acupuncture for Headache

Approximately forty-five million Americans suffer from chronic headache pain, with women afflicted three times more than men. Doctors have identified about a dozen major varieties of headache and at least sixty subtypes, including tension headache, migraine, and hunger headache. Scientists have started to piece together the mechanisms that bring on headaches, which arise from a complicated stew of chemical and neurological activity. And treatments for them continue to improve."

Triptans and Migraines
How have triptans changed the treatment of migraine headaches?

Medication and Rebound Headaches
How can medication lead to "rebound" headaches?

A: The role of individual triggers in bringing on a headache depends in part on the type of headache. The infamous triggers that you may have heard about, like alcohol or chocolate, are probably much less to blame for tension headaches than emotional stress or depression. When depression is fueling a headache, the pain may appear soon after waking.

"The science behind studies of food triggers is very poor. Most of the evidence is anecdotal—it's hard to double-blind red wine," says Dr. Elizabeth Loder, Director of the Headache Management Program at Spaulding Rehabilitation Hospital in Boston, referring to the standard study protocol in which both the patient and doctor are in the dark about who is getting the substance being tested and who is getting the placebo.

"Some patients do have food triggers, but they're very individual. Alcohol is definitely a vasodilator, but the evidence on dairy products is uncertain. Same with fruits. I resist giving patients lists of foods to avoid because they can become neurotic about their eating and lose an important pleasure. I suggest that patients eliminate one food at a time for a week or two, then slowly reintroduce them and notice any effects," says Dr. Loder.

The story is somewhat different for migraine headaches. Individual triggers such as food, stimuli, environmental changes, and personal chemistry are a central cog in the migraine machinery. Researchers are certain that triggers can launch a migraine and suspect they can be influential in starting other types of headaches too.

Scientists at the National Institute of Neurological Disorders and Stroke say about triggers: "It's like a cocked gun with a hair trigger. A person is born with a potential for migraine and the headache is triggered by things that are really not so terrible."

Triggers vary from person to person and there are dozens of suspect substances and events, so each headache patient has to discover on her own what sets off the pain. Lists of likely triggers often start with foods or drinks. The most often mentioned are alcoholic drinks, chocolate, aged cheese, the flavor-enhancer monosodium glutamate (MSG), the artificial sweetener aspartame, caffeine, nuts, and nitrites and nitrates, the chemical preservatives found in meats like baloney and salami.

A change in your habits or environment can set off a migraine. Fluctuations in weather, seasons, altitude, sleeping habits, physical activity, mealtimes, time zones and personal schedules have all been implicated. Also, changes in personal habits or patterns, intense activity or a quick drop-off in activity, moving, a dramatic change in your job, or a personal crisis can set off a migraine. Changing levels of hormones, especially among women, may also precipitate a migraine attack.

Q: How have the new generation of drugs called "triptans" changed the treatment of migraines?

A: The new class of drugs, called triptans, came on the market in the early 1990s and has been a huge relief for migraine headache sufferers. Second generation triptans, which may be even more useful, are now available as well.

These drugs were developed as researchers learned more about the chemistry of migraines. For years, doctors believed that migraines were caused largely by pressure on nerves from dilated blood vessels. Until recently, the leading drugs to fight these headaches were ergotamines (brand names Cafergot, Wigraine) or an injectable drug, dihydroergotamine mesylate (DHE). These drugs caused blood vessels to constrict.

But as scientists refined scanning and imaging tools and delved into genetic research, they downgraded the "vascular theory" from main culprit to an accomplice and identified other sources. They figured something was setting off a chemical or electrical chain reaction affecting blood vessels and head muscles as well as the flow of powerful neurochemicals. When researchers confirmed that the neurotransmitter serotonin was mixed up in the migraine stew, pharmacologists proceeded to create a drug to interact with serotonin and hinder the migraine chemistry. The first of this new group of drugs was sumatriptan (brand name Imitrex).

The development of sumatriptan also helped to fuel further research. "The new drug sumatriptan changed the ways doctors think about migraines," says Dr. Elizabeth Loder, Director of the Headache Management Program at Spaulding Rehabilitation Hospital in Boston. "They became a real medical condition that could be treated, not just a woman's problem."

