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Tension headache: A clinical study of its treatment by acupuncture

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Tension headache

A clinical study of its treatment by acupuncture

by Emad Tukmachi and Firhaas Tukmachi

 

 

ABSTRACT

The Western medical treatment of tension headache often encounters difficulties with regard to clinical diagnosis, treatment and financial costs. In this preliminary clinical study, 22 patients suffering from tension headache were randomly selected and treated with acupuncture. The results showed that four patients had complete relief from tension headaches and that there was a marked improvement in nine patients and fair improvement in six patients, with a failure to improve in only three patients. This paper also provides an introduction to the pathophysiology of, and therapeutic principles for, tension headaches from the conventional and traditional Chinese medicine points of view.

Keywords: acupuncture, tension headache.

 

Introduction

Headaches are such a common occurrence that they can easily be ignored. As the causes of headache can be numerous, however, it is important not to ignore them and to realise that they are a part of a bigger picture.

One of the most common disorders in neurological practice is the tension headache (Lipton, 1979). Most people might experience one or two tension headaches each month, or even more at times of stress (see Table 1 for tension headache facts). Unlike other headaches (including migraine), patients with tension headache are usually able to continue with normal activities despite having a constant throbbing headache. However, they are normally well between headache attacks. Thorough clinical investigations are not usually necessary unless patients present with unusual signs and symptoms, or something other than tension headache is suspected. Being such a common disorder, tension headache is responsible for the loss of more working hours than most major neurological and neurosurgical disorders for which curative treatment is available. From the point of view of conventional medicine, tension headache is a relatively neglected subject, largely because it does not cause death or permanent disability. The investigation of tension headache has also fared badly through being divided among different "specialists" such as neurologists, psychiatrists and internal physicians.  In order to increase knowledge of tension headache with regard to its mechanism, classification, clinical features and management by both western medicine and traditional Chinese acupuncture, in this article we have approached the disorder from a number of different angles and with a variety of tools.

 

 

Tension headache facts

• Tension headache affects many people in the U.K. and it has been reported that between4–5% of the UK population suffer from daily or near dailytensionheadache for a significant period of any one year (Scher et al 1998).

(It is is one of the most frequently encountered illnesses in the NHS and private practices which results in neither disability nor death (Stewart and Lipton 1994).

• Tension headache comes on during the day and usually gets worse as the day goes on. It typically presents with moderate or mild pain that is felt as tightness or squeezing pressure around the 'hat-band' area of both sides of the head and sometimes radiates down just one side of the neck. A tension headache can last from 30 minutes to a few hours or even up to seven days.

• Unlike migraine and other types of headache, accurate diagnosis of tension headache is made when it has no other ongoing symptoms (secondary symptoms of systemic diseases). Clinical investigations are not usually needed unless the patient has unusual signs and symptoms, or something other than tension headache is suspected.

• There are three main categories of aetiology: a. Emotional stress (psychological tension, anxiety, or reactive depression) (Martin P and Mathews A, 1978). b. Physical stress affecting the neck (tension in the muscles of the scalp and neck due to poor posture). c. Other causes such as specific foods, bright sunlight, illness, medications, climatic changes, tiredness, noise, alcohol, caffeine, etc.).

 

 

Pathophysiology of tension headache

 

The pathophysiology of tension headache is an unsolved problem as its main aetiology is still not clear (International Headache Society 1988).  However, in the past 20 years, clinical researchers and practitioners of alternative medicine have proposed that tension type headaches may be triggered by emotional or physical stress (e.g. an argument, fatigue, prolonged reading, dehydration or sitting for a long time with bad posture) (Martin P and Mathews A, 1978), or by environmental factors such as weather or even loud music.

There are two main types of tension headache; episodic tension headaches and chronic tension headaches. The first occurs when people experience stressful events (emotional, physical or environmental), while the second is associated with muscular tension or spasm that stretches from the back of the neck over the top of the head.

In the early 1990s, new research indicated that  headaches  (including tension and migrainous headaches) might be triggered by, or develop from, unknown metabolic or neurophysiological events affecting the trigeminal nerve distribution to the meningeal vessels and eventually leading to an increased activity of the serotonergic raphe nuclei in the brain stem (Moskowitz et al 1993).

