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By Alan D. Forker, MD, FACC
Although acupuncture can be traced back at least 2,000 years in China, only since James Reston visited China in 1971 and wrote about his post-surgical acupuncture experience in the American press did Western clinicians become more aware of acupuncture. However, many doctors consider acupuncture a placebo, primarily because of no access to reliable data.
English texts on acupuncture now are available,1,2 and there has been an explosion of published reports in the literature, though many trials are uncontrolled and the number of patients studied with adequate controls is small. A boost to clinicians’ interest occurred with publication of the NIH Consensus Development Conference on Acupuncture in 19983 and Eisenberg et al survey data.4
TCM Acupuncture vs. Western Adaptation
For the traditional Chinese practitioner, acupuncture is part of the therapeutic package. Understanding the flow of energy or qi (chee) through meridians, the balance of yin and yang, the diagnosis of diseases by a multitude of tongue abnormalities and palpation of the peripheral pulse (18 tongue findings and 29 types of pulse for starters2), and the treatment acupoints all over the body challenge the non-TCM trained practitioner in more ways than one. For instance, 10 different patients with migraine headache might be treated in 10 different ways by TCM.1 The goal in migraine TCM treatment is "keeping a clear head, so lucid yang can ascend and turbid yin descend."5
It would help our Western understanding if anatomic/physiologic demonstrations of qi, meridians, and acupoints were possible; and some valid research is starting to appear.6
Mechanism of Action
Acupuncture owes some of its recent respectability to the discovery of the release of opioid peptides, such as beta-endorphins, met-enkephalin, substance P, plus noradrenaline and 5-hydroxytryptamine.1 Plausible additional mechanisms of action are needed since opioid release may not explain potential long-term benefits such as psychoneuroimmune modulation, altered autonomic tone, and muscle relaxation and decreased emotional stress.
Pathophysiology of Migraine
The pathophysiology and etiology of migraine headaches are still unknown. In addition, the current pharmacologic therapy of migraine is complex and difficult to understand. This leaves plenty of room for patients to utilize complementary therapies, including acupuncture, chiropractic, and relaxation, the latter two of which are more common than acupuncture for treating headaches.4 (See Table 1 for Acupuncture Procedures.)
|Table 1: Types of acupuncture procedures|
|1.||Classical traditional Chinese medicine or "different strokes for different folks"|
|2.||Scientific, Westernized or formula: more of a cookbook approach with a routine set of acupoints|
|3.||Focus on trigger points, especially in the head and the neck region for migraine headache|
|4.||With or without mechanical, electrical, or thermal (moxibustion) needle stimulation|
|Adapted from: Filshie J, White A. Medical Acupuncture: A Western Scientific Approach.
Edinburgh: Churchill Livingstone; 1998.
Searches of MEDLINE, PubMed (only English), the Cochrane Library, and Best Evidence on the web yielded few high-quality clinical trial data. Literature and pain meta-analysis reviews also emphasize that point.7-11 The meta-analyses made the following conclusions:
• Most acupuncture results utilizing an adequate placebo control are equivocal.
• The majority of studies in the treatment of pain and migraine are methodologically poor.
• Necessary improvements include longer studies with more patients, better statistics with power calculations, independent assessment of outcomes needed, adequate control group, standardization of acupuncture techniques, description of therapists’ training and experience, and cost-effectiveness analysis.
Headache is particularly responsive to placebo therapy. For example, Xiuying et al treated 100 patients with "intractable migraine": 94% were improved and 57% cured. However, no control group was utilized and no description of methods for evaluation was given.5
Quality sources evaluating acupuncture for migraine all come back to the same four articles, which include a total of 211 patients.12-15 Two of these studies used a beta-blocker comparison plus trigger point stimulation primarily.12,15 Although both studies compared with a beta-blocker achieved greater benefit with acupuncture, again acceptable controls were not present. In one trial, Hesse et al created a placebo control as "touched superficially with a blunt end" of the needle.15
Three choices for an acceptable control are mock transcutaneous electrical nerve stimulation (TENS), sham acupuncture, and minimal acupuncture.1 However, mock TENS does not mimic needle insertion accurately. Instead it involves placement of patches and then showing patients the equipment although no current is given. Dowson et al used mock TENS in 48 patients and found no difference from classical acupuncture.13 Theoretically, mock TENS could be used in patients with head and neck pain, especially with trigger points, if the practitioner performed blind credibility testing that the patients found to be reliable.
The difference between sham and true acupuncture is that the sham acupoint is located approximately one inch away from the true acupoint, but depth and stimulation remain the same. None of the migraine trials utilized this description of sham acupuncture. Even if utilized, it may not be a good placebo, as it has a strong possibility of diffuse noxious inhibitory control like TENS.1
Minimal acupuncture involves a shallow insertion (approximately 2 mm) with very slight stimulation, usually located away from the typical acupoint. This appears to be the best placebo, and the only quality article in the literature utilized it.
Vincent, a London neurologist, recruited 30 migraine patients and utilized weekly TCM acupoints compared with minimal acupuncture.14 No baseline data were provided. Interestingly, the author says "classical TCM acupoint locations were used, although I do not believe they are essential for a therapeutic effect." Vincent predominately treated acupoints in the head and shoulder area. Weekly headache pain score decreased 43% at four months and 38% at one year in the acupuncture group; this was statistically significant compared to the minimal acupuncture group. In addition, the control patients were tested with a four-question credibility scale with the conclusion that minimal acupuncture was equally credible as true acupuncture.1 No other trial reproduces these results utilizing these techniques.