The pharmacology of headache treatments has been gaining steady momentum since the development of triptans. Sumatriptan and other first generation drugs are not only fast-acting (halting migraine pain within twenty minutes), but also combat accompanying symptoms like nausea, vomiting, and light sensitivity. The side effects are usually minimal (although not in everyone) — mainly dizziness, tingling, a warm sensation, and a light feeling of pressure in the chest. This may be why these drugs are not advised for people with heart problems or high blood pressure.

Since sumatriptan (Imitrex) came out, other even more advanced varieties of triptans have come on the market. Zolmitriptan (Zomig), naratriptan (Amerge) and rizatriptan (Maxalt) are now available in the United States and manufacturers have devised pill and nasal forms of these drugs.

The new generation of triptans are special because they are like a bouncer in a rough bar. When a fight or headache breaks out, they are there to halt further hostilities. Unlike many migraine medications that work only if they are taken when early signs appear, these new generation drugs can stop a fully launched headache cold. Even though they come only in tablets, their effects may last longer than sumatriptan.

This new generation of drugs also helps reduce nausea and a patient's sensitivity to light and sound, all without sedation. They do not work for everyone, but for some people they are a miracle. The newcomer, rizatriptan (Maxalt), has an ingenious delivery system. It is available in wafer form and dissolves on the tongue within seconds. This is particularly helpful to migraine sufferers who may not have a glass of water handy.

A: Many people probably have rebound headaches and don't know it. A rebound headache is the direct result of medication used to treat the headache symptoms. It is a cruel twist of fate that this headache is the direct result of taking too much headache medication.

The rebound headache is the offspring of painkillers, like barbiturates, opioids, or over-the-counter analgesics, to which a patient becomes physically dependent. Another common factor in these headaches is some form of caffeine; whether it is drinking multiple cups of coffee a day or a soft drink loaded with caffeine all afternoon, every afternoon. Many of is know the headache that can arise if we miss out on our daily dose of high-octane coffee.

Often, rebound headaches afflict someone who is taking regular medication for migraines or tension headaches. The headache sufferer becomes trapped in a cycle of daily pain pills for his headache. After a few weeks or months of steady consumption of the medication, the body grows dependent on the physiological effects it produces.

In just three weeks, you can become dependent enough on medication to feel a rebound headache when you stop the medication. Thus, when the pain reliever wears off, the headache returns and more medication is needed to quiet it. Any pain reliever taken more than once a week, whether it is generic aspirin or heavy-duty opioids, has the potential to bring on a rebound effect.

Rebound headaches are treatable but have to be recognized as such. In my book, The War on Pain, I tell the story of a patient suffering from tension headaches, as well as sleeping problems and depression. She was seeing a couple of doctors and her list of medications included blood pressure medication, asthma medication, an antidepressant, estrogen, Tylenol with codeine, Fioricet, and St. John's Wort. Despite all the drugs she was taking, her headaches were growing worse and her headache physician concluded that the drugs were as much at fault as her medical conditions.

As months passed, she was taking more and more Fioricet with codeine, which is a combination of a barbiturate, caffeine, acetaminophen, and an opioid. Her body had become tolerant to these drugs and as they wore off, the headache returned and demanded a larger dose to quell it.

Her problem was probably compounded by multiple medications overlapping in their effects. Her headache doctor treated the problem by gradually reducing the doses she was taking (as well as the number of drugs) and by prescribing less transient, longer acting drugs.

A: While it is true that women get more headaches than men, the usual explanation that they are caused by hormones does not answer the question. Men have hormones too (even a little estrogen in their systems) and women have a touch of the male hormone testosterone. So the hormone answer does not fill in all the blanks.

However, the fact that women have more headaches has for years stirred research into causes and new treatments. For a long time, scientists and researchers ignored headaches as a legitimate subject of study. They were dismissed as a "woman's problem" and so relegated to the realm of a psychological disturbance. The discovery of a new class of headache drugs, the triptans, which work on brain chemistry, has helped to push headache research into mainstream science.

"The new drug sumatriptan changed the way doctors think about migraines," says Dr. Elizabeth Loder, Director of the Headache Management Program at Spaulding Rehabilitation Hospital in Boston. "They became a real medical condition that could be treated, not just a woman's problem."

That said, there is such a creature known as a hormonal headache that strikes women. I tell the story in The War on Pain about a woman in her forties who had been having migraines since the age of five. During her childhood, they were limited to about two a year. She was able to eliminate more attacks by identifying and avoiding her personal headache triggers: bright sun, loud noise, exercise, and aged cheese.

