The efficacy of goshuyuto, a typical Kampo (Japanese herbal medicine) formula, in preventing episodes of headache

Successful treatment with traditional Japanese medicine (kampo medicine) Yokukansan as a migraine prophylactic drug: A case report

RATIONALE

The use of anti-CGRP antibody drugs as migraine preventive drugs is increasing worldwide, but there are still a certain number of cases where antibody drugs are ineffective or cannot be used due to high prices. Conventional prophylactic drugs or traditional Japanese medicine (kampo medicine) are still often used in such cases. However, to date, only limited evidence supports the efficacy of kampo medicine for headaches because these treatments have been used primarily empirically and traditionally. However, in recent years studies have begun to be published that describe the efficacy of kampo medicine for various types of headache. Here, we report the case of a patient who achieved a marked reduction in migraine frequency and severity by prophylactic therapy with the kampo drug yokukansan (TSUMURA Yokukansan Extract Granules).

PATIENT CONCERNS AND DIAGNOSES

The patient was a 50-year-old woman. She began to experience headaches around high school age and was diagnosed with migraine without aura at 42 years of age.

INTERVENTIONS AND OUTCOMES

She started prophylactic therapy with amitriptyline and topiramate and this treatment reduced the frequency of migraines for several years. However, the frequency began to increase again around 47 years, which is when she presented at our hospital. We achieved a temporary reduction in migraine frequency by adjusting the dose of drugs in her prophylactic therapy regimen, but the frequency increased again around age 49. We then tried monotherapy with the kampo medicine yokukansan, and this markedly reduced migraine frequency and severity over the following year. This therapy has remained effective to date.

LESSONS

We speculate that, in this case, migraine without aura was improved by prophylactic therapy with yokukansan due to its action on the glutamatergic system or serotonin system through suppression of orexin-A secretion or its anti-inflammatory effects as reported in previous animal studies. Yokukansan could be a usable kampo medicine for migraine prophylaxis in countries all over the world and should be investigated in a large clinical trial as soon as possible.

Mechanism of Wuzhuyu decoction on alcohol-induced gastric ulcers using integrated network analysis and metabolomics

Background: Gastric ulcers (GUs) are prevalent digestive disorders worldwide. Wuzhuyu Decoction (WZYT) is a traditional Chinese medicine that has been employed for centuries to alleviate digestive ailments like indigestion and vomiting. This study aims to explore the potential effects and underlying mechanisms of WZYT on alcohol induced gastric ulcer treatment. Methods: We employed macroscopic assessment to evaluate the gastric ulcer index (UI), while the enzyme-linked immunosorbent assay (ELISA) was utilized for detecting biochemical indicators. Pathological tissue analysis involved hematoxylin-eosin (H&E) staining and Periodic Acid-Schiff (PAS) staining to assess gastric tissue damage. Additionally, the integration of network analysis and metabolomics facilitated the prediction of potential targets. Validation was conducted using Western blotting. Results: The research revealed that WZYT treatment significantly reduced the gastric ulcer index (UI) and regulation of alcohol-induced biochemical indicators levels. Additionally, improvements were observed in pathological tissue. Network analysis results indicated that 62 compounds contained in WZYT modulate alcohol-induced gastric ulcers by regulating 183 genes. The serum metabolomics indicated significant changes in the content of 19 metabolites after WZYT treatment. Two pivotal targets, heme oxygenase 1 (HMOX1) and albumin (ALB), are believed to assume a significant role in the treatment of gastric ulcers by the construction of "compounds-target-metabolite" networks. Western blot analysis confirmed that WZYT has the capacity to elevate the expression of HMOX1 and ALB targets. Conclusion: The integration of network analysis and metabolomics provides a scientific basis to propel the clinical use of WZYT for GUs. Our study provides a theoretical basis for the use of Wuzhuyu decoction in the treatment of gastric ulcers.

Headache Education by E-Learning Through Social Networking Services (Social Media)

Introduction

Headache is a common public health problem, but its burden could be avoided by raising headache awareness and the appropriate use of acute medication and prophylactic medication. Few reports on raising headache awareness in the general public have been reported, and there are no reports on headache awareness campaigns through social networking services (SNS), or social media, in Japan. We prospectively performed a headache awareness campaign from March 2022 through 2 SNS, targeting nurse and wind instrumental musicians, because they are with high headache prevalence.

Methods

Through the 2 SNS, the article and video were distributed, respectively. The article and video described the 6 important topics for the general public about headaches, which were described in the Clinical Practice Guideline for Headache Disorders 2021. Just after reading or watching them as e-learning, we performed online questionnaire sheets to investigate the awareness of the 6 topics through the 2 SNS. The awareness of the 6 topics before and after the campaign was evaluated.

Results

In the SNS nurse-senka, we obtained 1191 responses. Women comprised 94.4%, and the median (range) age was 45 (20 to 71) years old. Headache sufferers were 63.8%, but only 35.1% had consulted doctors. In the SNS Creatone, we got the response from 134 professional musicians, with 77.3% of women. The largest number of respondents were in their 20s (range 18-60 years old). Headache sufferers were 87.9%. Of them, 36.4% had consulted doctors, 24.2% were medication-overuse headache. The ratios of individuals who were aware of the 6 topics significantly increased from 15.2%-47.0% to 80.4-98.7% after the online questionnaire in both SNS (p < 0.001, all).

Conclusion

E-learning and online survey via SNS can improve headache awareness.

