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Management of Vataja Shirashula with Kusthadi Shirolepa and Goghrita Pratimarsha Nasya - A Case Report

Shiras, also known as Uttamanga is the most vital part of our body. In Ayurveda, Shiro rogas are restricted to pain or discomfort seen around cranial vault and not the disorders of brain as such. Headache is the most frequent and troublesome reason to seek medical help in our day to day life. Tension type headache is the most common, primary, most neglected and difficult to treat occurring in about three-quarters of the general population. They can range from the occasional mild headaches to daily disabling headaches in some cases. Current allopathic approach is highly limited in treating the disease with just pain killers, which again have lot of side effects. 
Holistic Ayurveda approach practically is found to yield very good results in the patients of headache. Vataja Shiroroga can be an apt classical correlation of Tension-type headache. Atiuccha bhashana, Vegadharana, Ratrijagarana, Upavasa and Shoka are the major causes of Vataja shirashula. Classical books of Ayurveda advocate the use of Snehana, Swedana, Navana nasya, Snaihika dhumapana and local Vatahara kriya like Lepa and Parisheka as main mode of treatment. 
Nasya is a special therapy in all Shalakya disorders and Goghrita is considered as best Vatahara dravya. Kushtadi Lepa is indicated in Vataja Shiroroga classically. In this study, Kushtadi shirolepa and Goghrita pratimarsha nasya is done in a 19 year old patient having typical symptoms, to access the overall efficacy. After 1 month of therapy, significant improvement was seen in the symptoms. Mild recurrence was seen post follow-up period.


INTRODUCTION
Shiras is a one of the Sadhyopranahara marma and a vital seat of Prana. [1] Shirashoola involves all the aches and discomforts located in Shiras (head), and is considered as a synonym of Shiroroga. [2] There is elaborate classification of Shirorogas in our classics. Acharya Sushruta has explained 11 types of Shirorogas. [3] Among them, Vataja Shiroroga is the frequently encountered type of headache clinically. The reason might be the classically mentioned causes such as Vegadharana (suppressing the natural urges), Ratri-jagarana (staying awake at night), Upavasa (irrational fasting), Ati-ucchabhashana (speaking loud for longer hours), and Bhaya [4] (anxiety), which reflect the stressful daily regimen the people go through in their day to day lives.
Nasya is an important therapy in all Shirorogas as Nose is the gateway for the Shiras. [5] Acharya Sushruta advocates the use of Snehana, Swedana, Nasya, Shirolepa, Shiroabhyanga, Dhumapana, Parisheka and Upanaha using Vatahara dravyas, as Bahya upakramas. As Abhyantara upakramas, Snehapana, Anuvasana and Niruha bastis are explained. [6] Headache is an extremely frequent reason for seeking medical help. Tension-type headache is the most common primary headache disorder. The pain can radiate from lower back of the head, neck and eyes or other muscle groups in the body typically affecting both sides of the head. They account for nearly 90% of all headaches. Stress, sleep deprivation, bad posture, irregular diet habits, teeth clenching, eye strain and muscle tension around head and neck are some of the precipitating factors. [7] World Health Organization classifies it as episodic and chronic. Episodic TTH, occurring on fewer than 15 days per month, is reported by more than 70% of some populations. They usually last a few hours, but can persist for several days. Chronic TTH, occurring on fewer than 15 days per month, affects 1-3% adults. It often begins during the teenage years, affecting 3 women to every 3 men. Its pathology may be either stress related or associated with musculoskeletal complications in the neck. It can be unremitting and is much more disabling than episodic TTH. The headache in both the varieties is described as pressure or tightness, often like a band around the head, sometimes spreading into or from the neck. [8] Management involves careful assessment followed by discussion and explanation of the underlying pathology, physiotherapy with muscle relaxation and stress management, low dose of antitriptyline (10mg) may be necessary. [9] Case report A patient, aged 19 years, with OPD number 1082, at Government Ayurveda Medical College and Hospital, Mysore was apparently normal 3 month back. He gradually developed symptom of severe headache associated with mild giddiness. The site of headache was around the forehead and behind the neck, aching type, continuous severe pain with no periodicity. During stressful situations, he felt irritability and some sort of sound associated with mild pain in the ears. The symptoms used to aggravate during exposure to sun, at night and the relieving factor was having rest, analgesics and tying cloth tightly to forehead. He consulted local physicians for the same, where painkillers were given. He only had temporary relief from pain. Next day same headache used to recur. Hence he visited our hospital on 18 th November 2020.
No significant past history and no similar complaints in the family members. He was having mixed diet, usually spicy and irregular. The sleep was disturbed due to habit of late night awakening to study or to watch movies in android. No significant habits like alcohol intake or smoking.

