Headache is one of the most common pain conditions that I treat in my private practice, after neck and back pain. While most of the time, it is not debilitating, when it’s severe and chronic, it can severely affect the patient’s daily activity and decrease their quality of life. Migraine is usually a chronic condition and worldwide, it is considered the third most prevalent disorder (Rizzoli & Mullally, 2018). However, from a public health perspective, it is one of the conditions that are underdiagnosed and under-treated (Lipton 2018). Furthermore, when they are under the care of medical doctors, one-third of migraineurs uses opioid as an acute prescription (Greb, 2021). The risk factors for migraine include being female, having a family history, a history of mood disorders, and sleep disorders. The triggers can be stress, depression or anxiety, hormonal changes, lack of sleep, hunger, and alcohol consumption, and more (Eske, 2019).
In my practice, I’ve found acupuncture to be an effective tool in addressing tension-type headaches and migraines, used alone or with other modalities. In this report, I delved into the effectiveness of acupuncture on headaches by researching the current scientific evidence. I’ve also included the Traditional Chinese Medicine perspective on headaches, my suggested acupuncture treatment strategies, other beneficial and effective treatments for headaches, community resources, and lastly, the prognosis of headache pain.
Current research
While usage of acupuncture for chronic pain has increased in recent years, the evidence around acupuncture has remained insufficient and inconclusive.
According to Vicker et al. (2017), Acupuncture is effective for many chronic pain conditions, and the needling effects played an important role, independent of placebo effects. In this meta-data analysis, the authors further found, that there is increasing evidence that sham acupuncture was more powerful than the placebo effects.
For headaches and migraines, recent studies suggested acupuncture is effective in treating tension-type headaches and migraines. In 2016, a systemic review by Linde et al, titled Acupuncture for the prevention of episodic migraine, reviewed 22 trials with 4985 participants who had a migraine for less than 12 months. In this study, the authors found that the frequency of migraine for those who had received the verum acupuncture decreased by 50 percent, compared to 41 percent for those who received sham acupuncture. Furthermore, the positive effect from acupuncture was sustained at 6 months follow-up in three good quality large-scale studies. When the authors compare acupuncture to a routine drug, they found that the headache frequency decreased by 50 percent for 57 of 100 people versus 46 out of 100 people.
According to another systemic review on tension-type migraine, titled Acupuncture for the prevention of tension-type headache, the researchers looked at twelve trials with 2349 participants with tension-type headaches (Linde et al., 2016). They compared the acupuncture with the treatment of acute headache at routine care, sham acupuncture, or other prophylactic intervention for tension-type headache. There was a 51 percent reduction of headache frequency in the acupuncture group, compared to 43 percent in the sham group.
Both studies are significant and applicable in that they have increased the understanding of the current situation acupuncture’s effectiveness on headaches and migraines. However, the qualities of this evidence remained “moderate” due to the challenges of designing and performing clinical trials of acupuncture. The blinding and selection of control interventions remained to be challenging affecting the quality of the research (Linde et al., 2016).
Chinese Medical Theory on Headache
Giovanni Maciocia’s book, The Practice of Chinese Medicine: The treatment of Diseases with Acupuncture and Chinese Herbs provides a detailed description of TCM perspective on headache. He writes that constitution, emotion, overwork, excessive sexual activity, diet, accidents, childbirth, and external pathogenic factors are considered the causes of headaches. For example, if parents’ health were poor at the time of conception, due to overworking or over-exerting, then the child might suffer from a headache resulting from a weak constitution. One possibility can be that a child can be born with both kidney and spleen deficiency. Emotions are major factors that cause headaches. Excessive anger, worry, fear, shock, and mental work can cause and aggravate headaches. On Anger particularly, Maciocia states “among the emotional causes of headaches, this is by far the most common one” (1994). It can cause liver yang rising, liver fire, and usually manifesting on the sides of the head. When a patient is experiencing fear and anxiety chronically, this can deplete kidney energy, affecting the whole head or causing liver yang to rise due to depletion of kidney yin. What’s unique about TCM is that excessive sexual activity is considered also a cause of headaches, especially for men. If a person is experiencing a headache after sexual activity, then it is a sure sign of imbalance. He should then modify the level of sexual activity. Maciocia writes that the degree of excessiveness is relative and depends on individuals’ constitution and level of kidney essence(1994).
