Chinese investigators performed a well-designed, randomized trial to investigate the efficacy of true Chinese acupuncture compared with two different sham acupuncture approaches for the treatment of acute migraine attacks. Real acupuncture was superior to sham acupuncture, but the absolute pain relief was minimal.
Migraine is a frequent and disabling episodic headache with autonomic disturbances. Migraine attacks are usually treated with antiemetics followed by either analgesics or specific migraine drugs such as ergots or triptans.1 Acupuncture has a long tradition in Asian countries for the treatment of many pain conditions, including headache. Acupuncture is also becoming increasingly popular in Western countries, and most patients attending migraine clinics report that they have had experience with acupuncture. To date, most trials that used acupuncture in migraine or tension-type headache were performed for the preventive treatment of headache attacks; for example, to achieve a reduction in the frequency and severity of migraine attacks.2 A review of the existing literature concluded that a 6-week course of acupuncture was not inferior to a 6-month prophylactic drug treatment, but that specific Chinese point selection, point stimulation and needling depth were not as important as was traditionally thought.2 A study by Li et al., published in Headache, addresses another issue, namely, the use of Chinese acupuncture to treat acute migraine attacks.3
This well-designed trial allocated 175 patients with migraine randomly to three groups: the verum acupuncture group received Chinese acupuncture ('true' acupuncture), sham acupuncture group 1 was treated with acupuncture needles placed halfway between traditional acupuncture points, and sham acupuncture group 2 was treated with acupuncture needles placed outside the head region. The team used a proper power calculation and had adequate statistics, including correction for multiple comparisons. The primary end point was headache intensity on a visual analogue scale (VAS) ranging from 0 (no pain) to 10 (very severe pain) at four time points (0.5, 1, 2 and 4 hours). After 4 hours, the investigators found a significant difference between true and sham acupuncture with respect to changes in VAS scores from baseline (P = 0.007). The findings were in favor of true acupuncture. Additional differences were observed for pain relief and headache recurrence. The authors concluded that true acupuncture has specific physiological effects that distinguish genuine acupoints from non-acupoints.
Despite these seemingly positive results, the study by Li et al. has several shortcomings and strange observations. In a table, the authors summarize the baseline characteristics of the treated migraine attack in the study. According to this table, 37.9–50.8% of the patients had no accompanying symptoms, such as nausea, vomiting, or sensitivity to sound and light. According to the classification of the International Headache Society, the presence of autonomic symptoms is required to make a diagnosis of migraine.4 A reasonable interpretation, therefore, would be that up to half of the patients did not actually have a migraine attack. This idea is supported by the mean VAS score of headache intensity at baseline, which was 5.0 (range 4.0–5.8). Scores in this range reflect moderate headache intensity, whereas at least 50% of patients with migraine usually report severe headache during a migraine attack. In addition, the clinical relevance of a 1-point reduction in headache intensity after several hours—as was reported for the patients in the study who received true acupuncture—is debatable. Several years ago, my group performed a placebo-controlled trial of two analgesics, in various combinations with one another and with caffeine, for the treatment of migraine and tension-type headache in patients who usually treated their migraines with over-the-counter medication.5 We also used a VAS, and we observed a 2.2-point improvement in headache intensity with placebo after 2 hours. By contrast, the combination of aspirin, paracetamol and caffeine achieved a 4.5-point improvement in headache after 2 hours.6 The treatment effect in the Li et al. acupuncture study was, therefore, smaller than the placebo response in a trial investigating analgesics.
Two previous large-scale, randomized trials showed that real and sham acupuncture were equally effective for migraine prophylaxis.7, 8 Li et al., on the other hand, seem to show that real acupuncture is superior to sham acupuncture for the treatment of acute migraine. Whether these results indicate that real acupuncture has specific physiological effects, however, is open to question. One probable confounding factor in the trial was an 'unblinding' effect. The authors state that acupuncture of real acupuncture points elicits a feeling of 'de qi', which is not perceived when nonspecific acupuncture points are stimulated. In a Chinese population of patients, one can safely assume that participation in this trial was not the first and only exposure to acupuncture in many cases. Patients might, therefore, have experienced de qi before, and would consequently be able to deduce to which treatment group they had been assigned.
Finally, even if acupuncture is able to influence migraine headache, application of the procedure in daily life would be impractical. The idea of patients leaving the workplace with a mild headache to see a person performing acupuncture is difficult to conceive. In practical and scientific terms, analgesics and triptans are, in my opinion, still a better choice to treat migraine attacks in any situation.
Competing interests statement
The author declares competing interests.
Top of pageReferences
Evers, S. et al. EFNS guideline on the drug treatment of migraine—report of an EFNS task force. Eur. J. Neurol. 13, 560–572 (2006).
ArticlePubMedChemPortEndres, H. G., Diener, H. C. & Molsberger, A. Role of acupuncture in the treatment of migraine. Expert Rev. Neurotherapeutics 7, 1121–1134 (2007).
ArticleLi, Y. et al. Acupuncture for treating acute attacks of migraine: a randomized controlled trial. Headache 49, 805–816 (2009).
ArticlePubMedOlesen, J. et al. The International Classification of Headache Disorders. 2nd Edition. Cephalalgia 24 (Suppl. 1), 1–160 (2004).
ArticleISIDiener, H. C., Pfaffenrath, V., Pageler, L., Peil, H. & Aicher, B. The fixed combination of acetylsalicylic acid, paracetamol and caffeine is more effective than single substances and dual combination for the treatment of headache: a multicentre, randomized, double-blind, single-dose, placebo-controlled parallel group study. Cephalalgia 25, 776–787 (2005).
ArticlePubMedChemPortPageler, L., Diener, H. C., Pfaffenrath, V., Peil, H. & Aicher, B. Clinical relevance of efficacy end points in OTC trials based on the patients global efficacy assessment. J. Headache Pain (in press).
Linde, K. et al. Acupuncture for patients with migraine: a randomized controlled trial. JAMA 293, 2118–2125 (2005).
ArticlePubMedChemPortDiener, H. C. et al. Efficacy of acupuncture for the prophylaxis of migraine: a multicentre randomised controlled clinical trial. Lancet Neurol. 5, 310–316 (2006).
ArticlePubMedTop of pageAuthor affiliations
Department of Neurology and Headache Center, University Hospital Essen, Essen, Germany.
Correspondence to: H -C. Diener, Department of Neurology and Headache Center, University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany