E-ISSN:2456-3110

Case Report

Ardhavabhedaka

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 7 JULY
Publisherwww.maharshicharaka.in

Clinical insights and Ayurvedic management for Hemiplegic Migraine w.s.r. to Ardhavabhedaka - A Case Report

Shukla RK1*, Chandil A2, Ritu3, Sharma S4, Meshram R5
DOI:10.21760/jaims.9.7.54

1* Ratnesh Kumar Shukla, First Year Post Graduate Scholar, Dept of Kayachikitsa, Pandit Khushilal Sharma Govt Ayurveda College and Institute, Bhopal, Madhya Pradesh, India.

2 Ayushi Chandil, First Year Post Graduate Scholar, Dept of Kayachikitsa, Pandit Khushilal Sharma Govt Ayurveda College and Institute, Bhopal, Madhya Pradesh, India.

3 Ritu, First Year Post Graduate Scholar, Dept of Kayachikitsa, Pandit Khushilal Sharma Govt Ayurveda College and Institute, Bhopal, Madhya Pradesh, India.

4 Shraddha Sharma, Assistant Professor, Dept of Kayachikitsa, Pandit Khushilal Sharma Govt Ayurveda College and Institute, Bhopal, Madhya Pradesh, India.

5 Rajesh Meshram, Reader, Dept of Kayachikitsa, Pandit Khushilal Sharma Govt Ayurveda College and Institute, Bhopal, Madhya Pradesh, India.

Hemiplegic migraine, known as Ardhavbhedaka in Ayurveda, presents a unique challenge in its management due to its complex etiopathogenesis involving both Vata and Pitta Doshas along with Kapha Dosha. Hemiplegic migraine can be familial, meaning it runs in families, or sporadic, occurring in individuals without a family history.[1] Patients may rarely have a bilateral motor weakness either simultaneously or in succession.[2] This study explores the Ayurvedic approach to managing Ardhavbhedaka through a comprehensive review of classical texts, contemporary literature, and clinical experiences. The treatment protocol emphasizes personalized care, including Shamana (palliative) therapies to pacify aggravated Doshas, Srotosodhana (channel purification) procedures to remove underlying causative factors, and Rasayana therapies to strengthen the body's natural healing mechanisms. Ayurvedic management aims not only to alleviate acute symptoms but also to prevent recurrence and improve overall quality of life. This abstract highlight the efficacy and holistic nature of Ayurveda in addressing Hemiplegic migraine, offering insights for further research and integrative clinical applications.

Keywords: Hemiplegic Migraine, Ardhavbhedaka, Ayurveda, Management

Corresponding Author How to Cite this Article To Browse
Ratnesh Kumar Shukla, First Year Post Graduate Scholar, Dept of Kayachikitsa, Pandit Khushilal Sharma Govt Ayurveda College and Institute, Bhopal, Madhya Pradesh, India.
Email: 		Shukla RK, Chandil A, Ritu, Sharma S, Meshram R, Clinical insights and Ayurvedic management for Hemiplegic Migraine w.s.r. to Ardhavabhedaka - A Case Report. J Ayu Int Med Sci. 2024;9(7):339-345.
Available From
https://jaims.in/jaims/article/view/3614

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-05-14 2024-05-27 2024-06-07 2024-06-17 2024-06-27
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None Nil Yes 13.45

© 2024by Shukla RK, Chandil A, Ritu, Sharma S, Meshram Rand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

J Ayu Int Med Sci 2024;9(7)339
Ratnesh KS et al. Clinical insights and Ayurvedic management for Hemiplegic Migraine

Introduction

Hemiplegic migraine, referred to as Ardhavbhedaka in Ayurveda, presents a distinctive clinical entity characterized by severe headache often accompanied by sensory disturbances and motor deficits affecting one side of the body. This condition poses significant challenges in its management due to its complex etiopathogenesis involving the imbalance of Vata and Pitta Doshas along with Kapha Dosha, as described in Ayurvedic texts. Migraine, a prevalent neurological disorder globally, affects approximately 1 billion individuals worldwide, with a significant proportion experiencing hemiplegic migraine. Severe hemiplegic migraine attacks may be associated with encephalopathy or coma.[3] This variant is characterized by temporary weakness or paralysis on one side of the body during or before the onset of a migraine headache, complicating both diagnosis and treatment. Hemiplegic migraine can be triggered by factors such as acute stress, sleep disturbances (both lack of sleep and excessive sleep), emotional factors, physical exertion, and head trauma. There are also reports suggesting that conventional angiography may trigger hemiplegic migraine episodes.[4]