Diet plays a very important role in TCM. Not only what we eat can influence the headache, but also how much, how fast and in what emotional condition we eat, can affect the headache. If one consumes too much damp producing foods such as greasy fried foods, dairy products, excess white sugar, that can cause dampness overwhelming the spleen and manifest as forehead headache and heavy feeling in the head. It is also important to consider in the modern food culture, many chemicals are added to food, which can also be a cause of headaches (Maciocia, 1994).
Acupuncture Treatment Plans
Treatment Type 1. Acute Headaches (Onset is Less Than Two Weeks)
First, I start by checking any red flags. I refer my patients out to ER or medical doctor if any of these signs are present. The signs to look for, include new headache in older patients, abnormal neurologic examination including papilledema and change in mental status, the new change in headache pattern or progressive headache, new headache in the setting of HIV risk factors, cancer, or immunocompromised status, signs of a systemic illness (eg, fever, stiff neck, rash), triggered by cough, exertion, Valsalva maneuver, headache in pregnancy/postpartum period, first or worst headache (Rizzoli & Mullally, 2018). If cleared from above, the following treatments are recommended for acute stage headache patients.
Frequency of Acupuncture. I recommend my patients receive acupuncture 2-3 times a week for 2 weeks if they are having acute headaches. After that, once a week for 2-4 weeks treatments are suggested followed by re-assessment. If pain had disappeared and had not come back, for 6 weeks, I would release patients from my care, with the advice to come back in a month for a follow-up.
Assessment and Reassessment. Visual Analog Scale (VAS) will be used to measure pain level every session. Patients are recommended to take their pain level twice a day at home. Other assessment tools include FACES rating scale for young children or people with language difficulty.
Acupuncture Treatment Process. In the first week, I focus on stopping the pain by focusing on the symptoms and local areas of headache and use the local acupuncture points and related channels. In this phase, Acupuncture treatments include cupping, guasha, e-stim, and/or moxa focused on the local area. From week 2 to 6, I focus on identifying and addressing the root causes. In this phase, the root causes along with the local symptoms need to be addressed. Acupuncture, cupping, guasha, estim, and/or moxa will be utilized, focusing on the root causes.
Recommended Nutritional supplements. I recommend one or any combination of supplements including Melatonin, Vitamin D, Magnesium, Curcumin (Tumeric), and/or CoQ10. This is optional for patients and scientific evidence on taking these supplements is discussed and provided to them.
Lifestyle Recommendations. I recommend for my patients keep a pain journal (patient are asked to measure their pain twice a day, using VAS), do exercises for 15-30 minutes a day, maintain sleep hygiene, practice relaxation techniques, reduce the intake of alcohol, caffeine, recreational drugs, and sugar intake. I also suggest them to avoid fried foods, sodas, refined carbs, and processed food. Finally, I remind them to increase anti-inflammatory food include such as green leafy vegetables, herbs, almonds, walnuts, fatty fish (in moderation), olive oil, avocado, and fruits such as berries.
Treatment Type 2. Chronic Headaches (Tension-Type Headache and Migraines)
Frequency of Acupuncture Treatment. In the first 2-4 weeks, I suggest twice a week treatment. Then the patient can have once a week treatment for 4-5 weeks. At the time of re-assessment, if the pain had disappeared or significantly reduced, and had not come back for 8 weeks, I would recommend the patient to come back within a month for maintenance.
Acupuncture Treatment Process. In the first week, the goal is to stop the pain by identifying the channel in which the headache is manifesting and the causes of the headache using pattern diagnosis. Treat with acupuncture, herbs, cupping, guasha, estim, and/or maxa, depending on patients constitutional and current health factors. From week 2 to week 8, I focus on treating using both local and distal points to address both symptoms and causes. Finally, re-assessment should be done from week 8 to week 10, to discuss and discuss further treatment options.
Assessment and Reassessment. One or any combination of the following assessment tools will be used at the intake and re-assessment; Visual Analog Scale will be used to measure pain level every session. Patients are recommended to take their pain level twice a day. The short McGill Pain Questionnaire will be used at the initial intake and reassessment will be used for Migraine sufferers. Beck’s Depression Inventory (BDI) will be used for patients with chronic pain and a history of depression, QOLS (Quality of Life scale) will be used to monitor the quality of life.
