Acupuncture in headache treatment …

Chong-hao Zhao MD PhD

Headache & Pain

Updated 01.12.2024
Released 03.24.2003
Expires For CME 01.12.2027

Acupuncture in headache treatment

Author: Chong-hao Zhao MD PhD

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Editor: Shuu-Jiun Wang MD

Acupuncture in headache treatment

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Introduction

Overview

In 1997, the National Institutes of Health Consensus Development Panel suggested that acupuncture may be effective or useful in treating 14 disorders, including headache. The history of the practice of acupuncture in the United States and the theoretical framework for acupuncture in Chinese medicine are reviewed. The basic scientific background and clinical application of acupuncture in headache management are discussed.

Historical note and terminology

Acupuncture is an important therapy in East Asian medicine, the traditional medicine of China, Japan, and Korea. With the growth of interest in alternative medicine, acupuncture has become more popular in the United States as a treatment option. Even though more scientific studies are needed to confirm the efficacy of acupuncture, the National Institutes of Health Consensus Development Panel issued a report in November 1997 stating that acupuncture may be effective in several conditions and situations (43). The National Institutes of Health Consensus Development Panel concluded that promising results have emerged, such as showing the efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting and postoperative dental pain. There are other situations such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma, in which acupuncture may be useful as an adjunct treatment, an acceptable alternative, or be included in a comprehensive management program.

To Western thinking, it is difficult to understand how acupuncture relieves headache by placing needles in the scalp, much less by treating points in the hands and feet. This essay briefly reviews the historical and theoretical framework for acupuncture, the scientific evidence for its efficacy in headache relief, and its safety profile.

Acupuncture is thought to have existed in China in one form or another since at least the Xia Dynasty (2000 to 1500 BC) (21). The earliest major source on acupuncture is found in the textbook Huang Di Nei Jing (Yellow Emperor’s Inner Classic) from the Han Dynasty (200 BC to 100 AD) (21). It was first brought to Europe in the 1700s and was introduced to the United States during the 19th to 20th centuries. Acupuncture treatment for lumbago was recommended in Sir William Osler’s The Principles and Practice of Medicine, from the first 1892 edition through the sixteenth and final edition in 1947 (21). In the 1950s, China reported the use of electroacupuncture to obtain surgical analgesia (64). In 1996, the United States Food and Drug Administration changed the classification of acupuncture needles from Class III (experimental) medical devices to Class II (nonexperimental but regulated) medical devices (10). Being Class III hindered the standard use of acupuncture, as it could only be performed in approved research settings (eg, hospital laboratories). By November 1997, the National Institutes of Health Consensus Development Panel had concluded that acupuncture was effective or useful in 14 disorders, including headache.

From the Chinese perspective, acupuncture is necessarily embedded in a complex theoretical framework that provides conceptual and therapeutic directions. The theories of yin and yang, five elements (the evolutionary phases of fire, earth, metal, wood, and water), Qi (vital energy), meridians, and collaterals provide the most important guidance for acupuncture treatment. These theoretical principles are briefly described below.

Yin and yang. The concept of yin and yang is the generalization of the two opposite aspects in related objects and phenomena in the natural world. The Chinese believe that all the objects in the universe include the two opposite aspects of yang and yin, for instance, day and night, heat and cold, motion and tranquility, and sympathetic and parasympathetic functions. The yin and yang theory is among the most important principles underlying the practice of all Chinese medicine, including acupuncture. Disease and pain result from an imbalance of the yin and yang, and acupuncture treatment aims to restore the balance.

Qi. The ancient Chinese believed that Qi is the basic substance composing the world, and all that matters in the universe appears by the movements and mutations of Qi. The vital energy or life force, Qi is fundamental to the description of nature in Chinese medicine. According to traditional Chinese tenets and beliefs, Qi circulates inside the meridians and supports every life process and every organic function. Chinese doctors think pain results from stasis or blockade of the meridian Qi flow. An acupuncturist will apply needle stimulation to reopen the related meridian by giving an external force to the energy and Qi. After eliminating a severe blockage of Qi, pain will go away.

Jing-Luo. The Jing-Lou meridian network consists of major meridians (Jin channels) and minor meridians (Luo collaterals). Jing-Luo meridians are distributed throughout the body, and inside the meridians, Qi flows continuously. There are 14 major meridians, including 12 “regular” and two “curious” meridians in the body (80; 20), which are commonly used in acupuncture practice and mentioned in the literature. They are named according to their distributed organs, including lung meridian, pericardium meridian, heart meridian, large intestine meridian, triple energizer meridian, small intestine meridian, stomach meridian, gallbladder meridian, bladder meridian, spleen meridian, liver meridian, and kidney meridian. The two major curious meridians are Ren MO (conception vessel) and Du MO (governor vessel).