 

Such increase in serotonergic activity and in maximal vasodilatation might lead to a process in which many different substances are involved, e.g. PGE2, polypeptide neurotransmitters, albumin, endorphins, histamine, substance P, arachidonic acid and extravasations of lymphocytes (Limmroth et al, 1996, Parantainen, et al 1986 ).

 

In tension headache, neurogenic inflammation stimulates the pain-mediating C fibres, which then project the increased activity back to the trigeminal nerve system. It is concluded from this picture that vasoconstriction and neurogenic inflammation are the two main ways of generating tension headache.

 

 Causative factors in precipitating tension headache

 

Many factors may be involved in initiating tension headache and can play a major role in the severity and frequency of the attacks:

• Muscle over-activity in certain regions such as the scalp, forehead and neck can trigger tension headache and create a dull ache or tightness in these areas, often experienced as a tight band around the head or a heavy weight on top of the head (Lipton S, 1979).

• Psycho-physical tensions or stresses, for example excessive anxiety, excitement, depression, physical tiredness, anger and frustration (Martin P and Mathews A, 1978).

• Physical injuries such as spinal and head injuries.

• Dietary factors. Certain types of food may precipitate tension headache attacks because they contain chemical substances such as 5-hydroxytryptamine (in bananas, tomatoes and pineapples), histamine (in cheese and red wine), betaphenylethylamine (in chocolate), tyramine (in pickled herrings, cheese and marmite), sodium nitrite (in bacon, salami and hot dogs) and octopamine (in citrus fruits).

• Fatigue and ill health: Overexertion, exhaustion, overwork and failure to relax physically and/or mentally may trigger a tension headache attack. Lack of sleep is also very likely to provoke a headache reaction in predisposed patients.

• The menstrual cycle and hormonal factors:

i. Tension headache may manifest as part of premenstrual syndrome. A significant minority of women also experience attacks during and after the menstrual flow.
ii. Menopausal syndrome. Tension headache may start before the onset of menopause and become worse during it, but improve afterwards. This is much less common than premenstrual tension headache. 

It was suggested by Marcus (1995) that from the frequency of occurrence of ovulatory and premenstrual tension headache, these attacks were precipitated, respectively, by raised levels of oestrogen and by relatively sudden diminutions of circulating progesterone.  Current research findings have indicated that some contraceptives appear to aggravate tension headache and that others mitigate it. In conclusion, although menstruation and menopause may have a profound effect in determining the patterns of tension headache in certain patients, the mechanism of their action is unknown and is probably attributed to multiple concomitant causes rather than specific effects of hormonal changes.

• Drugs: Besides alcohol (especially red wine), a number of anti-depressant drugs may give rise to tension headaches and migraines in certain patients. For example reserpine, which is used to control hypertension, may provoke not only tension headache and migraine but other reactions such as shock, depression, stupor and narcolepsy. Similarly, one of the side effects of amphetamine is tension headache if it is used at a high dose or for prolonged periods at normal dosage. The use and abuse of amphetamines must therefore be noted.

• Other factors: Changes in the environment, such as climatic changes (very hot or very cold, dusty or smoky atmosphere and high humidity) as well as noise levels, high pitched sounds, intense odours and strong or poor light may initiate an attack of tension headache. Patients with tension headache have a strong response to thermal stimuli and tend to get attacks in association with hot weather or fever.

 

Clinical features of tension headache

Tension headache usually presents with a hatband distribution of symptoms: dull and persistent tightness, squeezing and gripping pain with tender areas over neck and scalp.  It may be unilateral or bilateral and may involve the temporal, occipital, parietal or frontal region or any combination of these. Most patients feel soreness on combing or brushing the hair. The severity of tension headache may be diminished by the patient adopting certain individually favoured positions. In certain cases, the patient may limit the movements of the head, neck and jaws to decrease the discomfort.

There is great variation in the symptoms and signs of tension headache and patients may find it difficult to give an accurate description of their symptoms, although they may be able to clearly distinguish between throbbing tension headache and migraine. Tension headache is not commonly accompanied by nausea and vomiting and is usually limited to the head, although it may include the face and the neck.

Very rarely, other associated symptoms may occur such as slight dizziness, tiredness, anxiety, insomnia and sensitivity to sounds and light.  Sometimes during the attack, the patient looks ill and may be moaning, groaning or tearful and supporting their head with their hand pressed against the painful region or against the corresponding side of the neck.

