Shirodhara

Shira means head and dhara means to stream or to pour. Thus, shirodhara (also known as shiraseka or shiraparisheka) literally means therapeutic streaming overhead. It is the procedure of pouring a suitable liquid on the forehead in a synchronized and rhythmic manner for a stipulated period. The reference from samhita for shirodhara is available under murdhni taila (oil applications to head). Various decoctions, milk, butter milk, sugarcane juice, ghee, oil etc. are used for shirodhara either in medicated or unprocessed forms. Conceptually shirodhara is indicated for eruptions on head having multiple openings/furunculosis, pricking type of pain in head (shirasthoda), burning sensation (daha), suppuration (paka) and wounds (vranas). [A. Hri. Sutra Sthana 22/24]. In all these conditions there is association of pitha dosha. So, it can be assumed that the procedure of shirodhara is mainly pacifying the pitta dosha. The medicines are chosen based on associated doshas. For example the group of four unctuous substances or sesame oil alone in vata, ghee and milk in pitha and decoction, sesame oil ,and butter milk in kapha.Shirodhara is said to have greater effect than head massage (shirobhyanga) and lesser effect than therapeutic procedure of placing tampon with oil over head region (shiropichu).[A.Hri Sutra Sthana 22/23] This is based on the pacification of vata dosha (vata shamana) property of the procedure as the session deals with the various oil applications of head where shirobasti is considered the supreme. This article deals with conceptual understanding and practical application of shirodhara.

Contributors

Section/Chapter/topic	Concepts/Panchakarma/Shirodhara
Authors	Adarsh P. M. 1, Deole Y.S. 2
Reviewer & Editor	Basisht G.3
Affiliations	1 Charak Samhita Research, Training and Development Centre, I.T.R.A., Jamnagar, India 2 Department of Kayachikitsa, G. J. Patel Institute of Ayurvedic Studies and Research, New Vallabh Vidyanagar, Gujarat, India 3 Rheumatologist, Orlando, Florida, U.S.A.
Correspondence emails	dryogeshdeole@gmail.com, carakasamhita@gmail.com
Publisher	Charak Samhita Research, Training and Development Centre, I.T.R.A., Jamnagar, India
Date of publication:	August 25, 2023
DOI	10.47468/CSNE.2023.e01.s09.144

Etymology and derivation

The word shirodhara comprises two words viz shiras and dhara. ‘Shiras’ means head and ‘dhara’ means pouring liquids on the body (seka). The word dhara comes from the Sanskrit root ‘dhr’ (dhr +nich+ang) which means falling of liquid. [ ] Thus, shirodhara is pouring liquid on the head.

Synonyms

Shiraseka, Parisheka [A. Hr. Sutra Sthana 22/23-26], Murdhaseka, Anusechana [Su. Sa. Sarira Sthana 10/21], Parishechana [Cha.Sa. Chikitsa Sthana 6/105], Avaseka [Cha.Sa. Chikitsa Sthana 5/181].

Classification

Shirodhara can be classified according to the type of medicated liquid used.

1. Taila dhara (therapeutic streaming of oil)
2. Sarpi dhara (therapeutic streaming of ghee)
3. Takra dhara (therapeutic streaming of medicated/plain butter milk)
4. Kshiradhara (therapeutic streaming of plain / medicated milk)
5. Kwatha dhara (therapeutic streaming of decoction)
6. Jala dhara (therapeutic streaming of water)

Taila dhara (therapeutic streaming of oil)

Here medicated taila (oil) is used for shirodhara which is either vatashamana (pacifying vatadosha) or vatakapha shamana (pacifying both vata and kapha dosha) in nature. Taila(oil) is the best medicine for vata. [Cha.Sa. Siddhi Sthana 1/29]. Udumbaradi siddha taila is mentioned for therapeutic streaming in the management of bleeding disorders (raktapitta) [Cha.Sa. Chikitsa Sthana 6/105]

Sarpi dhara (therapeutic streaming of ghee)

Medicated or non-medicated ghee can be used for shirodhara in vata, pitta and rakta vitiated conditions. Sarpi is mentioned for therapeutic streaming in pain produced by vitiation of vata. [Cha.Sa. Chikitsa Sthana 5/181].