Acupuncture points (acupoints), their anatomy, and physiological characteristics. The anatomy of acupuncture points has been investigated (45). They are in the vicinity of the small or large peripheral nerves and their bifurcations, motor points of neuromuscular attachments, blood vessels, ligaments, and suture lines of the skull. Dung further found that all the acupuncture points in the face and forehead region are located along terminal or cutaneous branches of the trigeminal nerve and between muscular branches of the facial nerve (07). Acupoints were found to have lower electrical impedance compared to non-acupoints (49). Increased skin conductivity was also reported in the acupoints in rats and men, compared to the nonacupoints- (24). It is still unclear what contributes to the difference in skin’s electrical properties. Diagnostic and therapeutic probes have been developed based on the distinction of skin electrical impedance and conductivity. Such probes can help the acupuncturists or researchers locate the acupoints by detecting the fall of cutaneous electrical resistance of the patients and even be used to treat those points (61). A PET-CT study on 30 migraineurs investigated the electroacupuncture-induced brain metabolism changes at specific acupoints and non-acupoints (76). Stimulation of the true acupoints increased the brain glucose metabolism in the middle frontal gyrus, postcentral gyrus, and the precuneus, parahippocampus, cerebellum, and middle cingulated cortex; brain glucose metabolism decreased in the left hemisphere of the middle temporal cortex. In comparison, activation of the non-acupoints increased the metabolism in the posterior cingulated cortex, insula, inferior temporal gyrus, middle temporal cortex, superior temporal gyrus, postcentral gyrus, fusiform, inferior parietal lobe, superior parietal lobe, supramarginal gyrus, middle occipital lobe, angular, and precuneus, whereas it decreased in cerebellum and parahippocampus. In Chinese medicine, acupuncture points are the sites through which the Qi of the organs is transported to the body surface by way of the above-described meridians. The acupuncture points are divided into three categories: acupoints of 14 regular meridians (described above), extraordinary points, and Ashi points. (1) The acupoints of 14 regular meridians are the major components of the acupoint system. One example is Hegu, the fourth point at the large intestinal meridian. It is commonly used in the treatment of head or orofacial pain. (2) The extraordinary points are located beyond 14 regular meridians and play special roles in management. For instance, Taiyang is located in the temporal region and is the fifth extraordinary head and neck point. It plays an important role in migraine treatment. (3) Ashi points are also called tender points. They do not have specific names and defined locations. They are important in the diagnosis and treatment of headache and pain.

Clinical aspects

Description

Ideally, acupuncture treatment should be given based on diagnosis principles of Chinese medicine (14). It may be difficult for a physician without an academic background in Chinese medicine, so the authors recommend a simple and useful principle: remember the concept of the yin and yang balance and treat the patient holistically. In migraine patients with temporal throbbing quality, excessive yang exists with a deficiency of yin. To rebalance the yin and yang, the practitioner would supplement the yin by tonifying the acupoints in the foot, such as spleen meridian 6 and liver meridian 3, and eliminate the excessive yang by draining points in the head and hand, such as extraordinary head and neck point 5, stomach meridian 8, and large intestine meridian 4. Stimulation of the yin points will soothe the patient and improve sleep. Suppression of the yang points will relieve the acute headache. Needling of the Ashi points in the head can also suppress the pain.

In Chinese medicine, acupuncture aims to restore the balance of yin and yang, cleanse the blockade of meridians, and resume the Qi flow. Ultimately, acupuncture aims to reduce headache frequency and severity through the proposed inhibition of the brainstem headache center, including the trigeminal nucleus caudalis.

Acupuncture treatment is typically given over the course of 4 to 6 weeks, two to three times per week. Each treatment involves six to 10 needlings lasting 20 to 30 minutes. The treatment goal is 50% or more pain, symptom, or functional improvement.

Indications

After an extensive review of literature produced from January 1970 to October 1997 searched through MEDLINE, Allied and Alternative Medicine, EMBASE, MANTIS, and nine journals not indexed by the National Library of Medicine, the National Institutes of Health Consensus Development Panel has concluded that acupuncture was a useful adjunctive therapy for headache management (43). Multiple randomized controlled studies have been done to investigate its efficacy in the treatment of different kinds of headache, including migraine, tension, and headaches with combined characteristics. The literature seems to support the use of acupuncture in migraine treatment, whereas there is not enough scientific evidence to evaluate its role in the management of other types of headache (41; 34; 35).

Contraindications

In general, acupuncture is a safe and noninvasive procedure. There are a few contraindications to the use of acupuncture (09; 39). Acupuncture applied with an electrical stimulator (electroacupuncture) should not be performed on those with cardiac pacemakers. Acupuncture should not be given to those with skin and soft tissue infections, or bleeding disorders or those on anticoagulants. It is not recommended in infants.

Pregnancy is not a contraindication for acupuncture treatment, although certain acupoints should be avoided.