Tension headaches may be brief and intense or prolonged and of low intensity. Episodic tension type headache may last from a few minutes up to a week and usually occurs infrequently. It can, however, progress to a chronic condition, where headache occurs all the time. Sufferers then endure headaches of varying intensity all day, every day, and can be woken by them at night. In general practice, tension type headache is diagnosed as being chronic when it is present for more than 15 days per month. In this case, a sufferer will notice the headache at the start of the day, and it will remain as a dull ache throughout the course of the day.

 

Management of tension headache

 

GENERAL OUTLINES OF TENSION HEADACHE MANAGEMENT

Self-help

1. Self-help

• Avoidance of stress: removing or minimising physical, mental  or climatic stresses.

• Improving diet: avoiding precipitating foods and adding Vitamin B12 and Vitamin C supplements). 

• Improving general life style: exercise and good sleeping patterns. 

2. Psychological and psychiatric measures ((Martin P and Mathews A, 1978)

• Management of emotional disturbance and anxiety.

• Management of depression

• Management of stress, physical fatigue and anger

3. Drug therapy:

• Analgesic drugs (e.g. paracetamol).

• Tranquilisers and muscular relaxants (e.g. diazepam).

4. Acupuncture treatment (Melchart et al 2001, Ahonen et al 1981, Borglum et al, 1977) by needling, with manual and/or electrical stimulation, of trigger points and classical Chinese acupuncture points.

 

Table 2. Summaries of tension headache management.

 

 

1. Self-help

• The patient should take measures to identify the physical, mental and climatic stresses that induce headache, and then try to avoid or minimise them. For example, strain in the neck and back might result from bad posture in swimming, climbing, decorating, using a computer or sitting.

• Corrective nutrition and a balanced dietary programme can assist treatment of tension headache. The patient should start reducing or eliminating foods which act as an irritant. These include pure sugar (sweets, chocolates and cakes), bananas, tomatoes, pineapples, cheese, red wine, pickled herrings, yeast extracts, preserved meats and citrus fruits.  Deficiency of various vitamins such as Vitamin B12 and Vitamin C may precipitate or trigger an attack in susceptible individuals at a time when they are otherwise in good health.

• Recent research (Solomon 1997; Stewart and Lipton 1994) indicates that exercise and general life-style changes play a major role in the treatment of tension headache and migraine.

 

2. Psychological and psychiatric measures

• When the primary cause of tension headache appears to be stress or sleep disorder, relaxation therapy is indicated.

• If there are signs of anxiety and/or depression, without apparent physical causation such as thyroid disorder, then counselling or psychotherapy may be indicated.

• Anti-depressant medication may be effective in replacing missing transmitter chemicals.

 

3. Drug therapy for tension headache (lance, 1982)

• Analgesics: Paracetamol is usually taken in full dose when a headache starts. A second dose after 4 hours may be taken if necessary. It is advised that the patient should not use combination tablets which contain paracetamol and codeine (such as co-codamol) as it is more likely to cause 'medication headaches' (known also as ‘rebound headaches’).

• Anti-inflammatory (non-steroid) drugs: These have the effect of reducing the production of prostaglandins in tissues and platelets and act as analgesic, antipyretic and anti-inflammatory medicines. The common drugs in this group are aspirin [this may be helpful in temporarily controlling headaches, but may cause gastric or intestinal irritation], and Indocid and Ibuprofen [these have the same mode of action as aspirin, but the side effects are likely to be more severe, for example epigastric discomfort, nausea, vomiting, gastritis, gastric ulcer and haemorrhage and other signs and symptoms related to bone marrow (agranulocytosis),  skin (allergies) and CNS (depression, insomnia and  psychosis)].

 

The traditional Chinese medicine theory of tension headache

 

Traditional Chinese medicine (TCM) classifies headaches in two main ways.

 

1. By pattern of disharmony.

The most broad differentiation is into excess (shi) and deficiency (xu) types. The excess type is characterised by acute, severe pain, a strong pulse and usually a coated tongue. The deficiency type is characterised by slow onset, chronic dull pain, a weak pulse and a tongue with less coating. Excess means the presence of an excess pathogenic factor which can be internally or externally generated, for example, pathogenic wind, damp or damp-heat are excess factors of external origin, whilst hyperactivity of Liver yang, Liver fire, Liver qi stagnation, dampness, phlegm and blood stasis are excess factors of internal origin. Deficiency means deficiency of qi, blood, yin, yang or jing and is always of internal origin.