During her twenties, thirties and early forties, the headaches came more often and more severely. The woman also found that her grandmother, mother, and aunt had suffered the same headache history. They finally disappeared when the women reached menopause.

During her peak headache years, this woman tried an assortment of treatments: biofeedback, intensive group therapy, acupuncture, stress reduction, the herb feverfew, as well as various drugs. Her headache specialist, Dr. Zahid Bajwa, Director of the Headache Center at the Beth Israel Deaconess Hospital in Boston, devised a two-pronged treatment focused on prevention and cutting off headaches when they flared up.

He started her on the antidepressant amitriptyline (brand name Elavil), not because he thought she was depressed, but because the drug alters the activity in brain chemicals that play a part in migraines.

For prevention, he prescribed another medication, and for sudden pain, he gave her the new-generation triptan, Maxalt. Despite all the treatments available, Dr. Bajwa said that true relief may only come with age and menopause.

Acupuncture for Headaches and Head Pain

Simply defined, a headache is a pain in the head due to some cause. Headaches may result from any number of factors, including tension; muscle contraction; vascular problems; withdrawal from certain medications; abscesses; or injury.

Headaches fall into three main categories: tension-type, migraine and cervicogenic. Tension-type headaches are the most frequent. Patients who endure tension-type headaches usually feel mild to moderate pain on both sides of the head. The pain is usually described as tight, stiff or constricting, as if something is being wrapped around your head and squeezed tightly.

While migraines affect far fewer people than tension-type headaches and have a much shorter duration, their symptoms are much more severe. They typically affect women more frequently than men, with pain that usually occurs on one side of the head. Migraines can be so severe that they can cause loss of appetite, blurred vision, nausea and even vomiting.

Cervicogenic headaches are the most recently diagnosed type of headache and are musculoskeletal in nature. They may be caused by pain in the neck or spine that is transferred to the head. Many times, cervicogenic headaches go undiagnosed because of their recent classification.

Nearly everyone will suffer a headache at some point in time. They are one of the most common physical complaints that prompt people to treat themselves or seek professional assistance. Some estimates say that up to 50 million Americans suffer from sever, long-lasting, recurring headaches. While most headaches are not necessarily symptomatic of another condition, they can be very distracting and account for significant amounts of time lost from work.

Traditional Chinese medicine (TCM) has a very consistent and philosophically-based framework for headache etiology, physiology, diagnosis and treatment strategy. Acupuncture, as an effective treatment modality, has been applied to headaches from the earliest beginnings of TCM.

Acupuncture is not only effective for migraine headaches, but also works very well with tension headaches, cluster headaches, post-traumatic headaches, and disease-related headaches that might be due to sinus problems, high blood pressure or sleeping disorders. The greatest advantage of acupuncture over Western medicine is that it does virtually no harm. Some medications can have serious side effects and can (in some instances) actually lead to patients experiencing a "rebound" headache. Unlike synthetic drugs, acupuncture has virtually no side effects, and the procedures for treating headaches are much less invasive with acupuncture than with surgery.

References

Carlsson J, Fahlcrantz A, Augustinsson LE. Muscle tenderness in tension headache treated with acupuncture or physiotherapy. Cephalalgia 1990;10:131-141.
Hesse J, Mogelvang B, Simonsen H. Acupuncture versus metoprolol in migraine prophylaxis: a randomized trial of trigger point inactivation. J Internal Med 1994;235:451-456.
Vincent CA. A controlled trial of the treatment of migraine by acupuncture. Clin J Pain 1989;5:305-312.
Vincent CA. The treatment of tension headache by acupuncture: a controlled single-case design with time series analysis. J Psychosomatic Res 1990;34:553-561.
Zhang L, Li L. 202 cases of headache treated with electroacupuncture. J Tradit Chin Med 1995;15(2):124-126.

Clinical bottom line: There is no evidence from high quality trials that acupuncture is effective for the treatment of migraine and other forms of headache. The trials showing a significant benefit of acupuncture were of dubious methodological quality. Overall, the trials were of poor methodological quality.

Recurrent headaches are a major source of morbidity and represent a significant economic burden. Acupuncture is widely used for the treatment of headache.

Melchart, D.; Linde, K., and Fischer, P. et al. Acupuncture for recurrent headaches: a systematic review of randomized controlled trials. Cephalalgia. 1999; 19(9):779-86.