Norheim described 78 reports of adverse effects from MEDLINE between 1981 and 1994.16 Most serious adverse events arise because of incorrect treatment in sensitive treatment locations (i.e., chest wall and ear), lack of sterility and disposable needles, and inadequate training. Twenty-three patients had a pneumothorax with chest wall acupuncture including one death in a chronic obstructive pulmonary disease patient with bilateral treatment. This can be avoided by not utilizing chest acupoints and by using less depth in puncture. In addition, 100 cases of hepatitis, 16 cases of auricular chondritis (two with necrosis and ear deformity), and one death in an asthmatic have been reported. Few of these reports describe technique, type of acupuncture, or education of the therapist.
Current Western Guidelines
The Canadian Headache Society Consensus Conference in 1995 concluded that biofeedback, relaxation therapy, cognitive-behavioral therapy, and chiropractic cervical manipulation may be of some value in migraine but that a "lack of firm evidence" was available for acupuncture.17
The NIH Consensus Conference in 1997 concluded there were "promising results" of acupuncture in adult postoperative and chemotherapy-induced nausea and vomiting and in postoperative dental pain. Acupuncture "may be useful" in migraine headache as an adjunct or alternative in a comprehensive management program.3
In 2000, the British Medical Association concluded that studies "suggest" acupuncture is more effective than controls for low back pain, dental pain, nausea and vomiting especially in postoperative adults, and migraine. Acupuncture has not been subject to a formal audit in the United Kingdom, and the National Institute of Clinical Excellence was established to evaluate and produce guidelines.18
Licensure and Regulation
Thirty-three states and the District of Columbia had acupuncture certification or licensure in 1999; acupuncture is recognized as within the scope of practice for physicians in 42 states and the District of Columbia.19 Seventy-nine percent of general practitioners in the United Kingdom would like to see acupuncture provided by the National Health Service.18
It is uncertain whether acupuncture has a valid role in the treatment of migraine headache. At this point only one trial of 30 patients, utilizing minimal acupuncture as placebo, supports its use.
I currently would recommend the following approach in treatment of migraine headache: First, identify and avoid emotional and environmental triggers; second, try a 5-HT receptor agonist; third, consider riboflavin, and/or feverfew, and/or a beta blocker; fourth, add biofeedback, and/or relaxation, and/or massage therapy; and fifth, if nothing else works or excessive side effects occur with the above, then try acupuncture.
Dr. Forker is Professor of Medicine, University of Missouri-Kansas City School of Medicine and Clinician-Educator at Mid America Heart Institute of Saint Luke’s Hospital in Kansas City.
1. Filshie J, White A. Medical Acupuncture: A Western Scientific Approach. Edinburgh: Churchill Livingstone; 1998.
2. Birch S, Felt R. Understanding Acupuncture. Edinburgh: Churchill Livingstone; 1999.
3. NIH Consensus Conference. Acupuncture. JAMA 1998;280:1518-1524.
4. Eisenberg DM, et al. Trends in alternative medicine use in the United States, 1990-1997: Results of a follow-up national survey. JAMA 1998;280:1569-1575.
5. Duo X. 100 cases of intractable migraine treated by acupuncture and cupping. J Tradit Chin Med 1999;19:205-206.
6. Cho ZH, et al. New findings of the correlation between acupoints and corresponding brain cortices using functional MRI. Proc Nat Acad Sci USA 1998;95: 2670-2673.
7. Richardson PH, Vincent CA. Acupuncture for treatment of pain: A review of evaluative research. Pain 1986;24:15-40.
8. Patel M, et al. A meta-analysis of acupuncture for chronic pain. Int J Epidemiol 1989;18:900-906.
9. ter Riet G, et al. Acupuncture and chronic pain: A criteria-based meta-analysis. J Clin Epidemiol 1990;43:1191-1199.
10. Tang JL, et al. Review of randomized controlled trials of traditional Chinese medicine. BMJ 1999;319:160-161.
11. Melchart D, et al. Acupuncture for recurrent headaches: A systematic review of randomized controlled trials. Cephalalgia 1999;19:779-786.
12. Loh L, et al. Acupuncture versus medical treatment for migraine and muscle tension headaches. J Neurol Neurosurg Psychiatry 1984;47:333-337.
13. Dowson DI, et al. The effects of acupuncture versus placebo in the treatment of headache. Pain 1985;21: 35-42.
14. Vincent CA. A controlled trial of the treatment migraine by acupuncture. Clin J Pain 1989;5:305-312.
15. Hesse J, et al. Acupuncture versus metoprolol in migraine prophylaxis: A randomized trial of trigger point inactivation. J Intern Med 1994;235:451-456.
16. Norheim AJ. Adverse effects of acupuncture: A study of the literature for years 1981-1994. J Altern Complement Med 1996;2:291-297.
17. Pryse-Phillips WE, et al. Guidelines for the nonpharmacologic management of migraine in clinical practice. CMAJ 1998;159:47-54.
18. Leake B, Broderick J. Current licensure for acupuncture in the United States. Altern Ther Health Med 1999;5:94-96.
19. British Medical Association. BMA Board of Science. Acupuncture: Efficiency, Safety, and Practice. 2000. London: Harwood Academic; 2000.