Long COVID with persistent headache
This is the case of a 43-year-old man who contracted SARS-CoV-2 infection at the end of October 2020. He initially presented with headache, anosmia and ageusia, fatigue, shortness of breath, no fever, some sweating, and no aversion to cold. By mid-November the symptoms had resolved; however, a slight anosmia persisted.
At the beginning of January 2021, severe headaches appeared, localized to the left parieto-frontal and parieto-occipital junctions, sometimes at the right parieto-frontal junction. Since January, the patient has received numerous Western medical treatments (Tramal, MST Continus sustained-release susp. 20 mg, Relpax, cortisone) without effect. Brain MRI was unremarkable.
23 March 2021 — First consultation :
The patient is currently on morphine treatment (MST Continus 20 mg), Zoldpidem (with Xanax as needed).
The patient presents with severe, continuous headache in the areas described above, with a stabbing quality and a sensation of heaviness of the head. There is nausea and belching, hard and difficult stools, marked fatigue, mild shortness of breath, some abdominal distension and fullness, good appetite, urination 6–8 times/day (normal), no chilliness but aversion to heat, no bodily heat, thirst for cool drinks (at least 2 L/day), disturbed sleep with frequent waking and difficulty falling back to sleep. The pulse is slightly slippery (hua) and slightly stagnant (zhi). The tongue tip is red, with a turbid coating. The abdomen is full, tense under the hypochondria, and shows an induration in the epigastric region (xin xia pi ying 心下痞硬).
Treatment:
Acupuncture: Zu San Huo (66.10–11–12), Zusanli (36ST), Shangjuxu (37ST), Neiting (44ST), Neiguan (6PC), Daling (7PC), Ling Gu — Da Bai (22.04–05), Zhongwan (12CV), Shangwan (13CV), Xiawan (10CV).
30 March 2021 — Second consultation :
Discontinuation of the morphine treatment (MST Continus 20 mg/day) and change to an anti-migraine treatment (Relpax) for a period of 2–3 days.
No change following the previous session. Since discontinuing the morphine, nausea has resolved and bowel movements have returned to normal.
Symptoms are otherwise unchanged. Dryness of the lips and mouth is now also noted.
Treatment:
Gua sha of the upper back (marked red sha) and of the chest (marked red sha over the sternum).
Acupuncture: Zusanli (36ST), Jiexi (41ST), Neiting (44ST), Chize (5LU), Hegu (4LI).
Herbal medicine: Modified Zhu Ye Shi Gao Tang:
Dan Zhu Ye 15, Shi Gao 30, Zhi Ban Xia 9, Mai Men Dong 9, Ren Shen 9, Zhi Gan Cao 9, Qiang Huo 12, Fang Feng 9, Chuan Xiong 9.
5 sachets, one sachet per day as decoction, 5 days of treatment.
19 April 2021 — Third consultation (the patient was on holiday for 2 weeks) :
Discontinuation of the anti-migraine treatment (tested for two days — no effect) and change to cortisone (prednisone 20 mg/day for 8 days, then 10 mg/day for 8 days, then 5 mg/day for 8 days) from 2 to 23 April.
Following the session of 30 March, fatigue was markedly reduced, and the headaches had slightly diminished.
Despite the cortisone treatment, there has been no change in the headaches, which remain severe.
Following the course of herbs, there were no notable effects.
The patient still has thirst for cool drinks, absence of aversion to cold, aversion to heat, easy sweating on exertion, dryness of the lips and mouth. Sleep is still poor (without Zoldorm, waking after 4 hours of sleep; with Zoldorm, waking after 6–7 hours).
The pulse is rapid (shuo), large (da), full (shi), and slightly slippery (hua). The tongue is slightly red, and the tip is very red.
Treatment:
Gua sha of the upper back (some red sha), of the supraclavicular fossa (marked red sha), of the deltopectoral groove (marked red sha), and of the chest (marked sha over the sternum).
Acupuncture: Zusanli (36ST), Jiexi (41ST), Neiting (44ST), Chize (5LU), Yangxi (5LI).
Herbal medicine: Bai Hu Jia Ren Shen Tang:
Shi Gao 45, Zhi Mu 15, Zhi Gan Cao 6, Ren Shen 6, Jing Mi one handful.
5 sachets, one sachet per day as decoction, 5 days of treatment.
3 May 2021 — Fourth session :
Following the herbal treatment, the headaches have markedly diminished (only slight residual pain in some areas and at times). Fatigue has resolved; sleep is good (without zolpidem); shortness of breath has resolved. Easy sweating on the slightest exertion and marked thirst still remain. The pulse is large (da) and slightly stagnant (zhi). The tongue tip is red, and there is some coating in the lower burner region.
Treatment:
Gua sha of the supraclavicular fossa, of the deltopectoral angle, and along the superomedial border of the scapula.
Acupuncture: Zusanli (36ST), Jiexi (41ST), Neiting (44ST), Chize (5LU — san dao ma configuration).
11 May 2021 — Fifth session :
Following the previous session, the headache had resolved, but returned slightly after 4–5 days.
Easy sweating, marked thirst, bodily heat and aversion to heat still remain.
Treatment:
Acupuncture: Zusanli (36ST), Jiexi (41ST), Neiting (44ST), Chize (5LU — er dao ma configuration).
Herbal medicine: Bai Hu Jia Ren Shen Tang (identical to the previous herbal prescription).
By the end of the herbal treatment, headache, fatigue, shortness of breath and sleep disturbance had all resolved.
Commentary :
This case originally involved a pathogenic factor that penetrated to the qi level and transformed into wind-heat, similar to the yangming pattern described in the Shang Han Lun. The heat injured the qi and the body fluids (jin ye), which accounts for the marked fatigue, shortness of breath and thirst. The intense heat rose and burst outward, producing the headaches, the dryness of the lips and mouth, the sweating, the bodily heat, the aversion to heat, and the sleep disturbances. The treatment principle consists of clearing heat, supporting the qi and engendering the body fluids.
The first prescription, Zhu Ye Shi Gao Tang, is appropriate for the sequelae of heat attack on yangming, where there is marked injury of the qi and yin with persistent lingering warmth. This formula is very close in action to the second prescription, Bai Hu Jia Ren Shen Tang. The latter treats situations of intense heat that injures the qi and the body fluids. Their difference lies in the differentiation of the severity of the heat and of the injury to qi and body fluids. Given the chronic nature of the situation, we first turned to Zhu Ye Shi Gao Tang, but this proved ineffective, as the heat still present was too strong. We therefore turned to Bai Hu Jia Ren Shen Tang, which — as the results confirmed — was perfectly suited to the situation.