Takra dhara (therapeutic streaming of butter milk)

Here medicated takra (butter milk) is used for shirodhara. It is indicated in diseases having kapha pitta vitiation. The drugs which are cold in touch/potency are indicated for shirodhara in headache due to vitiated pitta (paittika shirobhitapa)). [A. Hr. Uttara Sthana 24/11]

Ksheera dhara (therapeutic streaming of milk)

As the name suggests, medicated or non-medicated milk is advised for shirodhara in pitta associated diseases of vata. The milk processed with dashamula is indicated for therapeutic streaming overhead in headache due to vitiated vata dosha (vatika shirobhitapa). [A. Hri. Uttara Sthana 24/3]

Kwathadhara (therapeutic streaming of decoction)

Here, the liquid used is decoction (kwatha) which pacifies both vata and kapha (vata kapha shamana). In vatarakta associated with burning sensation, boiled and cooled decoction of jivaniya group of drugs is advised for therapeutic streaming. [Cha.Sa. Chikitsa Sthana 29/126]

Jaladhara (therapeutic streaming of water)

Even the use of mere cold water can give benefits of the shirodhara procedure in the case of paithika rogas (diseases having origin from pitta dosha). Therapeutic streaming of cold water (shita jala) is indicated for bleeding hemorrhoids. [Cha. Sa. Chikitsa Sthana 14/218]

Types of shirodhara based on reusage.

Types	Reusage
Uthama	fresh sneha each day
Madhyama	same sneha for 3 days
Adhama	beyond 3 days or mixed with already used sneha

Indications of shirodhara in general

• Headache (tension headache and migraine)
• Wounds especially affecting the upper part of the body above the clavicle (urdhva jatru).
• Suppurations in the scalp
• Ulcerations of the scalp
• Burning sensation [A. Hri. Sutra Sthana 22/25]
• The diseases affecting the upper parts of the body (neurological diseases).
• stress, psychic and psychosomatic diseases like psychosis, neurosis, epilepsy, irritable bowel syndrome.
• Insomnia
• Generalized anxiety disorders.
• Addition disorders like alcoholism
• Excess sweating, hypertension.
• Syncope
• Exhaustion without exertion.
• Loss of consciousness
• Enlargement of glands
• Diabetes
• Autoimmune skin diseases like psoriasis, dandruff, and chronic eczema.

Contra indications of shirodhara

• Shirodhara is not indicated in diseases arising out of dominance of kapha dosha.
• It is not advised during extreme hot and cold seasons.
• It is not advised at the time of mild increase of doshas.
• Contraindicated at noon and midnight.
• It is also prohibited on poor sunny days.

Shirodhara procedure

Purva karma (pre therapeutic procedure)

Collection of materials

Materials required	Quantity
Dhara patra (pot)	1
Dhara stand	1
Dhara droni (table)	1
Suitable liquids like oil, butter milk or milk	1.5 liter
Gauze	1
Cotton ear plugs	2
Soft pillow covered with rexin	1
Hot water for bath	Q. S
Vessels	3
Rasnadi churna for tala	5g
Towels	2
Attendants	2

Dhara dravya according to diseases

Diseases	Dharadravya
Klama, daha	Coconut water
Pittaja vikara	Cold water/milk
Vata pittottara	Ghee
Vathadhika, arumshika	Sesame oil

Dhara Dravya according to dosha

Dosha	Indicated dhara dravya
Kevala vata	Chatusneha (oil, ghee, muscle fat, bone marrow)
Pitta or rakta pradhana vyadhi or raktapitta associated with vata or kapha	oil and ghee in equal proportion
Kapha associated with vata	Oil (2 parts) + ghee (1 part)
Pitta	Different types of milk

