to control the acute attacks, as well as an antiepileptic drug (oral administration of 200 mg of sodium valproate twice a day) as a nonspecific prophylactic. These prescriptions initially worked. Although acute migraine episodes occurred five or six times a month, 50 mg of per oral sumatriptan was sufficient to control them. Nevertheless, the frequency of the attacks gradually increased to three times a week, and as a result, she had to take 100 mg of sumatriptan for each attack, which she did for 3 months before coming to the study clinic. Because sumatriptan sometimes did not work as a painkiller and the patient wished to discontinue it in order to avoid overuse, she consulted the study clinic for an alternative (non–Western medicine–based) therapy.

Her headaches were characterized by a throbbing pain at the left parietal lobe with severe neck and shoulder stiffness. Her symptoms were triggered by changes in the weather but improved slightly when she placed a cold cloth on her forehead or moved to a quiet and dark environment. The attacks mainly occurred in the morning, and she was often woken up by headaches. Sometimes, her routine daily activities were strongly impaired by severe headaches combined with general fatigue and nausea, to the extent that she had to go to bed, even though she had taken 100 mg of oral sumatriptan. Other physical symptoms included chronic constipation. Psychologically, she was experiencing intense stress due to family issues. Her face was slightly flushed, and her fingers were edematous, especially in the morning. She had a dark red tongue with a greasy, yellow coating.

Results

According to traditional Japanese and Chinese medical practice, an excess of damp-heat, especially in the upper body, was diagnosed, which might have caused her migraine without aura. Therefore, she was told to take an herbal medicine, sanno-shashin-to (Xie Xin Tang) extract formula (Kotaro Pharmaceutical, Osaka, Japan), once a day (two capsules before going to sleep at night) to prevent severe morning headaches. She was also allowed to continue taking the same antiepileptic drug. After 3 weeks of treatment, the frequency of her headaches had not changed. However, the intensity of her morning headaches had markedly decreased, even though she had stopped taking sumatriptan. Furthermore, her residual headaches rapidly disappeared within about an hour when she started taking an additional capsule in the morning. The patient has now been undergoing the same treatment for almost 2 years without any exacerbation of her migraine attacks. She has not taken sumatriptan since she started taking this herbal medicine.

Discussion

This report clearly demonstrated that sanno-shashin-to, an herbal medicine, has a strong pain-relieving effect against migraine without aura. Sanno-shashin-to was originally produced in ancient China and is described in Essentials from the Golden Cabinet. It consists of Rhei Radix et Rhizoma, Coptidis Rhizoma, and Scutellariae Radix. In traditional Japanese and Chinese medicine, this formula is used to drain an excess of damp-heat, which is characterized by fever, irritability, restlessness, a flushed face, red eyes, dark urine, constipation, and a greasy and yellow tongue coating. ⁷ More precisely, Rhei Radix et Rhizoma is the chief herb that drains the heat, especially from the upper part of the body. The subcomponents, Coptidis Rhizoma and Scutellariae Radix, also drain heat from the upper and middle parts of the body. ⁷ This formula can also be used to treat a wide variety of biomedically defined disorders, especially those affecting the upper part of the body (e.g., trigeminal neuralgia; infectious and purulent inflammations involving the head and neck; hemorrhaging from the optical fundus; and cerebrovascular diseases, including hypertension, atherosclerosis, and stroke). ⁷ Although the patient described here had no biomedically defined disorders, she experienced several symptoms as described above and had a history of trigeminal neuralgia. Thus, treatment with sanno-shashin-to was chosen.

Generally, traditional herbal medicines have been selected empirically from many types of primitive phytomedicine and developed on the basis of their efficacy and safety over a period of almost 2000 years. Therefore, these medicines are widely thought to be free from severe adverse effects, despite the lack of reliable statistical evidence from large-scale controlled studies to support this assertion. However, the adverse effects of some herbal formulas should still be noted. In particular, Scutellariae Radix, which is found in sanno-shashin-to, is well known to bring about hepatic dysfunction. ⁸ Moreover, this herb is suspected of having a causal association with interstitial pneumonitis. ⁹ Although such serious adverse effects are rare and the patient did not experience them during the observation period, regular blood testing and chest radiography are strongly recommended for patients who take this formula for a long period. If there are any signs of adverse effects, the treatment should be ceased immediately.

Drug adherence is also very important for herbal medicine–based treatment. Although doctors in Japan can prescribe more than 140 kinds of commercially available herbal medicine extracts, which ensures quality control and increases patient convenience, most of these extracts are supplied as granules or powders. Because each herbal medicine has a unique taste and smell, problems with either of these can lead to reduced adherence and can sometimes lead to patients not taking their medicine. However, some decoctions, including sanno-shashin-to, are also provided in capsule form. Therefore, sanno-shashin-to extract might be widely accepted by patients who are unfamiliar with herbal medicine.

Finally, it should also be noted that treatment with herbal medicines is cost-effective. Indeed, the cost of one capsule of sanno-shashin-to is no more than one-thirtieth of that of a sumatriptan tablet.

Conclusions

Although the details regarding the mechanisms underlying the pain-relieving effects of sanno-shashin-to extract remain unclear, this formula might be a very attractive option for the treatment of migraine. Many reports have described the treatment of headaches, including migraine, with various herbal medicines in Japan, but the current case is believed to be the first showing that sanno-shashin-to extract is effective at treating migraine. In particular, it should be noted that this herbal medicine has both prophylactic and therapeutic effects against migraine. Furthermore, distinct from other herbal medicines for headache, this formula is available in capsule form. Therefore, it might be a suitable candidate for future clinical studies.