 

2. By differentiation of affected channels

Occipital headache, which extends to the neck, is related to disharmony of the taiyang channel (Bladder and Small Intestine). Headache affecting the forehead and supraorbital regions is related to disharmony of the yangming channel (Stomach and Large Intestine). Bilateral or unilateral headache of the temples/parietal region indicates disharmony of the shaoyang channel (Gall Bladder and Sanjiao). Headache affecting the top of the head reflects disharmony of the jueyinchannel (Liver).

 

 

Acupuncture treatment of tension headaches

 

The treatment of tension headache by traditional Chinese acupuncture consists of regulation of qi and blood, dispersion of pathogenic wind, cold, heat or dampness, and removal of obstruction in the channels. Published research trials indicated that acupuncture is not only a treatment of choice (Karst et al 2000; Karakurum et al) but also an effective prophylactic measure in tension headaches (Lenhard and Waite 1983; Pascual and Polo 1989).

Acupuncture can be a time-consuming procedure, as each session of treatment might last for up to one hour, and in many patients 5-12 sessions may be needed. As a rule, a patient with tension headache should be given at least three sessions of treatment before a decision is made as to whether or not to continue with further treatment.

 

Clinical study of acupuncture treatment in tension headache

 

Twenty two patients who suffered from tension headache were recruited in this study. Twelve were male (average age 43.5 ± 9.7) and 10 female (average age 45.3 ±7.7). All patients visited our acupuncture clinic complaining of tension headache despite receiving conventional treatment for their problem. These patients were initially classified into three groups according to the duration of headaches: 1. up to ten weeks, 2. up to six months 3. six months and more.

 

Acupuncture materials, methods and points selection

 

Acupuncture materials

Disposable, sterilised and filiform needles (length 0.5 inch, 30 gauge) were used. The therapeutic effect was found to be at its best when the patient had experienced deqi (tingling, numbness, or cold or heat sensation at the site of the needle insertion, propagating a variable distance from that site). (Tukmachi 1999, 2004).

 

Acupuncture methods

Local and distal points were selected. Reducing method was used for the excess type and reinforcing method or tapping with a cutaneous hammer-shaped needle for the deficiency type (the cutaneous needle was raised and lowered regularly and smoothly, tapping the acupuncture points of the face and forehead). Mixed reducing and reinforcing method was used in cases of combined excess and deficiency.
 

At each session, the needles were retained for 20 to 30 minutes and three methods of stimulation were employed after the needle was in position and the desired needling sensation was obtained.

 

Reducing method

The needle body was rotated 120 to 180 degrees. A repeated anti-clockwise rotation was performed nine times and each rotation lased for about 10-15 seconds*. This method of reducing was repeated once every ten minutes and was used for robust patients suffering from an acute attack.

 

Moderate stimulation (mixed reducing and reinforcing)

In this method, the needle was rotated 60 to 90 degrees. This moderate reducing and reinforcing technique was applied to patients with a slightly weak constitution suffering from short-term chronic tension headache (one to two years).

 

Weak stimulation (reinforcing)

The needle was slightly rotated or flicked 10-15 times and care was taken that no stimulation sensation was felt on withdrawal of the needle. This weak reinforcing method was used in very weak patients who suffered from long term tension headache (more than two years).

 

Each session lasted from 20 to 40 minutes and usually, after two to four sessions of treatment, a good effect was obtained.

However, the outcome was considered to be ineffective when there was slight or no change in the patient's signs and symptoms after 13 – 16 weeksof treatment. During the course of acupuncture treatment, patients were persuaded to give up all drugs they were using for tension headache.

 

The selection of acupuncture points

The acupuncture points used in this study are as follows:

 

Classical points

Occipital headache: Fengchi GB-20, Kunlun BL-60, Houxi SI-3, Hegu L.I.-4.

Frontal headache: Touwei ST-8, Yintang (M-HN-3), Shuaigu GB-8, Waiguan SJ-5, Zulinqi GB-41.

Temporal/parietal headache: Baihui DU-20, Houxi SI-3, Zhiyin BL-67, Taichong LIV-3.