Evaluation of Vestibular Functions in a Case of Vestibular Migraine With Successful Treatment With Erenumab

This is the first report of vestibular examinations before and after the successful treatment of vestibular migraine (VM), a common cause of recurrent vertigo, with calcitonin gene-related peptide (CGRP) receptor inhibitor. We evaluated a 42-year-old female with VM and concomitant probable Meniere's disease, whose headache and dizziness have improved promptly with the administration of erenumab, a CGRP receptor inhibitor. The sensorineural hearing loss in pure-tone audiometry, dysfunctions shown in vestibular examinations (cervical and ocular vestibular evoked myogenic potentials), and mild endolymphatic hydrops shown in gadolinium-enhanced inner ear magnetic resonance imaging, all in the right ear, revealed no change compared with those observed before treatment. This case suggests that VM may be treated by blocking CGRP in the trigeminal ganglion, which suppresses the effects on the vestibular nucleus; herein, no effects were observed in the inner ear despite the clear amelioration of dizziness.

Developing an Artificial Intelligence-Based Pediatric and Adolescent Migraine Diagnostic Model

Introduction Misdiagnosis of pediatric and adolescent migraine is a significant problem. The first artificial intelligence (AI)-based pediatric migraine diagnosis model was made utilizing a database of questionnaires obtained from a previous epidemiological study, the Itoigawa Benizuwaigani Study. Methods The AI-based headache diagnosis model was created based on the internal validation based on a retrospective investigation of 909 patients (636 training dataset for model development and 273 test dataset for internal validation) aged six to 17 years diagnosed based on the International Classification of Headache Disorders 3rd edition. The diagnostic performance of the AI model was evaluated. Results The dataset included 234/909 (25.7%) pediatric or adolescent patients with migraine. The mean age was 11.3 (standard deviation 3.17) years. The model's accuracy, sensitivity (recall), specificity, precision, and F-values for the test dataset were 94.5%, 88.7%, 96.5%, 90.0%, and 89.4%, respectively. Conclusions The AI model exhibited high diagnostic performance for pediatric and adolescent migraine. It holds great potential as a powerful tool for diagnosing these conditions, especially when secondary headaches are ruled out. Nonetheless, further data collection and external validation are necessary to enhance the model's performance and ensure its applicability in real-world settings.

Perspectives of international multi-center clinical trials on traditional Chinese herbal medicine

With the introduction of various subjects, such as clinical epidemiology and evidence-based medicine, the qualities and levels of Traditional Chinese Herbal Medicine (TCHM) in China improved substantially, and the processes of internationalization of Traditional Chinese Medicine (TCM) are further accelerated. Since, a variety of drug products in China have been approved for marketing in other countries, and approximately 10 products have submitted the IND application to FDA of United States, of which various Chinese herbal preparations such as compound Danshen dripping pills, Xingling granules, and HMPL-004 have been approved to be investigated in phase III clinical trials. In general, multi-center studies of TCHM are increasing with years, but most of the studies are performed in some certain country, and the actual international multi-center clinical trials are very rare. Number of SCI literatures on multi-center clinical trials of TCHM that published in the recent decade also showed increasing tendency with years, despite the evident reduction in the past 2 years due to the influence of COVID-19 pandemic. Of the multi-center clinical trials of TCHM that performed by mainland China and other oversees regions, except for Taiwan, China, nearly 70% were focused on classic Chinese medicinal formulae and Chinese patent medicine, while the other 30% were on dietary supplements and plant extracts. Facing the future, the "human experience" has attracted close attentions from researchers throughout the world. Effectively utilizing the historic "human experience" is an important method to vitalize potential of original scientific and technological resources of TCHM. Performing multi-center clinical trials with high qualities is still an essential method for TCHM in accessing the mainstream medicine market. In addition, it is also required to further improve the evaluation techniques and methods that not only meet the international standards but also meet the characteristics of TCHM. Furthermore, we should also focus on the TCHM specific clinical values and scientific reports.

Molecular Dynamics Simulation of the Complex of PDE5 and Evodiamine

Alzheimer's disease is an irreversible neurological disorder for which there are no effective small molecule therapeutics. A phosphodiesterase 5 (PDE5) inhibitor is a candidate medicine for the treatment of Alzheimer's disease. Rutaecarpine, an indole alkaloid found in Euodiae Fructus, has inhibitory activity for PDE5. Euodiae Fructus contains more evodiamine than rutaecarpine. Therefore, we performed molecular dynamics simulations of the complex of PDE5 and evodiamine. The results showed that the PDE5 and (-)-evodiamine complexes were placed inside the reaction center compared to the case of PDE5 and (+)-evodiamine complex. The binding of (-)-evodiamine to PDE5 increased the root-mean-square deviation and radius of gyration of PDE5. In the PDE5 with (-)-evodiamine complex, the value of the root-mean-square fluctuation of the M-loop, which is thought to be important for activity, increased. This result suggests that (-)-evodiamine may have inhibitory activity.

An integrated approach for identifying the efficacy and potential mechanisms of TCM against atherosclerosis-Wu-Zhu-Yu decoction as a case study

ETHNOPHARMACOLOGICAL RELEVANCE

Atherosclerosis (AS) is a chronic disease that is associated with high morbidity. However, therapeutic approaches are limited. Wu-Zhu-Yu decoction (WZYD) is a well-known traditional Chinese medicine prescription that is traditionally used to treat headaches and vomiting. Modern studies have demonstrated the cardiotonic effects of WZYD. However, whether WZYD can alleviate AS and its underlying mechanisms remain unclear.