Preparation of butter milk for takra dhara

Two pala(96g) of Musta (Cyperus rotundus) or Yashtimadhu (Glycyrrhiza glabra) boiled in two prastha (1536ml) of milk and eight prastha(6144ml) of water and reduced up to two prastha(1536ml) by suspending them into liquid in a bag of thin cloth. The bag is also squeezed well at the end of boiling. The medicated milk thus obtained is cooled and fermented overnight. Decoction of four pala(192g) of amalaka (Emblicus officinalis) is prepared by boiling it with four prastha (3072ml) of water and reduced to one prastha(768ml). This decoction is mixed with the curd formed and churned to obtain the butter milk. This takra is used for dhara.

Preparation of medicated milk

2 prastha(1536ml) of cow’s milk along with 8 prastha(6144ml) of water and add 1 pala(48g) each of the roots of bala (Sida cordifolia) and shatavari (Asparagus racemosus) which is tied up in a muslin bag into the mixture and boiled over gentle fire till the total quantity reduced to that of milk. It is then diluted with an equal quantity of fresh tender coconut water after it is completely cooled.

Preparation of instrument of shirodhara yantra

• A table is placed with the head part facing the east in a room with all the necessary equipment.
• The pot has an aperture of the size of the circumference of little finger of the patient.
• The pot is tied to the dhara stand over the head.
• A wick having nine angula (finger’s breadth) length is suspended through this aperture.
• Distance between the tip of the wick and the forehead of the patient should be maintained four angula (finger’s breadth)

Preparation of the patient

• The patient should be advised to pass stool and urine.
• Patients’ blood pressure, temperature and pulse rate should be recorded before commencement.
• The posture of the patient must be in a supine position with the head slightly bent backwards.
• A thick strap of cloth is tied over the eyebrows, along the forehead, to prevent getting of liquid into the eyes. The tied strap is neither too tight nor too loose.
• The eyes and ears of the patient should be covered with cotton to prevent the entry of liquid into them.

Pradhana karma (therapeutic procedure)

• The physician/therapist should stand on the right side of the patient.
• The liquid used for streaming at the desired temperature should be filled into the pot.
• The hole of pot should be blocked with the thumb of physician while filling the pot.
• The block is released gradually once the pot is positioned.
• The lower end of the wick is made to oscillate gently between the either ends of the temples across the forehead.
• The vessel is refilled with liquid when the pot is emptied, by collecting it from the table (droni) and heating it if desired.
• Massage of the four limbs can be prescribed during the procedure according to the need.

Duration of the procedure

Dhara has to be continued until the person gets sweating.

Dosha/guna involved	Duration
Ruksha/Pitta associated vata diseases	96 minutes
Snigdha/kapha associated	72 minutes

Period of reusage of dhara dravya

The medicated liquids used for dhara can be reused for multiple sessions in the same patient based on their potency and form. The details are given in the following table.

Dhara dravya	Period of reusage
Kwatha(decoction)	1 day
Milk	1 day
Tender coconut water	1 day
Dhanyamla	3 days
Sneha	Sneha should be changed after 3 days, and then fresh sneha must be used for the next 3 days and on the seventh day both can be mixed and used.

Pashchat karma (Post therapeutic procedure)

• Patient’s head is wiped with a clean cloth.
• Cold water sprinkled over the face and mouth is washed.
• The patient should sit in a place devoid of wind but having breeze.
• Gentle tapping over the body and anoint with perfumes after having bath with lukewarm water.

Post therapeutic diet.

• Water boiled with coriander and dry ginger.
• Hot butter milk processed with spices, ghee and soup of pulses should be given to drink.
• Light to digest in restricted quantity is advised.
• Also, the diet and regimen advised during internal oleation (snehapana) must be followed.