 

Trigger points

These tender points are located in the muscles of the neck (posterior cervical) and scalp (temporalis) and they need a careful systematic search in the regions of the scalp, neck and top of the shoulders (trapezius).

 

Points according to pattern

For the purposes of this study, we differentiated patients into two main patterns.

For hyperactivity of Liver yang: Xingjian LIV-2 and Yanglingquan GB-34.

For deficiency of qi and blood: Qihai REN-6 and Zusanli ST-36.

 

Criteria for assessing curative effects

According to the traditional acupuncture treatment formulation (Tukmachi, 1991a, 1991b, 1991c, 1992, 1999, 2004), the responses of patients with tension headache were divided intofour grades:

 

Cured: the patient's subjective signs and symptoms disappeared following treatment, with no recurrence after a period of one year.

Marked improvement: the patient's subjective signs and symptoms improved remarkably, but a few infrequent, mild headache attacks still occurred.

Fair improvement: the subjective signs and symptoms were slightly alleviated and the patient continued to have infrequent attacks of headache.

Failed: no changes in the patient’s condition.

 

Results

Of the 22 patients, 2 (9%) suffered tension headache for up to 10 weeks, 3 (14%) for up to 6 months, and 17 (77%) for 6 months or more.

The results of acupuncture treatment are shown in table 3.

 

Therapeutic effects

Number of patients (%)

Duration of tension headaches

Treatment period
(Mean ± S.D. week)

Treatment frequency
(Mean ± S.D. times)

Up to 10 weeks (%)

Up to 6 months (%)

More than  6 months

Cured

4 (18)

2 (9)

2 (9)

0 (0)

2.0 ± 1.2

9.5 ± 0.9

Marked improvement

9 (41)

0

8 (36)

1 (5)

10.1 ± 8.1

27.5 ± 21.2

Fair improvement

6 (27)

0

4 (18)

2 (9)

12.7 ± 6.1

32.5 ± 13.5

Failed

3 (14)

0

3 (14)

0

15.3 ± 8.5

44.9 ± 16.5

Total (%)

22 (100)

2 (9)

17 (77)

3 (14)

10.0 ± 8.2

28.3 ± 20.3

Efficacy rate (%)

59

100

59

33

 

 

 

Table 3. The effect, period and frequency of acupuncture treatment

Four patients were classified as cured. In this group the treatment period was an average 2.0 ± 1.2 weeks (Mean± S.D.) with a treatment frequency of 9.5 ± 0.9 times. Marked improvement was recorded in nine patients, within an average of 10.1 ± 8.1 weeks of treatment. Fair improvement was recorded in six patients, with an average of 12.7 ± 6.1 weeks of treatment, and their treatment frequency an average of 32.5 ± 13.5 times. Three patient’s results were classified as failure, with their treatment period being an average of 15.3 ± 8.5 weeks and treatment frequency an average of 44.9 ± 1.65 times.

In total, the treatment period and treatment frequency for all patients were 10.0 ± 8.2 weeks and 28.3 ± 20.3 times, respectively. Using the calculation method above, the efficacy rate was 100% for patients with headache less than 10 weeks. However, the efficacy rates for patients were 59% and 33% for the groups of up to 6 months and more than 6 months duration respectively.

 

Discussion

Research studies of acupuncture treatment in tension headache have been reported in western and Chinese medical literature (Melchart et al 2001; Vickers et al 1999; Lee, 1971; Shanghai Institute of Acupuncture Research, 1972) and have shown subjective improvement in symptoms.

 

Twenty-two patients with variable degree of tension headache were selected for treatment with acupuncture. They were classified into three groups according to the duration of tension headache.  None of them had been able to achieve adequate control of their headaches with a wide variety of drugs, including analgesics and tranquillisers. The results were encouraging, with four out of 22 patients (2 each in groups 1 and 2). There was marked improvement in nine patients (8 in group two and 1 in group 3) and fair improvement in six (4 in group two and 2 in group three), with failure in only 3 patients in group two alone.