AIM OF THE STUDY

This study aims to investigate the antiatherosclerotic efficacy of WZYD and illustrate its potential mechanisms using an integrated approach combining in vivo and in vitro assessments, including metabolomics, network pharmacology, cell experiments, and molecular docking analyses.

MATERIALS AND METHODS

In this work, an atherosclerotic mouse model was established by administering a high-fat diet to apolipoprotein-E deficient (ApoE^-/-) mice for twelve weeks. Meanwhile, the mice were intragastrically administered WZYD at different dosages. Efficacy evaluation was performed through biochemical and histopathological assessments. The potential active constituents, metabolites, and targets of WZYD in atherosclerosis were predicted by metabolomics combined with network pharmacology analysis, the constituents and targets were further assessed through cell experiments and molecular docking analysis.

RESULTS

WZYD decreased the lipid levels in serum, reduced the areas of aortic lesions, and attenuated intimal thickening, which had antiatherosclerotic effects in ApoE^-/- mice. Metabolomics and network pharmacology approach revealed that the ten constituents (6-shogaol, evodiamine, isorhamnetin, quercetin, beta-carotene, 8-gingerol, kaempferol, 6-paradol, 10-gingerol, and 6-gingerol) of WZYD affected 24 metabolites by acting on the candidate targets, thus resulting in changes in five metabolic pathways (sphingolipid metabolism; glycine, serine and threonine metabolism; arachidonic acid metabolism; tryptophan metabolism; and fatty acid biosynthesis pathway). Cell experiments indicated that the ten key compounds showed antiproliferative effects on the vascular smooth muscle cell. Moreover, the key compounds exhibited direct interactions with the key targets, as assessed by molecular docking analysis.

CONCLUSION

This study revealed that WZYD exerted therapeutic effects on atherosclerosis, and the potential mechanisms were elucidated. Furthermore, it offered a powerful integrated strategy for studying the efficacy of traditional Chinese medicine and exploring its active components and possible mechanisms.

Wuzhuyu Decoction relieves hyperalgesia by regulating central and peripheral 5-HT in chronic migraine model rats

BACKGROUND

Chronic migraine (CM) is a highly disabling and burdensome disease. Wuzhuyu decoction (WZYD), a clinical used formula to treat and prevent episodic migraine and CM, has been reported to relieve the hyperalgesia of CM and increase brainstem and blood serotonin (5-hydroxytryptamine, 5-HT) in migraine model rats in previous studies; yet the mechanism is unclear.

PURPOSE

This study aimed to observe the hyperalgesia relief effect of WZYD and investigate the mechanistic association with the regulation on central and peripheral 5-HT.

METHODS

WZYD with different doses (3.372, 1.686 and 0.843 g/kg∙d) and the positive drug - sumatriptan (5.83 mg/kg∙3 d) were intragastrically administered in inflammatory soup (IS)-induced CM model rats, respectively. Hyperalgesia was assessed by facial mechanical withdrawal threshold and tail-flick latency. 5-HT was determined by ELISA. Western blot analysis, immunohistochemistry and immunofluorescence determination, and 16S rRNA gene sequencing were performed.

RESULTS

WZYD significantly relieved the hyperalgesia by elevating the facial mechanical withdrawal threshold and tail-flick latency. In WZYD groups, increased 5-HT and decreased calcitonin gene-related peptide in both the brainstem and plasma, downregulated TNF-α, IL-1β, and c-fos expression in the brainstem were observed in dose-dependent manner. Interestingly, 5-HT in colon tissues were also observed, which is associated with upregulating tryptophan hydroxylase, serotonin transporter and Piezo1 expression and increasing 5-HT and chromogranin A in enterochromaffin cells. Disorder of the microbiota, function and metabolism was correlated with 5-HT synthesis. WZYD could regulate the abundance of Anaerostipes and Acidifaciens.

CONCLUSION

WZYD has the pharmacological effect on relieving hyperalgesia in CM model rats, possibly by affecting central and peripheral 5-HT.

Classification of pediatric headache cases referred to a neurology department

BACKGROUND

Headaches are very common in children. The patients often have mild symptoms, but on occasion may have severe, secondary headaches. The present study aimed to clarify the details of children with headaches seen at the outpatient clinic of a pediatric neurological department.

METHODS

The present, retrospective observational study was conducted at a tertiary pediatric hospital in Japan and enrolled children referred to the neurology department outpatient clinic for headache between April 2018 and March 2021.

RESULTS

In total, 113 cases of headache were examined; of these, 99 (87.6%) were primary headaches, one case (0.9%) was a secondary headache, and 13 (11.5%) were unclassified or unspecified. There were 46 cases (40.7%) of tension-type headache (TTH), both confirmed and suspected, 30 cases (26.5%) of migraine, and 23 cases (20.4%) of a combination of the TTH and migraine. One case of secondary headache was attributed to an infection. Arachnoid cysts were found in seven patients (7.8%). Acute drug treatments were administered to 93 patients (82.3%), with acetaminophen being the most common drug, followed by ibuprofen. Prophylactic drug treatments were administered to 39 patients (34.5%), with goreisan (a Chinese herbal medicine containing Alisma orientale, Poria cocos, Polyporus umbellatus, Atractylodes lancea, and Cinnamomum cassia) being the most common (41%).

CONCLUSIONS

Few cases of secondary headache and none of emergency headache were diagnosed. The prevalence of arachnoid cysts was higher than in the general pediatric population, suggesting that arachnoid cysts might be associated with headache.