Possible complications

• Burning sensation (daha) may be produced due to excess sudation (atisweda).
• Erysipelas (visarpa). Possible reason may be sweda during impaired metabolism (samavastha)
• Pain (ruk) may be produced by pouring liquid at low temperature.
• Syncope (murchha) may be produced due to excess sudation (atisweda).
• Loss of voice (svarasada) may be developed by excess streaming of dry and cold liquids like butter milk.
• Joint dislocations (sandhidalana) by excess streaming of unctuous substances.
• Vomiting (chhardi) may be induced by application of unctuous streaming during impaired digestion.
• Bleeding disorder (raktapitta) may be produced by streaming oils having excessive hot and sharp potency and excess sudation.
• Hyperpyrexia (jwara) by application of unctuous streaming during impaired digestion.
• Urticaria (kotha) may be produced due to excess sudation (atisweda).

Reasons for complications

Improperly performed dhara like

• Pouring (dhara) from too much height
• Pouring (dhara) from too less height
• Too much fast
• Too much time

Precautions during the procedure

• The uniformity and continuity of stream should be maintained.
• The stream is neither too thick nor too thin.
• The oscillations should neither be too fast nor be too slow.
• The proper height should be maintained for pouring.
• Pouring should be done in a stipulated time.
• Pouring should not be done during extreme climates, at noon and midnight.

Importance in preservation of health and prevention

Shirodhara with medicated oil and ghee enhances:

• The stability of mind and speech
• Strength of the body
• Increases retaining power of mind.
• Gentleness of voice
• Softness of skin
• Sharpness of vision
• Nourishment of shukra
• Reduces excess body warming.
• Induces good sleep.
• Takradhara can prevent premature greying of hair.

Importance in management of diseases

• Medicated streaming with unctuous substances (snehadhara) can pacify the diseases arising out of tridosha.
• Streaming with milk (ksheeradhara) can cure insanity, epilepsy, sleeplessness, burning sensation of head and tension headache.
• Takradhara can pacify headache, reverse the ojakshaya, pacify pricking pain over palms and feet, urinary tract diseases, diseases involving head, eyes, and ears.

Mode of action of shirodhara

• The physiological effect of liquid used for streaming (dhara dravya) dripped on the forehead induced by the somato-autonomic reflex through thermosensors or pressure sensors in the skin or hair follicles via the trigeminal cranial nerve. The neurophysiological mechanism which might be linked up to this could help for balancing the functions of brain and hormonal functions. The impulses in the form of vibrations carried from forehead to hypothalamus which could have neurological, endocrinal, and psychological effects. Shirodhara can enhance the blood supply to brain and thus increases the oxygen supply which is required for excellent physiological and psychological functions.

List of theses works

Effect on essential hypertension

Total 25 patients having essential hypertension were sub-divided into three groups of 10 patients were given takradhara alone, 9 patients were given sarpagandha vati alone and both takradhara and sarpagandha vati were given for 6 patients. The study concluded that takradhara along with sarpagandha ghana vati offered better results in pacifying the entire range of symptomatology and mainly the cardinal signs in comparison to single therapy alone.

Effect on psoriasis

A comparative clinical trial in which 28 patients who had completed the treatments, 15 were in group A (virechana karma followed by shamana yoga) and 13 were in group B (takradhara in the form of shirodhara followed by shamana yoga). Marked improvement was found in 20% of patients in group A, while it was 23.08% of patients in Group B. Moderate improvement was found in 53.33 % of patients in Group A and 14.39 % of patients in Group B. Mild Improvement was found in 26.67 % of patients in Group A and 14.29 % of patients in Group B.

Effect on insomnia

In a comparative clinical trial on insomnia, out of 27 patients who had completed the trial 13 were in group A (Jatamansi tailadhara) and 14 were in group B (Jaladhara group). Among them complete remission, marked improvement was found in one of the patients of group A, moderate Improvement was found in 76.92% and mild Improvement was observed in 15.38% patients. None of the patients remained unchanged. In Jaladhara group, out of 14 patients, none of the patients had complete remission and marked Improvement, while moderate improvement in 85.71% and mild improvement in 14.29% patients were observed. None of the patient remained unchanged in this group.

