EVIDENCE SUMMARY: ACUPUNCTURE FOR MIGRAINE

Cochrane reviews are a specific type of systematic review, and two Cochrane reviews – one on acupuncture’s effectiveness for the prevention of tension-type headache (1), and another on acupuncture’s effectiveness for the prevention of episodic migraine (2), both concluded that acupuncture is effective for these conditions. It is worth noting that the effect of sham acupuncture was less than true acupuncture, but was still higher than one would expect. This is a very interesting topic itself, and the sham acupuncture used in many of the older trials, and some of the newer ones, is not actually inert, but can exert a physiological effect. A review published in 2014 on this topic (3) recommended that the use of skin-penetrating needles be avoided for sham acupuncture controls as they appear to have important physiologic activity. In order to combat this, special acupuncture needles have been developed which look like real needles, but are designed in such a way that they do not pierce the skin when used – there is a simple retraction mechanism in them.

A meta-analysis published in the Pain journal in 2017 (4), which looked at how long the effects of acupuncture persist over time, found that approximately 90% of the benefit of acupuncture relative to controls are sustained at 12 months.

There are many individual randomised controlled trials published on the effectiveness of acupuncture for migraine and headache. One which was published subsequent to those Cochrane reviews, appeared in the BMJ in 2020 (5). This was a multicentre, randomised clinical trial looking at 150 patients with episodic migraine without aura. This team called out two difficulties that have hampered acupuncture research in the past – firstly the issue of blinding – they included blinding assessment into their study, and secondly the use of a non-penetrating inert sham control to properly assess for placebo effects, which they accomplished with a specially designed retractable needle. Also noteworthy is a requirement for patients to be new to acupuncture treatment. The control group were managed in accordance with the migraine guidelines developed by the Canadian Headache Society Prophylactic Guidelines Development Group in 2012. This was also done for the two experimental groups. They taught patients about lifestyle factors that may contribute to an increased frequency of migraine, identifying migraine triggers through the keeping of a detailed diary, pain communication, sleep hygiene, and regular exercise. In case of severe pain diclofenac sodium enteric coated tablets were allowed as a rescue medication.

As an outcome of the trial, they found a significant reduction in key migraine outcomes for the real acupuncture treatment group, and the more rigorously conducted sham acupuncture group had a far smaller reduction. It seems likely that the additional measures taken for ensuring that the sham acupuncture was actually an inert intervention made quite a difference, even though there was no significant difference in the proportion of patients perceiving needle penetration between manual acupuncture and sham acupuncture groups – the patients couldn’t tell which group they were in.

Clinical Guidelines

Acupuncture is recommended as treatment for both chronic tension-type headaches and migraines under the UKs National Institute for Health and Care Excellence (NICE) guidelines (6)

German Migraine and Headache Society and the German Society of Neurology issued guidelines on treatment of migraine attacks and prevention of migraine (7), in which they state that there is evidence that acupuncture can be effective in treatment of acute migraine attacks. They cite a study done in Germany, comparing the efficacy of acupuncture with sumatriptan or placebo, and found that acupuncture and sumatriptan had a similar efficacy in the prevention of development to a severe attack and both were significantly superior to placebo. Sumatriptan was superior in the treatment of a migraine attack with severe headache. The same guidelines also recommend acupuncture for migraine during pregnancy, and also cites a Cochrane analysis which found acupuncture to be at least as effective as pharmaceutical prevention. That analysis found only minor differences between sham acupuncture and classical acupuncture, but this issue is relatively misunderstood.

 

Other

Johns Hopkins Medine lists acupuncture as being effective alone or when used with conventional therapies, to treat headache (8).

The Mayo Clinic lists acupuncture as a non-traditional therapy which may be helpful for chronic migraine and headache pain (9)

Conclusion

There is strong evidence that acupuncture is an effective treatment option for migraine and headache. This evidence is recognised by a number of highly regarded medical institutions, and has been incorporated into clinical guidelines in countries such as the UK and Germany.

Written By:
Seamus Fitzgerald

 

References:

 

  1. Linde K, Allais G, Brinkhaus B, Fei Y, Mehring M, Shin BC, Vickers A, White AR. Acupuncture for the prevention of tension-type headache. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD007587
  2. Linde K, Allais G, Brinkhaus B, Fei Y, Mehring M, Vertosick EA, Vickers A, White AR. Acupuncture for the prevention of episodic migraine. Cochrane Database of Systematic Reviews 2016, Issue 6. Art. No.: CD001218
  3. MacPherson H, Vertosick E, Lewith G, Linde K, Sherman KJ, Witt CM, Vickers AJ; Acupuncture Trialists’ Collaboration. Influence of control group on effect size in trials of acupuncture for chronic pain: a secondary analysis of an individual patient data meta-analysis. PLoS One. 2014 Apr 4;9(4):e93739
  4. MacPherson H, Vertosick EA, Foster NE, Lewith G, Linde K, Sherman KJ, Witt CM, Vickers AJ; Acupuncture Trialists’ Collaboration. The persistence of the effects of acupuncture after a course of treatment: a meta-analysis of patients with chronic pain. Pain. 2017 May;158(5):784-793.
  5.  Xu S, Yu L, Luo X, Wang M, Chen G, Zhang Q et al. Manual acupuncture versus sham acupuncture and usual care for prophylaxis of episodic migraine without aura: multicentre, randomised clinical trial BMJ 2020; 368 :m697
  6.  https://www.nice.org.uk/guidance/cg150/chapter/Recommendations#management-2
  7.  Diener H-C, Holle-Lee D, Nägel S, et al. Treatment of migraine attacks and prevention of migraine: Guidelines by the German Migraine and Headache Society and the German Society of Neurology. Clinical and Translational Neuroscience. 2019;3(1)
  8. https://www.hopkinsmedicine.org/health/wellness-and-prevention/acupuncture 

https://www.mayoclinic.org/diseases-conditions/migraine-headache/diagnosis-treatment/drc-20360207