Medication Overuse Headache Successfully Treated by Japanese Herbal Kampo Medicine, Yokukansan

Medication overuse headache (MOH) usually resolves after the overuse is stopped. However, it can be challenging to prescribe common prophylactic medications when patients are old or have concerns about the side effects of Western prophylactic medications. As an alternative therapy, traditional Japanese herbal Kampo medicine can be used. One of them, yokukansan (TJ-54), is often used for behavioral and psychological symptoms of dementia in Japan. Recently, it has been reported as an alternative medication for episodic, chronic, or MOH. We herein report a MOH in an older man already taking antihypertensive drugs. His MOH was successfully relieved by TJ-54 instead of the common prophylactic medications. His headache and nausea were relieved on day four of the treatment. After that, he did not need any analgesic drugs. Of course, we should pay attention to the side effects, pseudoaldosteronism, but TJ-54 may be one of the alternative treatment therapies for MOH.

Medication Overuse Headache Successfully Treated by Three Types of Japanese Herbal Kampo Medicine

Medication overuse headache (MOH) usually resolves after the overuse is stopped and starting prophylactic medications. However, it can be challenging to prescribe common prophylactic medications when patients have a history of side effects. As an alternative therapy, traditional Japanese herbal kampo medicine can be used. We herein report a case of a MOH woman with a history of side effects by such common prophylactic medications. A 50-year-old woman presented with a severe migraine attack. She had suffered from migraines for 10 years. She had taken loxoprofen and sumatriptan every day for over eight years. As prophylactic medications, lomerizine, valproic acid, and amitriptyline had been prescribed in the past, but they were discontinued due to side effects. Therefore, she could continue only propranolol as prophylactic medication. She had severe pulsatile headaches and nausea every day. We diagnosed triptan- and non-steroidal anti-inflammatory drug-overuse headache (the International Classification of Headache Disorders 3rd edition code 8.2.2 and 8.2.3.2) and chronic migraine (code 1.3). She was admitted and stopped loxoprofen and sumatriptan. We prescribed three types of Japanese herbal kampo medicines - kakkonto (TJ-1), goreisan (TJ-17), and goshuyuto (TJ-31). Her headache was relieved on day 5, and she was discharged on day 7. In the 40 days after discharge, she had only three times mild headaches with a numeric rating scale (NRS) of 2/10. She did not need any triptans nor anti-inflammatory drugs. We herein presented the MOH woman who was successfully treated using three types of kampo medicine. We should pay attention to their side effects, but kampo medicine may be useful for MOH treatment as acute and prophylactic medications for primary headaches.

Medicine in motion: Opportunities, challenges and data analytics-based solutions for traditional medicine integration into western medical practice

ETHNOPHARMACOLOGICAL RELEVANCE

Traditional pharmacopeias have been developed by multiple cultures and evaluated for efficacy and safety through both historical/empirical iteration and more recently through controlled studies using Western scientific paradigms and an increasing emphasis on data science methodologies for network pharmacology. Traditional medicines represent likely sources of relatively inexpensive drugs for symptomatic management as well as potential libraries of new therapeutic approaches. Leveraging this potential requires hard evidence for efficacy that separates science from pseudoscience.

MATERIALS AND METHODS

We performed a review of non-Western medical systems and developed case studies that illustrate the epistemological and practical translative barriers that hamper their transition to integration with Western approaches. We developed a new data analytics approach, in silico convergence analysis, to deconvolve modes of action, and potentially predict desirable components of TM-derived formulations based on computational consensus analysis across cultures and medical systems.

RESULTS

Abstraction, simplification and altered dose and delivery modalities were identified as factors that influence actual and perceived efficacy once a medicine is moved from a non-Western to Western setting. Case studies on these factors highlighted issues with translation between non-Western and Western epistemologies, including those where epistemological and medicinal systems drive markets that can be epicenters for zoonoses such as the novel Coronavirus. The proposed novel data science approach demonstrated the ability to identify and predict desirable medicinal components for a test indication, pain.

CONCLUSIONS

Relegation of traditional therapies to the relatively unregulated nutraceutical industry may lead healthcare providers and patients to underestimate the therapeutic potential of these medicines. We suggest three areas of emphasis for this field: First, vertical integration and embedding of traditional medicines into healthcare systems would subject them to appropriate regulation and evidence-based practice, as viable integrative implementation mode. Second, we offer a new Bradford-Hill-like framework for setting research priorities and evaluating efficacy, with the goal of rescuing potentially valuable therapies from the nutraceutical market and discrediting those that are pseudoscience. Third, data analytics pipelines offer new capacity to generate new types of TMS-inspired medicines that are rationally-designed based on integrated knowledge across cultures, and also provide an evaluative framework against which to test claims of fidelity and efficacy to TMS made for nutraceuticals.

Traditional uses, phytochemistry, pharmacology, pharmacokinetics and toxicology of the fruit of Tetradium ruticarpum: A review

ETHNOPHARMACOLOGICAL RELEVANCE

The fruit of Tetradium ruticarpum (FTR) known as Tetradii fructus or Evodiae fructus (Wu-Zhu-Yu in Chinese) is a versatile herbal medicine which has been prescribed in Chinese herbal formulas and recognized in Japanese Kampo. FTR has been clinically used to treat various diseases such as headache, vomit, diarrhea, abdominal pain, dysmenorrhea and pelvic inflammation for thousands of years.