Recommended Nutritional supplements. I recommend consider taking one or any combinations of Melatonin, Vitamin D, Magnesium, Curcumin (Tumeric), and/or CoQ10. This is optional for patients and scientific evidence on taking these supplements is discussed and provided to them.
Lifestyle Recommendations. I recommend for my patients keep a pain journal (patient are asked to measure their pain twice a day, using VAS), do exercises for 15-30 minutes a day, maintain sleep hygiene, practice relaxation techniques, reduce the intake of alcohol, caffeine, recreational drugs, and sugar intake. I also suggest them to avoid fried foods, sodas, refined carbs, and processed food. Finally, I remind them to increase anti-inflammatory food include such as green leafy vegetables, herbs, almonds, walnuts, fatty fish (in moderation), olive oil, avocado, and fruits such as berries.
Possible Obstacles and Challenges in Acupuncture Treatment
Sometimes, lack of compliance can hinder the treatment process. When patients start to feel better, they may want to drop out of treatment. There also can be a lack of trust or patience. It is, therefore important to communicate with the patient at each session. It is important to verbalize their progress by showing them the measurable outcomes such as a reduction in pain level. It is beneficial to address any difficulties that patients are facing, including their obstacles (i.e., lack of time, financial difficulty). When these issues are addressed proactively, it is easier to address these challenges in the treatment process. For example, if a patient is improving well, but can’t afford to pay for the treatments, then a payment plan option can be discussed. For some patients, taking supplements and herbs can be an unfamiliar or unpleasant experience. It is important to provide scientific evidence behind those recommended supplements and herbs. If compliance is seriously lacking, I recommend referring patients out to other trusted practitioners.
Alternative Approaches
Biofeedback
In 2018, Kondo et al. published a study aimed to provide a perspective on the effects of biofeedback across different health conditions. Out of 229 full text and systematic reviews, they looked at 16 good-quality, controlled, and systematic reviews on biofeedback alone or as an adjunct therapy. According to the result, biofeedback was found to be effective for reducing the frequency, duration, and intensity of migraine and tension-type headaches. This was significant because the total number of subjects who participated in these studies was more than 3500, which gave them “high confidence” in the efficacy level.
Exercises
Interestingly, exercise is found that it can sometimes both trigger or alleviate headaches. The types, intensity, and frequency of the exercises affect the pain differently. However, In general, exercising regularly does help prevent migraine headaches (Amin 2018).
Magnesium Supplementation
A magnesium supplement is effective for preventing migraine headaches. In a study by Grober (2015), when chronic migraineurs took oral Mg 600 mg for 12 weeks, the author saw that the frequency of migraine was reduced by 41.6% in the mg group and 15.8% in the placebo group.
Biomedical Considerations
Biomedical treatments include OTC medications such as NSAID (aspirin and ibuprofen), and prescription medications such as anti-nausea medications, beta-blockers, triptans (almotriptan, sumatriptan), and ergot alkaloids (ergotamine). Antiseizure medications such as topiramate, antidepressants, and Botox can be also used to prevent future migraines. Melatonin supplement is prescribed by medical doctors as well (Eske, 2019). Many of these medications are considered to have many unwanted side effects, and pediatric patients with migraines, in general, do not tolerate the strong medications very well (Stubberud, 2016).
Community Resources
There are many community and national-level resources online where patients can get more information about headaches. Here are my findings:
· American Migraine Foundation https://americanmigrainefoundation.org
· National Headache Foundation https://headaches.org
· American Headache Society https://americanheadachesociety.org/about/
· World Health Organization https://www.who.int/news-room/fact-sheets/detail/headache-disorders
· Mount Sinai Headache facial Pain Center https://www.mountsinai.org/locations/center-headache-facial-pain
· Montefiore Headache Center https://www.montefiore.org/headache-center
· Migraine Research Foundation https://migraineresearchfoundation.org/resources/find-a-doctor/comprehensive-headache-centers/
Prognosis
According to a study by Bigal and Lipton (2008), for 1 year, 84% of migraineurs showed that their symptoms persist over a year, 10% had complete remission, 3 % partial remission, and the other 3% developed chronic migraine. It is encouraging though, that acupuncture can reduce the frequency and intensity of migraines and tension-type headaches. The systemic review by Linde et al. (2016), saw that there was a 50 percent reduction in pain when acupuncture was administered once a week for 6-12 weeks. Also, at 6 months follow-up, the result remained the same. Chronic pain takes a longer time to heal, since addressing the underlying causes takes time. However, with acupuncture, it is expected to find the improvement within 6 months.