In another research on stress induced insomnia, there were 27 patients who completed the treatment in two groups of dhara. In first group tagaradi kwatha used for shirodhara, whereas mahishi dugdha used for the same in the second group. In Tagaradi Kwatha group, 17 patients completed the course of therapy. Among them complete remission and marked improvement were found in none of the patients, while moderate improvement was found in 23.53% patients and mild improvement was observed in 76.47% patients. None of the patients remained unchanged. In Mahishi Dugdha Dhara Group, out of 10 patients, none of the patients had complete remission, while marked improvement was found in 20% patients; moderate improvement in 60% and mild improvement was observed in 20% patients.

Effect on chittodvega (anxiety disorders)

In a study involving 20 patients comparing jaladhara (group A) and sankhapushpi rasayana (group B), out of 8 patients of Jaladhara group,only a patient(12.5%) gained marked improvement and remaining 7 patients (87.5%) showed moderate improvement.Total 12 patients of Sankhapuspi Rasayana group had completed the full course. Out of 12 patients 5 patients (41.7%) gained marked improvement and the remaining 7 patients (58.3%) were having moderate improvement.

Effect on shukravrita vata

There were 48 patients who completed the course of trial with 16 patients in each of the 3 groups. Subjects in Group A were treated with placebo, subjects in Group B were treated with Rasayana Yoga (6 gm/day) and subjects in Group C were treated with shirodhara(7 days) and Rasayana yoga. Psychological counseling was given to subjects in all the 3 groups that underwent treatment for a duration of 4 weeks. From the overall effect of therapy, it was gauged that though all the 3. groups showed improvement the maximum improvement was in group C which has combined shirodhara where 10.5% were cured and 79% markedly improved whereas in the other 2 groups. Nobody was cured and only 56.2% markedly improved in group B and none in group A. Thus, it was concluded that Ŝirodhārawith Rasayana Yoga is most effective in the treatment of shukra avrita vata and could even cure the disease.

Current research

Shirodhara has anxiolytic and ASC-inducing effects, and it promotes a decrease of noradrenaline and exhibits a sympatholytic effect, resulting in the activation of peripheral foot skin circulation and immunopotentiation.

A pilot study involving twenty participants concluded that the shirodhara with sesame oil improved the sleep quality measured by PSQI score and the score was lower as compared to the scores of shirodhara with warm water after 2 weeks and 6 weeks follow up. Whereas the shirodhara with sesame oil showed improvement with more score on quality of life as compared with shirodhara with warm water.

In a study conducted among sixteen healthy volunteers on shirodhara using oil containing Centella asiatica (Brahmi), Nardostachys jatamansi (jatamansi), and Withania somnifera (Ashwagandha) in a proportion of 10 mg of aqueous extract of each/ 100 mL of sesame oil, EEG showed an increase in the alfa rhythm after shirodhara. A decrease of beta activity was observed in two subjects, while one subject showed an increase in the central theta activity. The EEG changes are like those observed after deep meditation and alert relaxation. The V.A.S. score and M.A.S. score for stress and mood changed significantly.

In a comparative clinical study containing two groups involving forty-seven participants, one group has undergone shirodhara and other group had given sarpagandha vati for the management of hypertension. The results in the shirodhara group were better than those in the sarpagandha group. Although both sarpagandha vati and shirodhara helped in reducing systolic and diastolic pressures, the effect of shirodhara was more marked.

The comparative study between jatamansi taila dhara group and jaladhara group among thirty-one participants having insomnia have showed good improvement in both groups whereas a better improvement in jatamansi taila group for the chief complaints.

In a similar comparative clinical trial involving 137 participants the comparison between the tailadhara group and jaladhara group also revealed that symptoms like insomnia, anxiety etc. were completely relieved by shirodhara. In brief psychiatric rating scale statistically results of the dhara group are highly significant. Tailadhara provided better relief in all most all the symptoms of stress and in brief psychiatric rating scale compared to jaladhara.

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