Outcomes

Migraine. More studies of acupuncture have been done on migraine than any other type of headache. Acupuncture has demonstrated some benefits in the acute abortion of migraine. In a randomized controlled trial to study the efficacy of acupuncture treatment for acute migraine, 175 patients were randomized into three groups (28). One group received verum acupuncture, and subjects in the other two groups were treated with sham acupuncture. Each patient received one session of treatment and was observed over a period of 24 hours. Significant decreases in visual analogue scale (VAS) scores from baseline were observed in the fourth hour after treatment when visual analogue scale was measured in the patients who received either verum acupuncture or sham acupunctures (P < .05). The VAS scores in the fourth hour after treatment decreased by a median of 1.0 cm, 0.5 cm, and 0.1 cm in the verum acupuncture group, sham acupuncture group 1, and sham acupuncture group 2, respectively. The decrease was significant between the verum group and the sham acupuncture group 2 (P=0.007). Significant differences were also observed in pain relief, relapse, or aggravation within 24 hours after treatment. Wang and colleagues conducted a study on 150 patients to investigate the efficacy of acupuncture for acute migraine attacks compared with sham acupuncture (68). Every patient received a verum or sham acupuncture treatment when having a migraine attack, and medications were allowed if the pain failed to be relieved 2 hours after the acupuncture treatment. The mean VAS scores 24 hours after treatment were significantly decreased from 5.7 to 3.3 by 2.4 in the verum group versus 5.4 to 4.7 by 0.7 in the sham group (P = 0.001). The acute medication intake at 24 and 48 hours after the treatment was also significantly reduced in the real acupuncture group (P < 0.05).

Acupuncture has also demonstrated some favorable effects on migraine prophylaxis. In the Cochrane Database of Systematic Reviews, 22 trials with 4419 participants were evaluated (34). Six compared acupuncture to no prophylactic treatment or routine care only. After 3 to 4 months, patients receiving acupuncture had significantly higher response rates and fewer headaches. Fourteen trials compared a “true” acupuncture intervention with a variety of sham interventions. Pooled analyses did not show a statistically significant superiority for true acupuncture in any of the time windows for pooled responder rate ratio; however, there was a trend of significance of group differences (0.05 < p < 0.1) in four analyses (responder rate ratio, headache frequency, migraine days, and migraine attacks up to 2 months after randomization). Four trials demonstrated that acupuncture was slightly better than proven prophylactic drug treatment and associated with fewer adverse events. The authors concluded that (1) there was consistent evidence that acupuncture provided additional benefit to treatment of acute migraine attacks only or to routine care; (2) there was no convincing evidence for an effect of 'true' acupuncture over sham interventions; (3) acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment, and has fewer adverse events. Acupuncture should be considered a treatment option for patients willing to undergo this treatment. A systematic review and meta-analysis evaluated the therapeutic effect of acupuncture on migraine. Twenty-eight randomized controlled trials involving 2874 patients were included. The results showed that true acupuncture was more effective than sham acupuncture or medication. The true acupuncture treatment achieved significantly greater improvement in the reduction of the visual analog scale (VAS) score than sham acupuncture and fewer side effects than medications (46). The meta-analysis of 3380 participants from 20 studies demonstrated similar true acupuncture treatment outcomes (12). A systematic review of 20 randomized controlled trials involving 2725 patients compared the true and sham acupuncture in migraine management (27). The patients received the treatment with duration of one session or 30 minutes to 20 weeks, and were followed up from 0 weeks or 24 hours to 54 weeks. In comparison to sham acupuncture, true acupuncture improved migraine frequency, visual analog scale score, and responder rate, but there was no significant difference in the number of migraine days.

Vincent studied 30 patients with chronic migraine and found acupuncture treatment to be significantly better than sham treatment in the reduction of pain severity (48% vs. 14%) and the use of rescue medications (38% vs. 28%) (67).

Linde and colleagues completed a randomized controlled trial on 302 patients for the effect of migraine prophylaxis (36). Each patient received 12 sessions of treatment over 8 weeks. Compared to baseline, the mean number of days with headache of moderate or severe intensity decreased by 2.2 days in both the true acupuncture and sham acupuncture groups and by 0.8 days in the waiting list group. True acupuncture was no more effective than sham acupuncture in this study (36). A study by Alecrim-Andrade and colleagues evaluated the percentage of patients with a 50% or greater reduction in migraine attack frequency and number of days with migraine (01). In the second month of treatment, patients with real acupuncture treatment significantly improved more than those with sham acupuncture (P=0.021 and P=0.007). However, the differences between these two groups disappeared in the third month of treatment due to the high improvement of the sham acupuncture group. Patients rated verum acupuncture as superior to sham acupuncture in general effectiveness. Li and colleagues conducted a randomized controlled trial in 480 patients who received either verum or sham acupuncture (29). All patients received 20 treatments over a period of 4 weeks. There was no significant reduction in the number of days with migraine during weeks 5 to 8 (P < 0.05), but weeks 13 to 16 (P = 0.003, < 0.001, =0.011, respectively) in all three acupuncture groups compared with the control group. In a 24-week study of clinical trials on 249 patients, patients randomly received 4 weeks of treatment with true acupuncture, sham acupuncture, or no acupuncture waiting-list control, followed by 20 weeks of follow-up (83). The mean change of frequency of migraine differed significantly among the three groups at 16 weeks after randomization; a greater reduction was observed in the true acupuncture than in the shame acupuncture (P = 0.002) or waiting list (P < 0.001), and the significant reduction lasted throughout the remaining period of the study. A multicenter, randomized clinical trial studied 150 patients for the acupuncture effect as prophylaxis of episodic migraine without aura (72). Patients received 20 sessions of either true or sham acupuncture treatment over 8 weeks and 12 weeks of follow-up. True acupuncture resulted in a more significant reduction in migraine days of 3.5 versus 2.4 for sham acupuncture (P=0.005) at weeks 13 to 16 and 3.9 versus 2.2 (P < 0.001) at weeks 17 to 20. The migraine attacks at weeks 17 to 20 were also significantly more reduced in the true acupuncture group than in the sham group, 2.3 versus 1.6 (P < 0.001).