Summary of Key Learnings
Acupuncture is an effective tool to address both acute and chronic headaches. Acupuncture combined with other modalities would be beneficial for patients. Healthcare professionals are prudent to consider and suggest acupuncture as a first-line remedy, instead of suggesting medications as an acute treatment option. In the light of public health, this report would allow me to present this at various community centers and clinics, to educate the public and other health care professionals on the benefit of acupuncture.
References
Amin, F. M., Aristeidou, S., Baraldi, C., Czapinska-Ciepiela, E. K., Ariadni, D. D., Di Lenola, D., Fenech, C., Kampouris, K., Karagiorgis, G., Braschinsky, M., Linde, M., & European Headache Federation School of Advanced Studies (EHF-SAS) (2018). The association between migraine and physical exercise. The journal of headache and pain, 19(1), 83. https://doi.org/10.1186/s10194-018-0902-y
Bigal, M. E., & Lipton, R. B. (2008). The prognosis of migraine. Current opinion in neurology, 21(3), 301–308. https://doi.org/10.1097/WCO.0b013e328300c6f5
Eske, J. (2019). What is the difference between a headache and a migraine? Medical News Today. https://www.medicalnewstoday.com/articles/324890
Greb, E. (2021, Feb 11). Opioid overuse in migraineurs linked to more severe disability. Medscape. https://www.medscape.com/viewarticle/945679
Grober, U., Schmidt, J. & Kisters, K. (2015). Magnesium in Prevention and Therapy. Nutrients. 7, 8199-8226. doi:10.3390/nu7095388
Kondo, K., Noonan, K. M., Freeman, M., Ayers, C., Morasco, B. J., & Kansagara, D. (2019). Efficacy of Biofeedback for Medical Conditions: an Evidence Map. Journal of general internal medicine, 34(12), 2883–2893. https://doi.org/10.1007/s11606-019-05215-z
Linde, K., Allais, G., Brinkhaus, B., Fei, Y., Mehring, M., Shin, B. C., Vickers, A., & White, A. R. (2016). Acupuncture for the prevention of tension-type headache. The Cochrane database of systematic reviews, 4, CD007587. https://doi.org/10.1002/14651858.CD007587.pub2
Linde, K., Allais, G., Brinkhaus, B., Fei, Y., Mehring, M., Vertosick, E. A., Vickers, A., & White, A. R. (2016). Acupuncture for the prevention of episodic migraine. The Cochrane database of systematic reviews, 2016(6), CD001218. https://doi.org/10.1002/14651858.CD001218.pub3
Lipton, R.B., Munjal, S., Alam, A., Buse, D.C., Fanning, K.M., Reed, M.L., Schwedt, T.J., Dodick, D.W., & Munjal, S.(2018). Migraine in America Symptoms and Treatment (MAST) Study: Baseline Study Methods, Treatment Patterns, and Gender Differences. Headache. https://doi.org/10.1111/head.13407
Rizzoli, P., & Mullally, W. J. (2018). Headache. The American journal of medicine, 131(1), 17–24. https://doi.org/10.1016/j.amjmed.2017.09.005
Stubberud, A., Varkey, E., McCrory, D. C., Pedersen, S. A., & Linde, M. (2016). Biofeedback as Prophylaxis for Pediatric Migraine: A Meta-analysis. Pediatrics, 138(2), e20160675. https://doi.org/10.1542/peds.2016-0675
Vickers, A. J., Vertosick, E. A., Lewith, G., MacPherson, H., Foster, N. E., Sherman, K. J., Irnich, D., Witt, C. M., Linde, K., & Acupuncture Trialists’ Collaboration (2017). Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis. The journal of pain, 19(5), 455–474. https://doi.org/10.1016/j.jpain.2017.11.005
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