Acupuncture for headache - a review

Headaches are common – in fact, the most common symptom experienced by the human race. There are various causes of headache, and of course careful conventional diagnosis is necessary in case the headache arises from some dangerous disorder - in which case acupuncture is not appropriate.

Most headaches fall into two general categories – tension type headache and migraine. These problems can persist for years. The two types of headache are clearly different, and most research investigates one or other type. In individual patients, however, it may be difficult to decide which type they have, and indeed some people may have both types together.

Acupuncture is widely used as a prevention for both types of headache, and generally involves a course of treatment sometimes with continuing top up appointments.

Acupuncture trials for headaches

Acupuncture trials have generally investigated one or other type of headache, and this is reflected in the recent publication of two separate Cochrane reviews, drawing together the results of good studies.  There was a previous Cochrane review, but it combined both types of headache.

Each of the new reviews had separate sections looking at whether acupuncture was:

a) more effective than ‘usual care’ ie. continuing the patient’s previous treatment;

b) more effective than 'sham' (placebo) acupuncture, which tries to answer the question of whether acupuncture has a ‘specific effect’ in addition to its expectation effects. This raises the important and unresolved question of what is a suitable ‘placebo’ for acupuncture: since acupuncture is now widely regarded as acting through the nervous system, then needles inserted in the ‘wrong’ site are likely to be giving a lower dose of treatment rather than an inactive placebo; and

c) whether acupuncture was as effective as other treatments used to reduce the frequency of headaches. These reviews did not explore whether acupuncture has any benefit as a treatment for acute headaches.

All Randomised Controlled Trials were included that used an observation period of at least 8 weeks, and for preference the reviewers used a measurement of ‘response’, ie. whether patients had a 50% reduction in the number of days with headache. The scientific standard of rigour of the studies was assessed using the new Cochrane method: ‘assessing the risk of bias’.

Migraine prevention

Twenty-two trials (12 new) with a total of 4419 patients (mean 201) were included.

Six trials (including two large trials with 401 and 1715 patients) compared acupuncture to no preventative treatment or routine care only. After 3 to 4 months patients receiving additional acupuncture had higher response rates and fewer headaches. The only study with long-term follow up saw no evidence that effects dissipated up to 9 months after cessation of treatment.

Fourteen trials compared a 'true' acupuncture intervention with a variety of sham interventions. Pooled analyses did not show a statistically significant superiority for true acupuncture for any outcome in any of the time windows, but the results of single trials varied considerably.

Four trials compared acupuncture to proven preventative drug treatment. Overall, acupuncture was associated with slightly better outcomes and fewer adverse effects than preventative drug treatment.

Collectively, the studies suggest that migraine patients benefit from acupuncture, although (from the results of the sham controlled studies) the correct placement of needles seems to be less relevant than thought by classical acupuncturists.

Tension type headache treatment and prevention

Eleven trials (six new) with a total of 2317 patients (median 62) were included.

Two large trials compared acupuncture to treatment of acute headache or routine care only. Both found statistically significant and clinically relevant short-term (up to three months) benefits of acupuncture over control.  They measured the outcomes response, number of headache days and pain intensity. Long-term effects beyond three months were not investigated.

Six trials compared acupuncture with a sham acupuncture intervention, and five of the six provided data for meta-analyses. Small but statistically significant benefits of acupuncture over sham were found for response as well as for several other outcomes.

Three of the four trials comparing acupuncture with physiotherapy, massage or relaxation had important methodological or reporting shortcomings. Their findings are difficult to interpret, but collectively suggest slightly better results for some outcomes in the control groups than with acupuncture.

The available evidence suggests that acupuncture could be a valuable non-pharmacological treatment in patients with frequent episodic or chronic tension-type headaches.

Effectiveness and cost-effectiveness

 There seems to be little debate that, for some patients with tension-type headache, acupuncture can provide clinically valuable relief and is superior to acupuncture at the 'wrong' site. For migraine, although acupuncture is an effective and safe alternative to drugs, it is not clear how much of this is due to a general neurological effect of the needles and how much due to expectation. Or, indeed, how much it matters – some argue that any treatment that reduces the symptoms, reduces work loss, and reduces expenditure on drugs is clearly to be recommended.

The costs of acupuncture were not considered by the review. However, evidence from trials suggests that its cost effectiveness for chronic headache is in the region of £10,000 per QALY(Quality adjusted life year).

Figures are not readily available for comparing this directly with the cost effectiveness of drug treatments. Drugs for migraine tend to be expensive, and migraine can have serious economic consequences, so for patients with frequent attacks a course of acupuncture at about £250 is likely to be competitive. For patients with tension type headache, the pharmacological options may be cheaper for the health service, but acupuncture may still be more cost effective from the patient’s point of view.