Studies comparing acupuncture with conventional drugs, including caffeine or ergotamine and flunarizine, showed significantly better outcomes in the acupuncture group regarding reduction in headache severity and frequency (14; 02). In a study on 114 patients with migraine comparing acupuncture and metoprolol, the proportion of responders (reduction of migraine attacks by at least 50%) was 61% in the acupuncture group and 49% in the metoprolol group (P=0.261) after 9 to 12 weeks of treatment. Both physicians and patients reported fewer adverse effects in the acupuncture group (54). Yang’s group investigated the efficacy of acupuncture compared with topiramate treatment in chronic migraine prophylaxis in 66 patients (73). In the acupuncture group, 33 patients received acupuncture treatment for 24 sessions over 12 weeks; topiramate was administered to 33 patients, with a 4-week titration initiated at 25 mg/day and increased by 25 mg/day weekly to a maximum of 100 mg/day, followed by an 8-week maintenance period. A significantly larger decrease in the mean monthly number of moderate or severe headache days from 20.2±1.5 days to 9.8±2.8 days was achieved in the acupuncture group compared with 19.8±1.7 days to 12.0±4.1 days in the topiramate group (p< 0.01). The 50% responder rate was 75.8% in the acupuncture group versus 30.3% in topiramate group (P< 0.01). Only 6% of the acupuncture group had adverse events, compared to 66% of the topiramate group. A systematic review compared the acupuncture effect versus standard pharmacological therapy for migraine prevention (81). Seven randomized controlled trials were included, with a total of 1430 participants. The studies showed acupuncture to be more effective than the standard treatment for migraine prevention. The preventive medications included in the studies were flunarizine, topiramate, beta-blocker including metoprolol, valproic acid, and botulinum toxin. Acupuncture was significantly more effective at reducing the frequency of migraine attacks, headache days, and headache intensity. It also showed a significantly better improvement in the proportion of responders with at least a 50% reduction in migraine days and better MIDAS scores. The authors concluded that acupuncture is just as effective and has fewer side effects than many of the standard pharmaceutical agents.

Facco and colleagues conducted a study on 160 patients who suffered from migraine without aura to compare the treatment effect of true acupuncture, ritualized mock acupuncture, standard mock acupuncture, and rizatriptan (11). A total of 127 patients completed the study. The MIDAS Index significantly improved only in the true acupuncture group at 3- and 6-month follow-up compared to the only use of rizatriptan (P< 0.0001).

Acupuncture may be used as an adjunct to prophylactic drugs. Foroughipour’s group studied the benefit of adding acupuncture to 100 patients with migraine for whom prophylactic drugs had not produced a fall of at least 50% in the number of headache days (13). Patients received 12 sessions of either true or sham acupuncture treatment three times per week for 4 weeks. Compared to the baseline, there was a reduction in the number of attacks in both groups. However, adding true acupuncture to conventional prophylactic drugs did significantly better than adding sham acupuncture for the successive 4 months of follow-up (P< 0.001 at the end of each of the first 3 months and P = 0.001 the fourth month). Acupuncture may provide patients a positive outcome in terms of functionality and quality of life.

Vickers and colleagues studied 401 patients in a primary care setting, with predominantly migraine, who received acupuncture versus control intervention (usual care with no acupuncture) over 3 months (65). Headache score, Short-Form 36 (SF-36) health status, and use of medication were assessed at 3, 6, 9, and 12 months. Compared to the control group at 12 months, patients in the acupuncture group experienced less headache score (34% reduction from the baseline vs. 16% in control, P = 0.0002), 22 fewer days of headache per year (p = 0.003), improvement in physical role functioning (P = 0.036) and energy (P = 0.02) and change in health (P = 0.0004), and 15% less medication (P = 0.02).

Vijayalakshmi’s group studied 60 migraineurs over 30 days to compare acupuncture treatment to oral flunarizine along with paracetamol (66). The quality of life was assessed with the WHOQOL BREF (WHO Quality of Life Biomedical Research and Education Foundation) questionnaire, and the disability was assessed with the MIDAS (Migraine Disability Assessment) questionnaire. Both acupuncture and the drug study groups improved migraineurs’ life quality and disability; however, acupuncture did significantly better than the drug (P < 0.005).

In the meta-analysis of 15 randomized controlled trials involving 2545 participants to study the prevention of chronic migraine, acupuncture was found to effectively reduce the monthly headache days, which was better but not significantly superior over the prophylactic effect of botulinum neurotoxin A (BoNT-A) (86).