Ayurveda, an ancient Indian system of medicine, offers a holistic approach to managing such conditions, emphasizing the balance of Doshas (bioenergetic forces) and the restoration of overall health through personalized therapies. Average age of onset is 12 to 17 years. Female to male prevalence ratios range from 2.5 to 1 to 4.3 to 1.[5] Understanding the prevalence and clinical features of Hemiplegic migraine within an Ayurvedic framework is crucial for developing effective management strategies that not only address acute symptoms but also aim to prevent recurrence and enhance quality of life of affected individuals. This introduction sets stage for exploring Ayurvedic principles and practices in management of Hemiplegic migraine, highlighting need for integrative approaches that combine traditional wisdom with modern medical insights.

Roopa of Ardhavabhedaka

One half of head develops severe throbbing and pricking pain, giddiness and piercing pain, disease develops either at interval of fortnight (15 days) or ten days and subsides of its own accord.[6]

Acharya Chakrapani, a Charaka Samhita commentator, explained the phrase Ardhavbhedaka by saying “Ardha Mastaka Vedana.”[7] The Pratyatma Linga of Ardhavabhedaka must be “Pain in the half of the region of head.”[8]

Dosha according to different Acharya:

Acharya Charak or Madhavnidan: Vata or Vata-Kapha
Acharya Sushrut: Vata-Pitta-Kapha
Acharya Vaghbatt: Vata

Samprapti of Ardhavabhedaka

Vata Prakopak Ahara-Vihar Nidan Sewan

↓

(Vyayama, Ushna, Teekshn-Ahara, Vegadharana, Atapa Sewan, Atichinta, Anidra, etc.)

↓

Madyapana, Amla Sevan, Pratapa, Santapa and Chintaadhikya increases Prakoopita Dosha.

↓

Dooshana of Durbala Rasadhi Dhatu’s

↓

Prasara of Doshas in Siras of Shira

↓

Sthansanhraya in Siras due to Shirovaha Sroto Vaigunya

↓

Sthansanshraya in Manya, Bhru, Shankha, Akshi, Lalata, Karna Pradesh

↓

Shirogata Srotas Dosha Dooshya’s lodged

↓

Vata damages Siras of Shiras, causing Shaithilyata, Akunchana

↓

Rakta Dusti vascular disturbance in the form of Shoola in Shiras Ardha Parshwa

↓

Throbbing and pricking pain in one half of the head region. (Ardhavabhedaka)


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Ratnesh KS et al. Clinical insights and Ayurvedic management for Hemiplegic Migraine

Hemiplegic Migraine

Hemiplegic migraine is a rare subtype of migraine with aura, characterized by the presence of motor weakness as an aura manifestation at the time of migraine attack. Typically, migraine aura has visual symptoms as aura, but occasionally impairment in sensation or speech may also be seen. A hemiplegic migraine is a distinct condition in which motor weakness occurs.

Hemiplegic migraine is characterised by recurrent attacks with headache and aura manifestations. Emotional and intense physical stress, viral infections and head trauma are the more common reported trigger factors for hemiplegic migraine attacks.[9]

Symptoms usually occur over 20-30 mins, the symptoms can last for a few hrs to days and rarely can last up to 4 weeks. The symptoms resolve completely in a majority of the cases. Most of the patients with hemiplegic migraine have associated headaches. Headache is almost always present during attacks and it is often severe. The localisation of headache is variable: bilateral, unilateral, ipsilateral or contralateral to the motor symptoms. Symptoms of severe attack, including hemiplegia and impaired consciousness, can last for many days to months before they resolve completely. The motor symptoms may outlast a headache.

Aura symptoms

Unilateral weakness is always present during Hemiplegic migraine attacks and it is considered the most important sign; weakness can rarely be bilateral and sometimes it may switch side. Besides motor weakness, sensory symptoms (such as tingling, numbness and paraesthesia), visual defects (scintillating scotoma, hemianopia) and aphasia are most frequent aura symptoms. Sometimes, migraine attacks may include other signs and symptoms such as fever, seizure, bilateral visual disturbances, a ‘brainstem aura’ with vertigo, dysarthria, ataxia, tinnitus, impaired consciousness and even, in worse conditions, coma. The duration of symptoms is usually 20-60min but, in some cases, aura and motor deficit may onset quickly and simulate an ischaemic attack. The complete recovery from attacks is rule, but in severe migraine attacks, hemiplegia and altered consciousness may persist for weeks until total recovery.[10]

Case Report

According to the patient, she is a 24 year old girl who has been suffering from migraine since last 6 years and is currently suffering from severe headache, nausea, vertigo, numbness in the half of the body and pain in the right hand and leg. She came to our hospital for her problem.