 

The efficacy of acupuncture treatment was 100% for group one compared to 59% and 33%for groups two and three respectively. Most of the patients in this study preferred acupuncture to any the other treatment that  they had received, and those patients regarded as "cured" or "markedly improved" did not require any further treatment. We found that the average treatment period to achieve “cure” was 2.0 ± 1.2 weeks with a mean frequency of 9.5 ± 0.9 acupuncture treatments.  However, marked improvement was also elicited in patients treated within an average period of 10.1 ± 8.1 weeks for a mean number of 27.5 ± 21.2 acupuncture treatments. A fair improvement was noticed in patients treated within a mean period of 12.7 ± 6.1 after receiving an average of 32.5 ± 13.5 acupuncture treatments. We noticed that, the introduction of a longer treatment period (15.3 ± 8.5 weeks) with a high acupuncture treatment frequency (44.9± 16.5) just 3 patients failed to respond

 

 

Although this was not a doubleblind study, all the patients had already been treated with conventional medicine in different specialised centres. On the basis of these preliminary observations, a crossover, doubleblind and controlled study is needed. This report suggests that acupuncture is an effective and safe type of treatment for tension headache. It can offer a new avenue of study for neurologists, neurophysiologists and pain researchers, and lead the way to a better and more profound understanding of, and eventually to a better medical control of human pain.

 

Sample cases

 

CASE 1

History:

A patient aged 42 years who suffered from tension headache for eight months with a frequency of 12-20 attacks per month was selected for this study. A typical attack of tension headache was associated with lethargy, weakness, tiredness and lack of concentration. These headaches usually lasted for up to a few hours but sometimes the whole day, and were worsened by any head or body movement. On several occasions he was seen by both his GP and a specialist. Despite the regimen of analgesics and tranquillisers, his attacks had increased steadily.

 

We saw him in our clinic when he was suffering an attack of severe tension headache that required him to be brought by a relative to the clinic rather than coming on his own.

 

The patient received four sessions at 24 hour intervals in the first week, each of 30 minutes to 1 hour duration. This was followed by two half-hour sessions per week for 6 consecutive weeks. Two sets of acupuncture points were used in this case. Local points: Yangbai GB-14, Fengchi GB-20 and Jianjing GB-21 stimulated bilaterally using manual stimulation. Distal points: Taichong LIV-3 and Yanglingquan GB-34 stimulated bilaterally with manual technique. The needles were retained for 20-50 minutes and sometimes manipulated once every ten minutes. Following the fifth session of acupuncture treatment the headache and the associated symptoms had disappeared completely.

 

Case 2

This 39-year old woman had suffered from daily tension headaches for the past 5 months with no other major symptoms. She slept poorly and woke up feeling muzzy, with headache at the back and side of her head. She had at least 2-4 episodes of tension headache daily, of variable intensity, and each lasting for 2-4 hours. Consequently, the tension headaches interfered significantly with her social and working activities. She was treated by her GP with analgesics without success. A few weeks prior to her first visit for acupuncture, the frequency and severity of the headaches had increased steadily (to more than 4-5 attacks daily), even though she was taking powerful analgesics. She came to seek acupuncture treatment as a last resort.

The treatment protocol was an acupuncturesession for four consecutivedays, followed by twice-weekly sessions for four weeks. The following acupuncture points were used. Local points: Tender local points were needled as well as bilateral acupuncture points Shangguan GB-3, Yangbai GB-14, Fengchi GB-20 and Jianjing GB-21. Distal points: Hegu L.I.-4, Taichong LIV-3, Neiting ST-44, Yanglingquan GB-34, Zulinqi GB-41 and Yanggu SI-5.

After her fourth acupuncture session, she stated that she felt “much better in herself” with improvement in her sleeping pattern. After the completion of 15 sessions of treatment, she was experiencing no headaches and the morning muzziness was gone. Follow-up showed a lasting remission.

 

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Emad Tukmachi1 and Firhaas Tukmachi2

1Acupuncture Clinic, Nuffield Hospital, Clayton Road, Newcastle-U-Lyme, Staffordshire, ST5 4DB. Email: tukmachi@talk21.com  website: www.clinical-acupuncture.co.uk

2Fourth Year Medical Student, Queen Mary Medical School, London University, London. Email: Firas_1000@hotmail.com

Website: www.dermadoc.co.uk

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By Dr. Emad Tukmachi (1) and Dr. Firhaas Tukmachi (2) MBChB, DTM(Dublin), PhD(London) (1); MBBS ( (Londonr) MRCGP (2)
All rights reserved. Any reproducing of this article must have the author name and all the links intact.

Author: MBChB, DTM(Dublin), PhD(London) (1); MBBS ( (Londonr) MRCGP (2)

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