Four hundred and eighty migraineurs were recruited in China to study the cost-effectiveness ratio (expressed as cost per 1 day reduction of headache days from baseline to week 16) in terms of the choices of meridians and specific acupoints (05). Patients were assigned to the Shaoyang-specific acupoint group, Shaoyang-nonspecific acupoint group, Yangming-specific acupoint group, and sham nonacupoint group. Treating specific acupoints in Shaoyang meridians is more cost-effective than the other three groups (P < 0.05).

Supasiri and colleagues conducted a study to examine whether five sessions of acupuncture are non-inferior to 10 sessions for migraine treatment (57). Compared to baseline, both groups prevented migraine attacks, reduced the headache severity, and improved quality of life; however, there was no significant difference in the therapeutic benefits up to 1 month after the treatment.

The role for the use of acupuncture in menstrual migraine treatment is still unclear; a meta-analysis of 13 studies with 826 subjects failed to show that true acupuncture was superior to sham acupuncture in reducing monthly migraine frequency and duration, average headache intensity, and analgesic use after treatment or follow-up (75). Further research is needed for more supportive evidence before acupuncture can be recommended in the treatment of menstrual migraine.

Migraine patients, particularly chronic sufferers, often have associated emotional problems. In addition to migraine pain relief, acupuncture may also help to adjust the psychological status of the patients. Li and colleagues conducted a systemic review and meta-analysis to study the effects of acupuncture on the mental health of migraine patients. Thirteen randomized controlled trials, including 1766 migraine patients, were studied. During the 3- to 6-month follow-up, acupuncture was found to significantly improve anxiety (P=0.035), depression (P=0.048), short-form 36 mental health status (P=0.001), Visual Analogue Scale pain score (P=0.002), and migraine-specific quality of life (P< 0.001), when compared to sham acupuncture and western medicine (30).

Migraine is a risk factor for the development of subsequent stroke. The protective role of acupuncture in reducing stroke risk for migraine patients has been studied (32). For a follow-up of 19 years, acupuncture receivers had reduced the risk of stroke by 60% (adjusted hazard ratio 0.4, 95% confidence interval, 0.35-0.46), when compared with those who did not receive acupuncture. The cumulative incidence of stroke in acupuncture users was also significantly lower (P< 0.001).

Tension-type headache. The role of acupuncture in tension-type headache is unclear. A study in Cochrane Database of Systematic Reviews evaluated 12 trials with 2349 participants (35). Seven trials compared acupuncture with sham acupuncture, a small but significant reduction of headache frequency over sham over a period of 6 months. The benefits of acupuncture over sham acupuncture were also found for response, with 52% of responders in the acupuncture group versus 43% in the sham group, but no statistically significant difference was mentioned. A randomized, placebo-controlled, crossover-design study evaluated 18 patients and found that the acupuncture group had significantly more pain relief than the sham-needling group (18). White and colleagues completed a multicenter, randomized, controlled trial on 50 patients (70). The study found that patients in both the true and sham groups experienced a significant headache reduction during the course of treatment, but no significant difference existed between these two groups. A randomized, placebo-controlled study by Karst and colleagues found a significant but weak improvement in quality of life parameters (clinical global impressions, Nottingham Health Profile) after the true treatment group, but no significant difference between true and sham acupuncture in the reduction of headache severity and frequency, despite a 5-month follow-up (25). In a multicenter, sham-controlled, patient- and observer-blinded, randomized study on 407 patients, ten 30-minute sessions were given over a 6-week period (08). At the 6-month follow-up, 33% of patients who received true acupuncture achieved 50% or greater headache frequency reduction, compared to 27% in the sham group. The difference was insignificant (P=0.18); however, the reduction of headache days was significantly better in the real acupuncture group (P=0.004). A randomized, sham-controlled, crossover trial was conducted on 34 patients with chronic tension-type headache (03). The study found that electroacupuncture is superior to sham intervention by reducing 60% of head pain from the baseline versus 38% in the sham group (P=0.005) after 10 treatment sessions within 5 weeks. Electroacupuncture analgesia is associated with increased serum brain-derived neurotrophic factor, implying the involvement of central nervous system neuroplasticity.

Chronic headache. Sun and Gan conducted a systematic review of clinical trials from 1966 to 2007 to evaluate acupuncture for managing chronic headache (56). Thirty-one studies were reviewed, including migraine (n=17), tension-type headache (n=10), or mixed headache (n=4). Most included trials comparing true acupuncture and sham acupuncture showed a trend in favor of acupuncture. In 14 trials, the combined data demonstrated a statistically significant higher responder rate in the acupuncture group compared to the sham group (53% vs. 45%) during the period of 8 weeks to 3 months after the randomization. Pooled data from seven trials showed a 62% responder rate in the acupuncture group compared to 45% in the medication (propranolol, ergot, metoprolol, flunarizine, etc.) group during the same follow-up period; the difference was statically significant.

Cluster headache. Extremely little information is available on the effect of acupuncture on cluster headache. Gwan reported a single case relieved by acupuncture (17). In a small study, acupuncture significantly raised CSF metenkephalin levels but only improved symptoms in two of seven patients (19).