AIM OF THE REVIEW

The present paper aimed to provide comprehensive information on the ethnopharmacology, phytochemistry, pharmacology, pharmacokinetics, drug interaction and toxicology of FTR in order to build up a foundation on the mechanism of ethnopharmacological uses as well as to explore the trends and perspectives for further studies.

MATERIALS AND METHODS

This review collected the literatures published prior to July 2020 on the phytochemistry, pharmacology, pharmacokinetics and toxicity of FTR. All relevant information on FTR was gathered from worldwide accepted scientific search engines and databases, including Web of Science, PubMed, Elsevier, ACS, ResearchGate, Google Scholar, and Chinese National Knowledge Infrastructure (CNKI). Information was also obtained from local books, PhD. and MSc. Dissertations as well as from Pharmacopeias.

RESULTS

FTR has been used as an herbal medicine for centuries in East Asia. A total of 165 chemical compounds have been isolated so far and the main chemical compounds of FTR include alkaloids, terpenoids, flavonoids, phenolic acids, steroids, and phenylpropanoids. Crude extracts, processed products (medicinal slices) and pure components of FTR exhibit a wide range of pharmacological activities such as antitumor, anti-inflammatory, antibacterial, anti-obesity, antioxidant, insecticide, regulating central nervous system (CNS) homeostasis, cardiovascular protection. Furthermore, bioactive components isolated from FTR can induce drug interaction and hepatic injury.

CONCLUSIONS

Therapeutic potential of FTR has been demonstrated with the pharmacological effects on cancer, inflammation, cardiovascular diseases, CNS, bacterial infection and obesity. Pharmacological and pharmacokinetic studies of FTR mostly focus on its main active alkaloids. Further in-depth studies on combined medication and processing approaches mechanisms, pharmacological and toxic effects not limited to the alkaloids, and toxic components of FTR should be designed.

Core prescription pattern of Chinese herbal medicine for depressive disorders in Taiwan: a nationwide population-based study

Background

Depressive disorders (DD) affect not only mood and behavior but also various physical functions. Traditional Chinese medicine (TCM) has been shown to have some benefits in treating DD. However, one formula or one single herb might be not show high efficacy when used to treat depression. Thus, this study aimed to examine the core prescription pattern of Chinese herbal medicine (CHM) among patients with DD in Taiwan as a reference for related research and clinical applications.

Methods

All patients, who had been diagnosed with major depressive disorder or minor depression or dysthymia without any other baseline diseases and had at least one CHM outpatient clinical visit from 2002 to 2011, were extracted from three randomly sampled cohorts, namely the 2000, 2005 and 2010 cohorts of the National Health Insurance Research Database (NHIRD) of Taiwan. The collected data was analyzed to explore the patterns of herbal products.

Results

There were 197,146 patients with a diagnosis of DD and of these 1806 subjects had only a diagnosis of DD and utilized CHM. The most common formula was Gan-Mai-Da-Zao-Tang (12.19%), while Suan-Zao-Ren (3.99%) was the most commonly prescribed single herb. The core pattern of prescriptions consisted of a combination of Gan-Mai-Da-Zao-Tang, Jia-Wei-Xiao-Yao-San, Chai-Hu-Jia-Long-Gu-Mu-Li-Tang, He-Huan-Pi, Yuan-Zhi and Shi-Chang-Pu.

Conclusions

This study describes the CHM core prescription pattern used to treat patients in Taiwan with DD and it is a potential candidate for study in future pharmacological or clinical trials targeting DD.

Paediatric migraine with visual hallucination auras appearing in the form of a human body

The most common type of migraine aura is multifaceted visual aura, such as scintillating scotoma or geometrical patterns, visual hallucinations in which a physical body is extremely rare. We report a paediatric case of migraine in which visual hallucinations appeared as auras in the form of a human body. The patient was an 11-year-old girl suffering from migraine with curious visual aura. The auras were atypical visual hallucinations that were sometimes accompanied by auditory hallucinations. Approximately 5-20 min before the headache, the patient would see a middle-aged man wearing sunglasses in her field of vision. Acetaminophen (10 mg/kg) and Japanese herbal medicine administered when necessary effectively treated the headaches. Finally, the patient was no longer complaining of her hallucination auras. Although the pathophysiology of migraines accompanied by auras is unclear, it appears that cerebral blood flow and cortical spreading depression are involved in auras.

Myrcene and terpene regulation of TRPV1

Nociceptive Transient Receptor Potential channels such as TRPV1 are targets for treating pain. Both antagonism and agonism of TRP channels can promote analgesia, through inactivation and chronic desensitization. Since plant-derived mixtures of cannabinoids and the Cannabis component myrcene have been suggested as pain therapeutics, we screened terpenes found in Cannabis for activity at TRPV1. We used inducible expression of TRPV1 to examine TRPV1-dependency of terpene-induced calcium flux responses. Terpenes contribute differentially to calcium fluxes via TRPV1 induced by Cannabis-mimetic cannabinoid/terpenoid mixtures. Myrcene dominates the TRPV1-mediated calcium responses seen with terpenoid mixtures. Myrcene-induced calcium influx is inhibited by the TRPV1 inhibitor capsazepine and Myrcene elicits TRPV1 currents in the whole-cell patch-clamp configuration. TRPV1 currents are highly sensitive to internal calcium. When Myrcene currents are evoked, they are distinct from capsaicin responses on the basis of Imax and their lack of shift to a pore-dilated state. Myrcene pre-application and residency at TRPV1 appears to negatively impact subsequent responses to TRPV1 ligands such as Cannabidiol, indicating allosteric modulation and possible competition by Myrcene. Molecular docking studies suggest a non-covalent interaction site for Myrcene in TRPV1 and identifies key residues that form partially overlapping Myrcene and Cannabidiol binding sites. We identify several non-Cannabis plant-derived sources of Myrcene and other compounds targeting nociceptive TRPs using a data mining approach focused on analgesics suggested by non-Western Traditional Medical Systems. These data establish TRPV1 as a target of Myrcene and suggest the therapeutic potential of analgesic formulations containing Myrcene.

