Acupuncture for migraine and chronic headache
Dr Clare Thornley looks at the evidence-based studies investigating the effects of acupuncture on migraine and chronic tension-type headache
There is now compelling evidence that migraine and chronic tension-type headache — common conditions that are challenging to treat in general practice — respond to acupuncture.
Cochrane Reviews, now 4,000 in number, are internationally recognised as the highest standard in evidence-based healthcare. The first Cochrane Review on acupuncture for idiopathic headache appeared in 2001 and was tentatively positive. Since then, a number of large, randomised, controlled acupuncture trials have been published.
In 2008, the Cochrane Review was updated and split into two separate reviews: acupuncture for migraine prophylaxis and acupuncture for tension-type headache. The results of these are recorded in the Cochrane Database of Systematic Reviews, with the authors concluding that acupuncture should be considered a treatment option for both these conditions.
This article looks at the evidence contained in the two Cochrane Reviews on acupuncture for migraine and chronic headache, and examines the contentious matter of placebo controls in acupuncture trials.
The size of the problem
- Migraine
Migraine affects around 15-20 per cent of the adult population, with a female-to-male ratio of two to one. In addition, 10 per cent of children are affected, with equal prevalence in boys and girls. Despite suffering on average 13, often debilitating, attacks a year, fewer than half of migraineurs are receiving any treatment.
Prophylaxis is not always required if migraine attacks are infrequent, and identifying and avoiding triggers can sometimes reduce the frequency or severity of episodes. However, for those whose migraines are severe enough to require prophylaxis, medication is usually the next step.
Beta-blockers may be particularly useful when the migraineur also has hypertension, but contraindications such as asthma, depression and peripheral vascular disease limit their use. The side-effect profiles of treatments such as amitriptyline and topiramate are not insignificant, whilst pizotifen is of doubtful efficacy. Triptans, although often dramatically beneficial in acute migraine, do not appear to alter the frequency of attacks in the long term, and overuse can result in worsening headaches.
- Chronic headache
Tension-type headaches are very common, usually episodic, and of mild-to-moderate intensity. Most respond to simple over-the-counter analgesics. However, around 3 per cent of women and 1.5 per cent of men experience this type of headache on at least 15 days a month, which fulfils the International Headache Society diagnostic criteria for chronic daily headache – a significant cause of work absenteeism.
After clear-cut aetiology (e.g. analgesic overuse) has been identified and been dealt with, chronic daily headache remains one of the most challenging common conditions to treat in general practice.
Guidelines recommend antidepressants such as ami-triptyline for chronic tension-type headaches. However, these are often unacceptable to, and poorly tolerated by, patients.
Controlled acupuncture trials
In acupuncture trials, true acupuncture (also known as verum acupuncture) is usually compared with one or more of the following:
- standard drug treatment;
- standard non-drug treatment;
- routine care/waiting list (typically receiving acute treatment only);
- a ‘sham’ acupuncture technique. Also sometimes called ‘fake’ acupuncture, sham techniques usually involve placing needles in non-traditional areas and/or inserting them more superficially than in normal practice.
Verum acupuncture points are usually standardised to some degree for trials, as are the frequency of treatment and number of sessions. This is a somewhat artificial approach, as these could vary considerably in real-life practice. Most trials consist of around 10-15 sessions of treatment once or twice weekly.
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