Other types of headache. In a controlled cross-over study of 41 patients with both migraine and tension headache, Loh and colleagues found more patients benefited from acupuncture than medication treatment (59% vs. 25%) (38). Acupuncture for frontal and orbital headache was also reported as helpful in noncontrolled studies (71; 33).

Adverse effects

In a survey of 78 acupuncturists involving 31,822 consultations, a total of 2178 adverse events or side effects for an incidence of 684 per 10,000 were reported (69). The most common side effects, including bleeding, needling pain, aggravation of symptoms, and aggravation followed by resolution of symptoms, were reported in 70% of the cases.

Melchart’s group conducted a prospective investigation of the adverse effects of acupuncture in 97,733 patients from July 2001 through April 2002, involving 9429 German physicians (40). The number of acupuncture treatment sessions exceeded 760,000. A total of 6936 mild adverse events (7.10%) were reported. The reported mild adverse events in the order of frequency were needling pain, hematoma, bleeding, orthostatic problems, forgotten needles, and others (local skin irritation, deterioration of symptoms, headache, and fatigue). Five serious adverse effects were noted in six patients. Two patients developed pneumothorax. The other four adverse effects reported were an exacerbation of depression, an acute hypertensive crisis, a vasovagal reaction, and an acute asthma attack with angina and hypertension. In another study of 1968 patients who received acupuncture treatment in clinical trials, 74 (3.76%) suffered at least one adverse event (85). The most common adverse events were subcutaneous hematoma and hemorrhage in the needling points. The older patients and male gender had a higher risk of the occurrence of adverse events.

Mild adverse effects generally will resolve within 1 to 2 days, with no specific care needed. Local compression to the acupoint immediately after the needle removal can reduce the risk of bleeding or hematoma. Pneumothorax is the most frequent serious complication in the category of organ trauma (09). The acupuncture practitioner should be very familiar with the chest wall and mid-back anatomy to avoid inserting the needle too deeply to puncture the lung. AIDS and hepatitis can also be transmitted (09); however, the use of one-time disposal needles in acupuncture treatment has significantly reduced the risk of cross-infection.

The long-term prognosis of acupuncture on headache is still under investigation. In Vincent’s study of patients with chronic migraine, a significant reduction of pain intensity and medication number was found immediately posttreatment compared to the sham group (67). The effect remained at follow-up of 4 months and 1 year. It is unclear whether the improvement remains significantly better than the sham group at the time of follow-up. Another randomized, placebo-controlled study of 30 patients with tension-type headache showed that acupuncture reduced the frequency of headaches, analgesic consumption, and the headache pain index at follow-up of 1 and 12 months, compared to baseline, but not compared with the sham group (61). Vickers’ study demonstrated continuing headache relief and functional and health status improvement at 12-month follow-up (65).

Special considerations

Pregnancy. Acupuncture can be used to treat nausea and vomiting in early pregnancy (26; 52) and is considered safe (53). There are few data regarding the safety of using acupuncture for headache in pregnant women. Acupuncture practitioners should know that certain acupoints, such as large intestine meridian 4 and spleen meridian 6, are contraindicated for pregnant women (20); large intestine meridian 4 and spleen meridian 6 are otherwise commonly used acupoints for headache management (38; 70; 02). These two points may be used to assist induction of labor at term and preparation of first-trimester abortion, probably due to the effect of supporting cervical ripening at term (47) and increasing cervical dilation in the first trimester (77). If an acupuncturist does not feel comfortable using acupuncture for pregnant patients, he or she may use other nonpharmacological treatment alternatives, such as relaxation techniques, biofeedback, and physical therapy. These modalities are considered safe and effective to treat headache in pregnant women (22; 50).

Anesthesia. Acupuncture analgesia has been proposed to mediate by the presynaptic inhibition of afferent pain transmission in the dorsal horn through the gate-control mechanism, release of beta-endorphin binding to the mu opioid receptor, and release of serum magnesium blocking the NMDA-receptor (45; 82). Two acupoints, large intestine meridian point 4 (Li 4) and lung point 7 (Lu 7), are often used in the acupoint selection to treat headache. Li 4 has long been documented in traditional Chinese acupuncture literature to relieve orofacial pain, and Lu 7 for head and neck pain.

Pediatric patients. The literature on acupuncture treatment in the pediatric population is limited, particularly high-quality randomized controlled trials. Gottschling and colleagues conducted a double-blind, randomized, bi-center, placebo-controlled trial to investigate the headache day change after receiving active laser acupuncture versus placebo laser acupuncture treatment (15). At 4 months after the randomization, the mean headache days per month decreased significantly by 6.4 days in the treated group (P < 0.001) and by 1.0 days in the placebo group (P = 0.22) compared to the baseline.

Geriatric patients. The age range of patients selected for the studies of acupuncture treatment for headache is typically wide, from young adult to elderly. Thus, there is insufficient evidence available for discussion.

Genetically vulnerable patients. After a careful MEDLINE search, there is no literature about acupuncture treatment of headache in genetically vulnerable patients available for discussion.

Patients with impaired renal function. After a careful MEDLINE search, there is no literature about acupuncture treatment of headache in patients with impaired renal function available for discussion.