Clinical Findings
The patient was conscious and well oriented. On examination, PR-75/min and BP was 125/80mm of Hg. Under systemic examination, CNS, CVS, Loco motor system, RS had no abnormal deviations. In GIT examination, the tongue was coated. In Eye examination, visual acuity was 6/6 both eyes for distance and N6 for near. ENT examination revealed mild tenderness present at ethmoidal sinus. Rest part of examination was insignificant. Hematological findings: Hb%-12.5gm/dl, Total blood count -WNL

Diagnosis and Assessment
The differential diagnosis of this type of headache includes tension type of headache, migraine headache and meningitis. Migraine is excluded as the headache is not associated with visual disturbances, nausea or vomiting, no aggravation on physical work and is non-episodic. Meningitis can be ruled out as there were no acute symptoms like fever, vomiting or convulsions. Hematological findings do not support it either. Tension type of headache will be final diagnosis because the patient has history of sleep deprivation, stress, eye strain and irregular eating habits, which are the precipitating factors of the disease. The site of headache is around the forehead band like and aching type.

Treatment Plan
As the classical and modern approach advocates that Nidana parivarjana (avoiding the causative factors) is the prime approach to Vataja shirashula, the patient was counseled to change the food habits, manage the stress related to studies, get less exposed to hot sun, android phones and to sleep on time. Apart from these, the patient was advised application of Kushtadi Shirolepa [10] , which is classically indicated in Vataja Shirashula, over the forehead daily for 1 month mixed with Ardraka swarasa. As the patient was unable to visit the hospital, he was advised Pratimarsha nasya. Since Snehana and Navana nasya are classically indicated in Vataja shiroroga, Goghrita [11] , which is considered as best Vatahara dravya, was selected. The patient was advised to instill warm ghee in the dose of 2 drops in each nostril, early morning once a day.  communis). The fine powders of both the drugs are taken in 1: 1 ratio. The mixture is triturated with required quantity of Ardraka swarasa and the paste obtained is applied over forehead. In the original reference, the liquid used is Kanji (a special fermented liquid). Since it is not easily available, Ardraka swarasa, which is also indicated in Shirashula [15] has been advised here for application at home. Pharmacological Properties of the Drugs [16]  Kustha mula (Saussurea lappa) has Vatakaphahara property and is Shirashulahara. It is anti-inflammatory and spasmolytic.  Eranda mula (Ricinus communis) is Shiropidahara, Shulahara and Tridosha shamaka. It is stimulant in nature.  Ardraka swarasa (Zingiber officinale) is Shulahara, Vibandhahara and Vata-kaphahara. It is stimulant in nature. [16]  Goghrita is Vata-pitta shamaka, Sheetoshna veerya, Snehana, Agnivardhaka and Rasayana in nature. [17] RESULT After completion of the therapy, the patient had complete relief from headache, giddiness and tinnitus. The sleep pattern was also improved. There was no irritability on exposure to noise. The patient appeared to be more relieved and pleased.
On completion of follow-up period, the patient complained of recurrence of very mild headache once during reading his book for long.

DISCUSSION
Headache is the most common, and yet most the most difficult clinical problem encountered by the physicians. Ayurveda gives special importance by mentioning Shirorogas separately. The different forms of pains or discomforts felt in the cranial vault are included under Shirashula. Vataja shiroroga is the commonest disease, given the rise in etiologies leading to Vata dosha vitiation in this stressful run for life era.
Manasika bhavas like Chinta, Shoka, Bhaya etc leads to Jatharagni mandya, which in turn leads to Apakva amarasa formation. Malarupi kapha is increased in quantity, which goes to Rasa-Rakta Samvahana and reaches Shiras. Their Sanga occurs due to Khavaigunya. It causes Khavaigunya in Manovaha srotas leading to Raja and Tamo guna increase. Thus it leads to Vata dosha prakopa and hence Vataja Shirashula. [19] Tension type headache is the most common type of headache and is experienced at some time by the majority of the population in some form. Though the pathology is poorly understood, it may be stress related or musculo-skeletal involvement in the neck. Emotional strain or anxiety is a common precipitant to TTH. [20] Nasa is described as the gateway of Shiras. The drug thus administered reaches Shringataka (a Sira Marma in Nasa srotra) and spreads in the Murdha (brain) reaching the Marma of Netra (eye), Shrotra (ear), Kantha (throat), Siramukha (opening of the vessels, etc.). Then by virtue of its potency, it scrapes the vitiated Doshas from Supraclavicular region and expels them from Uttamanga. [21] The drug that enters nasal pathway will have vascular absorption, enters systemic circulation, has direct pooling into the intra cranial region, lymphatic transportation, effect on neuro-endocrinal junction is also well established. [22] The drug Kushta is indicated in Shirashula by Acharya Sharangadhara. [23] As it is Vata shamaka and has Shulahara property, it can relieve headache. Ardraka is directly indicated in Shirashula by Bhavaprakasha. [24] Its Shulahara, Vatahara and Teekshna property makes it a handy drug to use in all types of headaches. The drug Eranda is a known Vatashamaka and is Shulahara in nature. Hence it implies the efficacy seen in the patient.

Kushtadi Shirolepa contains Kushta, Eranda and
Ardraka as ingredients. All have Vatahara and Shulahara property. 6. Nose is the gateway for Shiras and Nasya is the best therapy for all Shirorogas. 7. Goghrita is a well-known Vatahara and best Snehana dravya. By the virtue of its property its instillation as Nasya can effectively cure Shiroroga. 8. At the end of the therapy, the patient had wonderful results and was completely cured.