Past history: Migraine (In the last 6 year)

Personal History

DietVegetarian
Appetite Low
BowelIrregular
SleepDisturbed
MicturitionNormal

Family History: NAD

Dashavidhapareeksha

PrakritiVata Pitta
VikritiVata Pitta Kapha
SaraMadhyama
SamhananMadhyama
PramanaMadhyama
SatwaAvara
SatmyaMadhyama
Ahar ShaktiMadhyama
Vyayam ShaktiMadhyama
VayaMadhyama

Ashta Vidha Pareeksha

NadiVata Pitta
MutraPrakrita
MalaVibandha
JivhaLipta
ShabdaPrakrita
SparshaMridu
DrishtiPrakrita
AkritiMadhyama

General Examination

  • Pallor - Absent • Icterus - Absent • Koilonychias - Absent • Lymphadenopathy - Absent • Edema - Absent

On MRI Brain
Screening MRI of Brain Screening on High Field M.R. System suggest Small Focal Gray Matter Deposit is seen in body of left lateral ventricle suggestive of Heterotoρια Gray White Matter signal intensity is normal diffusion restriction or acute infarct in brain is seen.


J Ayu Int Med Sci 2024;9(7)341
Ratnesh KS et al. Clinical insights and Ayurvedic management for Hemiplegic Migraine

Assessment criteria

Headache impact test: (HIT-6) This questionnaire was designed to help you describe and communicate the way you feel and what you cannot do because of headaches. To complete, please circle one answer for each question.

SNSeverity of Headache ScoreScore
1.No headache.0
2.Tolerable headache1
3.Do not disturb the routine work2
4.Disturb the routine work3
5.Intolerable headache4

SNNature of headache ScoreScore
1.Avedana0
2.Manda Vedana1
3.Sambheda Toda2
4.Shastra / Vajrapata Vedana3

SNDuration of Headache: ScoreScore
1.No headache0
2.1 -3 hours1
3.4-12 hours2
4.13-24 hours3
5.Over 24 hours / continuous4

SNNauseaScore
1.Nil0
2.Occasionally1
3.Moderate, but does not disturb the routine work2
4.Severe, disturbing routine work3
5.Severe enough, small amount of fluid regurgitating from mouth4

SNVomitingScore
1.Nil0
2.Only if headache does not subside1
3.Vomiting 1-2 times2
4.Vomiting 2-3 times3
5.Forced to take medicine to stop vomiting4

SNVertigoScore
1.Nil0
2.Feeling of giddiness1
3.Patient feels as if everything is revolving2
4.Revolving signs + black outs3
5.Unconscious4

SNAuraScore
1Nil0
2Last for 5 minutes1
3Last for 15 minutes2
4Last for 30 minutes3
5Last for more than 60 minutes4

Treatment plan

Shodhana chikitsaDosesAnupana
Yoga Basti
Anuvasana - Kottamchukkadi Taila 80ml
Niruha - Dashmoola Kwath 360 ml		A,A,N,A,N,A,N,A
Bahya Chikitsa
Abhyanga - Vatashamaka Taila
Swedana - Dashmoola Kwath
Shirodhara - Jatamansi Kwath
Abhyantar Chikitsa
§ Mahavatvidhwans Ras 60 mg
§ Sameerpannag Ras 60 mg
§ Ekangveer Ras 60 mg
§ Sootshekhar Ras 60 mg
§ Khurasani Owa (Hyoscyamus niger) 60 mg
§ Lajjalu Panchang (Mimosa pudica) 60 mg		360mg × BdLuke warm water
§ Brahmi Vati 250mg ×BdLuke warm water
§ Maharasnadi Kwath40ml ×BdLuke warm water
§ Pathyadi Kwath Extract 300 mg
§ Shirsuladi Vajra Ras 100mg
§ Godanti Bhasma 100mg
§ Laghu Sutsekhar Ras 100 mg		600mg × BdLuke warm water

Result

SNSymptomsBefore TreatmentAfter Treatment
1.Severity of Headache42
2.Nature of Headache42
3.Duration of Headache42
4.Nausea42
5.Vomiting21
6.Vertigo31
7.Aura40

Discussion

These symptoms lead to Doshadushti, manifesting as Tridoshaja (Su.), Vata-Kaphaja (Ch.), and Vataja (Va). Rasa and Rakta Doshas are also affected, as noted by Acharya Charaka in Shiroruk (Ch.Su.24/13). Simultaneously, Srotodushti in Rasa-Raktavahasrotas (the blood vessels of the head) occurs, which corresponds to the vascular phenomenon observed in migraine.