Clinical vignette

Patient 1. A 47-year-old Caucasian man with a 10-year history of episodic migraine complained of recurrent bilateral throbbing headache in the temporal region. He used to suffer from three to five headache attacks per month. Each attack lasted 4 to 8 hours. The headache score was 6 to 8 on the 10-point VAS scale, with nausea, light, and noise hypersensitivity. No visual aura was reported before the headache onset. The headache was triggered by lack of sleep and stress and relieved by staying in the dark and quiet room. The International Headache Society diagnosis was episodic migraine without aura. The patient requested a trial of acupuncture for headache abortion. Inspection of the tongue revealed a deep red body with a thin yellow coating. In Chinese medicine, his headache history, symptoms, and signs are consistent with the diagnosis of a flare-up of liver fire and hyperactivity of liver (55). The treatment principle is to restore the balance of yin and yang by draining the excessive yang and supplementing the deficiency of yin. Using a draining technique, bilateral yang points extraordinary head and neck point 5 (EX-HN 5, Taiyang) at temporal regions were suppressed. Yin points to spleen meridian point 6 (SP 6) and liver meridian point 3 (Liv 3) were strengthened using the tonifying technique. An empirical point for headache and orofacial pain, large intestine meridian point 4 (Li 4), and several local tender points in the head were also drained. All the needles were manually twisted for 20 seconds, 5 minutes apart, and they remained in the body for 25 minutes. The patient reported significant headache relief after 5 minutes of needling and fell asleep afterward. He was headache-free at the end of the treatment session.

Patient 2. A 45-year-old Caucasian man presented to the headache center for a 20-year history of chronic tension-type headache. The pain was described as mild to moderate (visual analogue scale score 3 to 7) in severity, band-like, and pressing. The pain used to build up late in the day and was aggravated by stress. No nausea, vomiting, phonophobia, photophobia, or analgesic overuse was reported. Physical examination only revealed tenderness at bilateral temporal regions. The headache symptoms and tongue inspection (red and dry body with little coating) were consistent with a diagnosis of deficiency of “kidney essence” (Kidney yin deficiency) in Chinese medicine (55). The treatment principle was to rebalance the yin and yang. The yang points of EX-HN 3, bilateral EX-HN5, and LI4 were drained for the relatively excessive yang. Yin points of bilateral SP6 and KI 3 were tonified to supplement the yin and essence. During a retention time of 20 minutes, all the needles were either drained or tonified for 10 seconds, 5 minutes apart. The visual analogue scale score decreased from 4 to 1 after the treatment. After a total of eight sessions of acupuncture (two times per week), he was discharged from the clinic with a daily pain score of 0.

Patient 3. A 62-year-old Caucasian man with a 40-year history of episodic cluster headache presented to a headache center for recurrence. During the cycle, his headache started 1 hour after sleep, with each episode lasting 15 to 45 minutes. There were three to five episodes per day. Each cycle lasted 3 to 4 months. There were one to two cycles per year. During a recent cycle, he was treated with acupuncture two times per week for 10 sessions. He had no cluster attack following the second treatment session, even though he purposefully attempted to provoke an attack by drinking alcohol. He presented to the headache center again with recurrence of the headache 1 month after the last session of acupuncture treatment. His headache was building at the time of examination. His visual analogue scale score went up from 3 to 7 within 5 minutes, with a left-side red and watery eye and ptosis. A physical examination found painful spots at the left-side infraorbital region, lateral canthus, splenius capitis muscle, and semispinalis capitis muscle. The pain location and quality, and red tongue with yellowish coating were consistent with a diagnosis of hyperactivity of stomach fire (excessive yang of stomach) (55). The treatment principle was to rebalance the yin and yang. A draining technique was applied to the yang points of stomach meridian 2, bladder meridian 10, and gallbladder meridian 20, as well as the Ashi points at the orbital-frontal regions. The yin point spleen meridian 6 and kidney meridian 3 were tonified. Each point was manipulated for 10 to 20 seconds alternatively, and the pain score went down to 0 within 5 minutes of needling. The autonomic symptoms resolved at the same time. After two treatment sessions, the attack frequency remained the same but with a 50% reduction in attack intensity and duration. He requested resuming western medical therapy, despite the trend of improvement, due to financial concerns.