Chinese herbal medicine for headache: A systematic review and meta-analysis of high-quality randomized controlled trials

BACKGROUND

Chinese herbal medicines (CHMs) are widely used to relieve headache in Asia. However, it is uncertain whether there is robust evidence on the effects of CHMs for headache.

PURPOSE

To assess the effectiveness and safety of CHMs for headache using systematic review of high-quality randomized controlled trials (RCTs).

METHODS

Electronic search was conducted on six databases from inception to January 2018. We included the RCTs that met the requirement of at least 4 out of the 7 domains according to the Cochrane risk of bias tool.

RESULTS

Thirty RCTs with 3447 subjects were ultimately included for analysis and all trials were conducted in Asia. Meta-analysis showed that CHMs monotherapy were superior to placebo in reducing headache frequency [SMD -0.48 (95% CI -0.76, -0.20); p < 0.01], headache days [SMD -0.29 (95% CI -0.45, -0.13); p < 0.01], headache duration[SMD -0.58 (95% CI -0.81, -0.36); p < 0.01], headache intensity [SMD -0.42 (95% CI -0.62, -0.23); p < 0.01] and analgesic consumption [SMD -0.36 (95% CI -0.52, -0.21); p < 0.01] and improving clinical efficacy rate (p < 0.01). Similarly, CHMs monotherapy were superior to western conventional medicines (WCMs) in headache frequency [SMD -0.57 (95% CI -0.84, -0.29); p < 0.01], headache days (p < 0.01), analgesic consumption [SMD -1.63 (95% CI -1.98, -1.28); p < 0.01], headache intensity [SMD -0.81 (95% CI -1.06, -0.57); p < 0.01], and clinical efficacy rate [RR 1.24 (95% CI 1.18, 1.31); p < 0.01], except reducing headache duration (p > 0.05). CHMs adjunct therapy can improve clinical efficacy rate compared with WCMs alone [RR 1.15 (95% CI 1.09, 1.22); p < 0.01]. Meanwhile, CHMs had fewer adverse events than that of controls.

CONCLUSION

The findings supported, at least to an extent, the use of CHM for headache patients; however, we should treat the results cautiously because the clinical heterogeneity.

Metabolomics Strategy Using High Resolution Mass Spectrometry Reveals Novel Biomarkers and Pain-Relief Effect of Traditional Chinese Medicine Prescription Wu-Zhu-Yu Decoction Acting on Headache Modelling Rats

Headache is a common episodic or chronic neurologic disorder. Treatment options and diagnosis are restricted by an incomplete understanding of disease pathology and the lack of diagnostic markers. Wu-Zhu-Yu decoction (WZYD), a traditional Chinese medicine (TCM) formula containing four TCM herbs, is commonly used in the treatment of headache in China. To deeply understand more about headache and investigate the pain-relief mechanism of WZYD, a comprehensive metabolomics study combined with multivariate data processing strategy was carried out. An LC-high resolution mass spectrometry-based metabolomics approach was applied to characterize metabolic biomarker candidates. Multiple pattern recognition including principal component analysis-discriminant analysis, partial least squares-discriminant analysis and hierarchical cluster analysis were used to determine groups and confirm important variables. A total of 17 potential biomarkers were characterized and related metabolic pathways were identified. The study demonstrated that the established metabolomics strategy is a powerful approach for investigating the mechanism of headache attack and WZYD. In addition, the approach may highlight biomarkers and metabolic pathways and can capture subtle metabolite changes from headache, which may lead to an improved mechanism understanding of central nervous system diseases and TCM treatment.

Comprehensive Qualitative Ingredient Profiling of Chinese Herbal Formula Wu-Zhu-Yu Decoction via a Mass Defect and Fragment Filtering Approach Using High Resolution Mass Spectrometry

The Wu-Zhu-Yu decoction is a traditional Chinese medicine formula for the treatment of headache. To reveal its material basis, a rapid and reliable liquid chromatography-high resolution mass spectrometry method was established for comprehensive profiling of the chemical ingredients in the Wu-Zhu-Yu decoction. The method was used on a quadrupole time-of-flight mass spectrometer along with an advanced data processing procedure consisting of mass accuracy screening, mass defect filtering and fragment filtering. After eliminating interference with a filtering approach, the MS data profiling was made more distinct and accurate. With the optimized conditions of only 35 min LC separation and single sample injection of each positive or negative ion mode, a total of 168 compounds were characterized, including 23 evodiamine and its analogous alkaloids, 12 limonoids, 17 gingerols, 38 ginsenosides, 15 flavonoids, 16 organic acids, 14 alkaloids, 5 saponins, 3 2,2-dimethylchromenes and 25 other compounds. The fragmentation patterns of representative compounds were illustrated as well. Integrative qualitative analysis of the Wu-Zhu-Yu decoction by high resolution mass spectrometry was accomplished and reported for the first time. The study demonstrated that the established method was a powerful and reliable strategy for comprehensive detection and would be widely applicable for identification of complicated components from herbal prescriptions, and may provide a basis for chemical analysis of other complex mixtures.