The phenomenon of Urdhavagamana by Vata, due to its Chala Guna or along with Pitta, causing Urdhavagpravriti at Kapha Sthana, elucidates the predominance of Vata Pitta dosha in the establishment of pathogenesis.


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Ratnesh KS et al. Clinical insights and Ayurvedic management for Hemiplegic Migraine

Probable mode of action of treatment

Kottamchukkadi Tail has Aama Pachana (improves digestion power and digest the toxins released from Undigested food) effect when taken internally and has Lekhaniya effect when used externally. It does Doshavilayana (liquefaction of Dosha) and Srotoshodhana which helps in relieving Margavarana (obstruction of channels) of Vata. It will reach to Sukshma Srotas (minute Channels) and thus help in pacifying Vata Dosha. Ushna, Ruksha and Tikshna (sharp) Properties help in pacifying Sheeta (cold) - Snigdha (unctuous) properties of Kapha efficiently.[11]

Dashmoola Kwath serves critical functions such as nourishment, hydration, and detoxification. When the Swedavaha Srotas is impaired, it manifests symptoms like irregular sweating, skin roughness, and overall body heat. Sweat contains sodium chloride, water, urea, lactic acid, potassium, calcium, and other substances that are also present in extracellular fluid, providing essential nutrition to cells. Excessive sweating depletes these fluids, particularly sodium chloride, leading to feelings of exhaustion or weakness.

Swedana, with its properties like warmth and sharpness, stimulates the body and increases metabolic activity. The warmth quality of Sweda dilates capillaries, enhancing circulation, which in turn promotes the elimination of waste products and improves the absorption of oils or medications through the skin. It also stimulates muscles and nerves, aiding in their revitalization. Heat application through Swedana can induce a hypoalgesia effect by distracting from pain stimuli. Sweating regulates body temperature, water balance, and electrolyte levels.[12]

Medicated Swedana Karma acts by-[13]

1. Producing sedative/ tranquilizing effect and thus results in relieving the pain.
2. Relieving stiffness.
3. Relieving coldness.
4. Relieving heaviness.

Shirodhara with Jatamasi Kwath traditionally recommended for various conditions such as headache, migraine, insomnia, attention deficit hyperactivity disorder (ADHD), anxiety, phobias, depression, essential hypertension, and other psychosomatic disorders.

According to Ayurvedic texts, certain vital spots (Marma) are located in the forehead and head regions. Specifically, Marma points like Sthapni, Utshepa, Avarta, Shankha, and Apanga are situated in this area. Acharya Bhela mentions that the spot between both eyebrows (Bhrumadhya) is where Chitta (Mind) resides, and it is also the location of the Sthapni Marma.

Many Marma points in the head region are predominantly influenced by the elements of fire (Agni) and air (Vayu). The Sthapni Marma is positioned at the same level as the pituitary and pineal glands, which are vital for hormone regulation and the overall endocrine system. Mental stress and irritability are factors that can disrupt the normal function of the endocrine system. By stimulating the Sthapni Marma and indirectly affecting the pituitary gland, Shirodhara therapy is believed to bring about changes at a psychosomatic level.

A traditional formulation for neurogenic disorders affecting the central nervous system (CNS) and peripheral nervous system (PNS). This combination Enhances metabolic processes in both CNS and PNS, facilitating neuro-muscular communication. Regulates blood flow to affected areas, counteracts oxygen deprivation, and stimulates cerebro-neural functions. Supports the healing of injured nerves and blood vessels, and promotes the recanalization of blood vessels. Provides nutritional support to nerves and blood vessels.[14-16]

Mahavatvidhwansak Rasa enhances metabolism in CNS and PNS, coordinates neuro-muscular activities. Sameerpannag Rasa enhances tissue oxidation, counteracts oxygen deprivation, and normalizes neuro-muscular metabolism. Ekangveer Ras facilitates healing of damaged nerves and blood vessels, promotes blood vessel recanalization, and activates sensory and motor functions. Sootshekhar Rasa provides nutritional support to aid rapid healing of damaged tissues. Lajari has regenerative effects on neuro-lesions. Khurasani Owa alleviates neuro-irritation.

Brahmi is highly regarded as a powerful brain tonic that supports mental activity, enhances brain function, and helps manage feelings of nervousness and restlessness. Its calming and nurturing qualities make Brahmi particularly beneficial for coping with the demands of a busy schedule and stressful environments.