Main outcomes: clinical outcomes related to headache (pain intensity, frequency, global assessment etc.)

Inclusion criteria were randomised or quasi-randomised trials; migraine, tension or cluster headache; acupuncture needles inserted at pain, trigger or traditional points with manual, electo- or laser stimulation; treatment phase greater than four weeks; published and unpublished trials.

Reviewers conducted comprehensive searches including the main databases and references of retrieved reports. Methodological quality of trials were assessed using the Oxford rating scale, maximum score is five (Jadad et al., 1996). A second methodological quality scoring method was also used, the Internal Validity Scale, maximum score six. Additional information was sought from trial authors but only yielded further data on one trial. Reviewers provide a descriptive summary of all included reports and a vote count of clinical outcome. A quantitative analysis on a sub-set of trials (sham-controlled studies) was performed by reviewers even though trials were heterogeneous with respect to quality, type of acupuncture given, outcome measures etc. A rate ratio (proportion of responders in acupuncture group/proportion of responders in sham-control group) was calculated with 95% confidence intervals using random effects.

Acupuncture treatment varied considerably across trials. Treatment periods ranged from two to 17 weeks. Methodological quality of the trials was variable, scores ranged from 1 to 5, (median=1, max=5) using the Oxford scale, and 1 to 5 (median=2.5, max=6). Individual scores for each report was not given by the reviewers, but based on the range of scores above, many trials would have had inadequacies in randomisation and blinding leading to over-estimation of treatment effects. Trials also had small group sizes (<30 patients), inadequately defined outcomes and diagnostic criteria, and inadequate reporting of results and statistical testing.

There were fourteen sham-controlled trials. Based on a vote-counting exercise of trials comparing acupuncture to sham-acupuncture, six trials reported a statistically significant result, two trials reported no statistical significant difference between groups, and three reported a positive trend in favour of acupuncture that were not supported by statistical tests. Individual quality scores of these trials were not presented in the review. However, based on a description of the trials by reviewers, it would seem that the trials that reported positive effects had methodological flaws (not adequately randomised and not adequately blinded).

A sub-group analysis of ten of the 14 trials with dichotomous outcomes showed a statistically significant benefit of acupuncture over placebo. We disagree with this analysis as it is not valid to pool data for meta-analysis when trials are so heterogeneous.

Seven trials compared acupuncture with active control groups, five with standard drug treatment and two with physiotherapy. Based on a vote-counting exercise, two trials reported a statistically significant result, one reported no statistical difference between acupuncture and placebo, and four trials were negative but not supported by statistical tests. The reviewers described the two positive trials as being of doubtful validity. There was no description given about the sensitivity of these trials.

Reviewers were not helpful with this review. First they did not provide the quality scores of the included trials after going to the trouble of measuring it using two quality scales. Had they done, it would have been interesting to determine if the trials reporting positive results were those with low quality scores. The reviewers imply this in the text and tables. Secondly, a quantitative analysis should only be performed when data are similar. In this case they were not. Trials are heterogeneous with respect to type of acupuncture given, disease definition, outcome measures, and study architecture. Inadequately randomised and blinded trials have been lumped together with those that were of higher quality which has led to an erroneous conclusion about the effectiveness of acupuncture by the reviewers.

The later Cochrane review informed us that the median quality score was 1.5 (out of a range of 1.5). This is important because there is good evidence that studies with scores of 2/5 or below are likely to be biased and show greater effects of treatment than better conducted trials. The later Cocharne review did not pool data, but commented that studies with a higher quality score the results seemed "less positive for migraine".

Given the very small size of most trials, and their inadequate quality, the best conclusion is that there is no evidence for any effect of acupuncture in headache, unless and until someone does a large high quality trial that proves the opposite.

This review is substantially the same as a Cochrane review edited in 2000. The Cochrane review will, of course, be updated:

D Melchart, K Linde, P Fisher, B Berman, A White, A Vickers, G Allias. Acupuncture for idiopathic headache. The Cochrane Library. Update Softeware.

Acupuncture for Headaches and Head Pain

If you have any questions please sent your suggestion to peng.zengfu@gmail.com Copyright(C) 2006 Beijing International Acupuncture Center. Last update：Tuesday, 24 April, 2007

If you have any questions please sent your suggestion to peng.zengfu@gmail.com
Copyright(C) 2006 Beijing International Acupuncture Center.
Last update：Tuesday, 24 April, 2007