Use of Kampo diagnosis in randomized controlled trials of Kampo products in Japan: a systematic review

BACKGROUND

The Committee for Evidence-based Medicine (EBM) of the Japan Society for Oriental Medicine started compiling Evidence Reports of Kampo Treatment (EKAT) in 2007. EKAT is a compilation of structured abstracts of randomized controlled trials (RCTs), along with comments by a third party reviewer. As of 31 December, 2012, there were 378 RCTs of Kampo medicines in Japan. The primary research question of this study is "How frequently is Kampo diagnosis used in RCTs of Kampo medicines?" The secondary research question is "When is Kampo diagnosis used in RCTs?"

MATERIALS AND METHODS

The structured abstract (SA) of each RCT article was reviewed to examine how Kampo diagnosis was used in RCTs, especially how Kampo diagnosis was used in the randomization process.

RESULTS

Kampo diagnosis was used before randomization in 27 RCTs (7.1%), after randomization in 31 RCTs (8.2%), and not used in 320 RCTs (84.7%). Before randomization, Kampo diagnosis was used as a criterion for inclusion in 10 RCTs, criterion for exclusion in 9 RCTs, and criteria for both inclusion and exclusion in 2 RCTs. Kampo formulas were determined according to Kampo diagnosis in 7 RCTs. After randomization, subgroup analyses according to Kampo diagnosis were done in 27 RCTs, and grade of disease severity at Kampo diagnosis was used for analysis as an endpoint in 4 RCTs.

CONCLUSIONS

Kampo diagnosis was used before randomization only in approximately 15% of RCTs, and the number of RCT articles using Kampo diagnosis after randomization was almost the same as that before randomization. Further studies to determine the good RCTs conforming to CONSORT requirements and good systematic reviews conforming to PRISMA requirements are needed to clarify the significance of Kampo diagnosis.

The review of innovative integration of Kampo medicine and Western medicine as personalized medicine at the first multidisciplinary pain center in Japan

Background

The Japanese medical system is unique because it is the only country in the world where Western medicine and traditional Japanese medicine including Kampo medicine, traditional Japanese herbal medicine, are used in our daily clinical practice. Pain is essentially an interactive psychophysiological behavior pattern. Thus, an interdisciplinary approach is often recommended in providing appropriate therapeutic care for the patients suffering from chronic and intractable pain. In addition, we have been prescribing Kampo medicines in combination with Western medicines as personalized medicine in order to treat patients with chronic pain at our pain center. The aim of our study was to conduct a survey on the current use and the effect of Kampo medicines in our multidisciplinary pain center.

Methods

Retrospective analysis was performed on 221 out of 487 patients suffering from chronic pain.

Results

The most frequent medical complaints for which Kampo medicines were prescribed were lower back/lower limb pain, neck/upper limb pain, various facial pains, headache/migraine, whiplash-associated disorder, and frozen shoulder. Kampo medicines were prescribed based on patient-centered Kampo diagnosis. Moreover, several Kampo medicines generally for the management of psychological symptoms were prescribed for about 70% of the patients. Pain improvement in the patients was categorized as follows: 26.3% with marked improvement, 12.7% with moderate improvement, 38.9% with some improvement, and 19.9% with no improvement.

Conclusions

Two thirds of the chronic pain patients with the use of Kampo medicines combined with Western medicine experienced further pain improvements.

Herb–drug pharmacokinetic interaction of artificial calculus bovis with diclofenac sodium and chlorpheniramine maleate in rats

Objectives

To investigate the herb–drug pharmacokinetic interaction of artificial calculus bovis (ACB) with diclofenac sodium (DS) and chlorpheniramine maleate (CPM) in rats.

Methods

A sensitive high-performance liquid chromatography coupled with tandem mass spectrometry method was developed and validated for the simultaneous determination of DS and CPM in rat plasma. The proposed method was successfully applied to compare the herb–drug pharmacokinetic interaction of ACB with DS and CPM in rats following intragastric administration.

Key findings

The proposed method had good linearity and no endogenous material interfered with the analytes and internal standard peaks. The lower limit of quantification of DS and CPM was 1 and 0.1 ng/ml, respectively. There was no apparent pharmacokinetic interaction between DS and CPM. Co-administration of ACB with DS noticeably increased the area under the concentration–time curve (AUC0-∞) and peak plasma concentration (Cmax) of DS, while the parameters time of peak concentration (Tmax), clearance (ClZ/F) and apparent volume of distribution (VZ/F) of DS significantly decreased. Meanwhile, co-administration of ACB with CPM noticeably increased the Tmax, ClZ/F and VZ/F of CPM. A marked decline in AUC0-∞ and Cmax of CPM occurred in the presence of ACB.

Conclusions

This study indicated that co-administration of ACB with DS and CPM can result in an apparent herb–drug pharmacokinetic interaction in rats.