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Ratnesh KS et al. Clinical insights and Ayurvedic management for Hemiplegic Migraine

Maha-Rasnadhi Kwatha is a polyherbal formulation that has been demonstrated to be safe and non-toxic, offering potential relief to patients. It is composed of extracts from 26 different plants traditionally used in medicine for various purposes, including pain reduction, inflammation reduction, and antipyretic effects.[17]

This combination of Pathyadi Kwath, Laghu Sutshekhar Rasa, Godanti Bhasma, and Sirosuladi Vajra Rasa is a safe and effective polyherbal preparation formulated with specific quantities of herbal ingredients. Each ingredient in combination extract is carefully chosen for its efficacy in treating migraine, headaches, and related discomforts.

Conclusion

In conclusion, this case report highlights the effective integration of clinical insights and Ayurvedic management in treating hemiplegic migraine, specifically under the framework of Ardhavabhedaka. This underscores the potential of holistic treatments in managing complex neurologicalconditions.

References

1. Ducros A. [Familial and sporadic hemiplegic migraine]. Rev Neurol (Paris). 2008 Mar;164(3):216-24.

2. Ducros A, Denier C, Joutel A, Cecillon M, Lescoat C, Vahedi K, Darcel F, Vicaut E, Bousser MG, Tournier-Lasserve E. The clinical spectrum of familial hemiplegic migraine associated with mutations in a neuronal calcium channel. N Engl J Med. 2001 Jul 05;345(1):17-24.

3. Russell MB, Ducros A. Sporadic and familial hemiplegic migraine: pathophysiological mechanisms, clinical characteristics, diagnosis, and management. Lancet Neurol. 2011 May;10(5):457-70.

4. Hansen JM, Hauge AW, Ashina M, Olesen J. Trigger factors for familial hemiplegic migraine. Cephalalgia. 2011 Sep;31(12):1274-81.

5. Thomsen LL, Eriksen MK, Roemer SF, Andersen I, Olesen J, Russell MB. A population-based study of familial hemiplegic migraine suggests revised diagnostic criteria. Brain. 2002 Jun;125(Pt 6):1379-91.

6. Shastri KA. Shirorogavigyaniyaadhyaya 25/15. In: Sushruta Samhita of Maharshi Sushruta. Varanasi: Chaukhambha Sanskrit Sansthan; 2012. P. 166.

7. Shastri SN. Trimarmiyasiddhi 9/75-76. In: Charak Samhita of Agnivesha. Varanasi: Chaukhambha Bharti Academy; 2018. P. 1067

8. Tripathi B. 23/7. In: Ashtanga Hridyayam of Srimadavaghbhata. Varanasi: Chaukhambha Sanskrit Pratishtana; 2003. P. 726.

9. Toldo I, Brunello F, Morao V, et al. First attack and clinical presentation of hemiplegic migraine in paediatric age: a multicenter retrospective study and literature review. Front Neurol 2019;10:1079.

10. Thomsen LL, Ostergaard E, Olesen J, et al. Evidence for a separate type of migraine with aura: sporadic hemiplegic migraine. Neurology 2003;60:595–601.

11. Kumar Tarun, Thakur Anup, Kottamchukkadi Taila: A Theoritical Analysis, WJPR, Vol 7, Issue 9, 2018

12. Neetu Sharma, Nidhi soni, Vijay Jatolia. Successful Ayurveda Management of Trigeminal Neuralgia. AYUSHDHARA, 2024;11(1):36-39.

13. Namita Patel A Comparative Clinical Study to Evaluate the Effect of Dashmool Kwath Nadi Sweda and Local Steam Bath in Sandhi – Gata-Vata. International Ayurvedic Medical Journal {online} 2022

14. Sushrut samhita, Chaukhamba Sanskrit Sansthana, Edition: Reprint, volume 1. Chaukhamba Publication Hindi commentary Sharira sthana, 2014; 5/28: 61.

15. Shushrut samhita Dalhana comm. Ayurved Tatva Sandipika, edited K. S. Shastri. Sharir Sthana 5/28 Page 56. Varansi; Chaukhamba Surbharati Prakashana.

16. Shushrut samhita, Chaukhamba Sanskrit Sansthana, Edition: Reprint, volume 1. Chaukhamba Publication Hindi commentary Sharira sthana, 2014; 6/17: 70.

17. Kavita Bapu Kharat, Varsharani Niphade, Amol Gulve, A case study on the Ayurvedic management of Ankylosing Spondylitis, WJPR, Vol 11, Issue 7, 2022.


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