Scientific basis

Proposed mechanisms of acupuncture analgesic effect on the trigeminal nucleus caudalis. The trigeminal nucleus caudalis receives the central inhibitory modulation from many rostral structures, including the nucleus raphe magnus, periaqueductal gray area, rostral ventromedial medulla, insular cortex, hypothalamus, and somatosensory cortex (04). Most of the acupuncture studies regarding the effect on trigeminal nucleus caudalis have been completed in animal models. A PET-CT study was conducted on human subjects to investigate the brain metabolism change after acupuncture in patients with migraine (74). Higher brain mechanism was observed in the traditional acupuncture group in certain areas compared to the non-needling group. These areas included the middle temporal cortex, orbital frontal cortex, insula, middle frontal gyrus, angular gyrus, postcingulate cortex, and precuneus and middle cingulate cortex. In the control acupuncture group, the increase of metabolism was found in the middle temporal cortex, supratemporal gyrus, supramarginal gyrus, and middle cingulate cortex. The metabolism increase was correlated to the reduction of Visual Analog Scale (VAS) pain score in both groups. A randomized, controlled trial using functional MRI (fMRI) was conducted to study the effect of long-term acupuncture treatment on resting-state brain activity in migraine patients (84). A total of 80 migraineurs without aura were enrolled to receive either active acupoint acupuncture or inactive acupoint acupuncture treatment for 8 weeks. The active acupuncture points were those typically selected for migraine treatment, and inactive acupuncture points were those near the active acupuncture points but not typically used for migraine treatment. Twenty patients in each group were randomly selected for an fMRI scan at the end of baseline and at the end of 8 weeks of treatment. In this trial, the regional homogeneity (ReHo) approach of fMRI was used to investigate the blood oxygen level-dependent (BOLD) signals in the brains of patients with migraine during the resting state, which helped to understand the functional regulation in particular brain regions. After 8 weeks of treatment, both the active acupoint group and the inactive group showed a significant decrease in VAS pain score. The headache severity reduction in the active acupuncture group was significantly better than in the inactive group (P = 0.015). Moreover, in the active acupoint group, the decreased VAS score was significantly related to the increased average regional homogeneity values in the anterior cingulate cortex (ACC) and insula. In the inactive group, the decreased VAS score was only correlated to the increased average regional homogeneity values in the anterior cingulate cortex.

The mechanism of acupuncture on headache remains unclear, more studies are needed. Evidence derived from animal and human studies is listed below:

Suppressive effect of acupuncture on the trigeminal nucleus caudalis
	• Suppression of C-fos protein (measurement of increased neural activity) expression in the trigeminal nucleus caudalis (51).
	• Inhibition of evoked potential in trigeminal nucleus caudalis following tooth pulp stimulation (23; 42; 06). This inhibitory effect is antagonized by naloxone and methysergide, suggesting an effect through activation of the descending serotonergic systems linking up with the opioidergic systems (58).
	• Suppression of jaw opening reflex response to tooth pulp stimulation or direct stimulation of the trigeminal nucleus caudalis (62). The suppressive effect can be aborted by transection of the spinal trigeminal nucleus at the level of the obex (63).
Stimulation of structures with central inhibitory effect on trigeminal nucleus caudalis
	• Stimulation of C-fos protein expression in dorsal raphe nucleus, locus ceruleus, hypothalamus, thalamus, and rostral ventromedial medulla (88).
	• Increase or normalization of the decreased low-frequency fluctuation in the rostral ventromedial medulla (31).
	• Stimulation of the periaqueductal gray area (60).
	• Activation of the nucleus raphe magnus (37).
	• Activation of the secondary somatosensory cortex, which modulates nociceptive response in the trigeminal nucleus caudalis (48; 87).
	• Increase of metabolism in PET-CT (74) or fMRI blood oxygen level-dependent signal (84) in the insula cortex.
Acupuncture-stimulated neurochemical modulation of trigeminal nucleus caudalis function
	• Inhibition of stimulus-evoked substance P release in the trigeminal nucleus caudalis (79). This can be antagonized by naloxone and methysergide (58).
	• Modulation of trigeminal nucleus caudalis through the 5-HT1A suppressively and 5-HT3 receptors positively (59; 78).
	• Inhibition of trigeminal nucleus caudalis through modulation of opioidergic systems (58). The above scientific findings suggest that acupuncture’s suppressive effect on headache may be mediated by direct or indirect inhibition of the trigeminal nucleus caudalis.

Moreover, acupuncture lowered the serum nitric oxide level in patients with migraine (16). Nitric oxide may be linked to the pathogenesis of migraine (44).

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All contributors' financial relationships have been reviewed and mitigated to ensure that this and every other article is free from commercial bias.

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Chong-hao Zhao MD PhD

Dr. Zhao of the California Headache and Pain Center, Los Angeles, has no relevant financial relationships to disclose.
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Shuu-Jiun Wang MD

Dr. Wang of National Yang-Ming University and Taipei Veterans General Hospital has no relevant financial relationships to disclose.
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Mark J Stillman MD
Todd D Rozen MD

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Acupuncture in headache treatment

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Acupuncture in headache treatment

Introduction

Overview

Historical note and terminology

Clinical aspects

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Indications

Contraindications

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Adverse effects

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Acupuncture in headache treatment

Introduction

Overview

Historical note and terminology

Clinical aspects

Description

Indications

Contraindications

Outcomes

Adverse effects

Special considerations

Clinical vignette

Scientific basis

References

Contributors

Author

Editor

Former Authors

This is an article preview. Start a Free Account to access the full version.

Questions or Comment?

Also in This Category

Neurogenetics and genetic and genomic testing

Acute traumatic spinal cord injury

Tumors of the skull base

Primary headache associated with sexual activity

Toxic and nutritional deficiency optic neuropathies

Third nerve palsy

Nystagmus

Brain death/death by neurologic criteria

This is an article preview.
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to access the full version.