Simultaneous determination of three alkaloids, four ginsenosides and limonin in the plasma of normal and headache rats after oral administration of Wu-Zhu-Yu decoction by a novel ultra fast liquid chromatography-tandem mass spectrometry method: application to a comparative pharmacokinetics and ethological study

A novel, sensitive and reliable ultra fast liquid chromatography-tandem mass spectrometry (UFLC-MS/MS) method has been developed and validated for simultaneous quantitation of eight main active ingredients (evodiamine, rutaecarpine, dehydroevodiamine, limonin, ginsenoside Rb1, Rd, Re and Rg1) in rat plasma after oral administration of Wu-Zhu-Yu (WZY) decoction, which is a celebrated and widely used Traditional Chinese Medicine formula for the treatment of headache. The analytes and internal standard (IS) were separated on a SHIM-PACK XR-ODS II column, and the detection was performed on a UFLC-MS/MS system with turbo ion spray source. The lower limits of quantification were 1.5, 0.5, 1.0, 2.0, 2.0, 1.0, 0.5 and 0.2 ng ml(-1) for evodiamine, rutaecarpine, dehydroevodiamine, limonin, gensenoside Rb1, Rd, Re and Rg1, respectively. Linearity, accuracy, precision and absolute recoveries of the eight analytes were all within satisfaction. The IS-normalized matrix factor was adopted for assessing the matrix effect and accompanied with a satisfactory result. The validated method has been successfully applied to compare pharmacokinetic profiles of the eight active ingredients in rat plasma between normal and headache rats after administration. Exact pharmaceutical effect of WZY decoction on headache was demonstrated by the ethological response of headache rats induced by nitric oxide donor after administration. The results indicated that the absorption of evodiamine, rutaecarpine, gensenoside Rb1, Re and Rg1 in headache group were significantly higher than those in normal group with similar concentration-time curves while no significant differences existed in limonin and ginsenoside Rd between the two groups.

[Kampo medicines as useful therapeutic agents in clinical practice of neurology: case reports & representative medicines]

Doctors in any department should have at least minimum knowledge of Kampo medicines. However, doctors who specialize in neurology often have inadequate knowledge of Kampo medicines. The efficacy of Kampo medicines in treating intractable diseases such as neurodegenerative diseases is not adequately understood and needs to be investigated in the future. On the other hand, Kampo medicines are often effective for treating common symptoms such as headache, dysesthesia, pain, and vertigo, encountered in daily medical practice. Because many patients suffer from these symptoms, the impact of these symptoms on our society is not small, even though the causes of these symptoms are not crucial. Having the skill to prescribe even a dozen or so Kampo medicines (for example, goshuyuto, goreisan, goshajinkigan, sokeikakketsuto) increases the treatment options and may be very beneficial in daily medical practice. In this article, I provide instructions on the use of representative Kampo medicines and present some case reports to elucidate their use. Amassing and sharing clinical experiences regarding the use of Kampo medicines would strengthen the medical evidences of Kampo medicines.

Traditional Japanese Kampo Medicine: Clinical Research between Modernity and Traditional Medicine-The State of Research and Methodological Suggestions for the Future

The Japanese traditional herbal medicine, Kampo, has gradually reemerged and 148 different formulations (mainly herbal extracts) can be prescribed within the national health insurance system. The objective of this article is to introduce Kampo and to present information from previous clinical studies that tested Kampo formulae. In addition, suggestions on the design of future research will be stated. The literature search was based on a summary, up until January 2009, by the Japanese Society of Oriental Medicine and included only those trials which were also available in either Pubmed or ICHUSHI (Japan Medical Abstracts Society). We included 135 studies, half of these studies (n = 68) used a standard control and 28 a placebo control. Thirty-seven trials were published in English [all randomized controlled trials (RCTs)] and the remaining articles were in Japanese only. The sample size for most studies was small (two-third of the studies included less than 100 patients) and the overall methodological quality appeared to be low. None of the studies used Kampo diagnosis as the basis for the treatment. In order to evaluate Kampo as a whole treatment system, certain aspects should be taken into account while designing studies. RCTs are the appropriate study design to test efficacy or effectiveness; however, within the trial the treatment could be individualized according to the Kampo diagnosis. Kampo is a complex and individualized treatment with a long tradition, and it would be appropriate for further research on Kampo medicine to take this into account.

Current status of Kampo (Japanese herbal) medicines in Japanese clinical practice guidelines

BACKGROUND AND AIMS

Kampo (Japanese herbal) medicines are often used in clinical practice in Japan. However, it is unclear how Kampo medicines are quoted and evaluated in current clinical practice guidelines (CPGs). Here, we systematically reviewed Japanese CPGs, and aimed to reveal how Kampo medicines are described in the CPGs.

MATERIALS AND METHODS

We reviewed the quasi-comprehensive list of Japanese CPGs available from the Toho University Medical Media Center (TUMMC) having the largest data base on Japanese CPGs, and also used a hand search. CPGs containing Kampo products were classified into three types based on how Kampo was handled. CPGs that provided recommendations based on evidence were classified as "type A". Those which cited references but did not provide any recommendations were classified as "type B". Those which described the Kampo practice or Kampo-related terms without providing any relevant references were classified as "type C".

RESULTS

By the end of March of 2007, 35 (10.1%) of 346 CPGs listed by TUMMC contained descriptions of Kampo products. We discovered one Kampo-related CPGs in a hand search process. Of these 36 CPGs, 6 were "type A", 13 were "type B", and 17 were "type C". Although results from pertinent randomized controlled trials (RCTs) were available, we noticed that some well-known RCTs studying Kampo medicines are missing in corresponding CPGs.

CONCLUSIONS

We revealed that the citation rate of Kampo medicines in CPGs was approximately 10% and that some pivotal trials for Kampo medicines were not quoted in CPGs. Kampo medicines in CPGs should be assessed more comprehensively and scientifically.