Acupuncture May Have Late Effects in Migraine Prophylaxis

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FYI. s. fuchs dc " I think this study showed that there is a difference between realand sham acupuncture, but thedifference is clinically minor, " corresponding authorsFan-rong Liang, MD, professor and vice president of the Chengdu University ofChinese Medicine, told Medscape MedicalNews. AcupunctureMay Have Late Effects in Migraine ProphylaxisineJanuary 13, 2012 — New research has found no significantdifference between 3 styles of traditional Chinese acupuncture and shamtreatment in the number of days patients had a migraine during the studyperiod, the primary endpoint.However,significant differences on this measure did become apparent several weeks afterthe end of treatment. The researchers, led by Ying Li, MD, PhD, and Hui Zheng,MD, PhD, from the Chengdu University of Traditional Chinese Medicine, Sichuan,China, also found small differences in the frequency of migraine, the intensityof migraine, and the intensity of pain, all of which were secondary outcomes ofthe trial. " Ithink this study showed that there is a difference between real and shamacupuncture, but the difference is clinically minor, " correspondingauthors Fan-rong Liang, MD, professor and vice president of the ChengduUniversity of Chinese Medicine, told MedscapeMedical News.The studywas publishedonline January 9, 2012, in the CanadianMedical Association Journal.Yang Meridians InChinese medicine, migraines are said to affect the yang meridians. The Shaoyangmeridians are thought to be superior for treating migraines, as they go throughthe lateral side of the body, Dr. Liang said. " Inthe view of traditional Chinese medicine, migraine is classified as a diseaseof the Shaoyang meridian, so specific points of the Shaoyang meridian are thebest choice for migraine management, " said Dr. Liang. " Nonspecificpoints of the Shaoyang meridian are the secondary choice, whereas the points ofother meridian should be the last choice. " To testthis hypothesis, researchers set up 3 acupuncture groups (Shaoyang-specific,Shaoyang-nonspecific, and Yangming-specific [another approach based on Chinesetheory]) and a control group (sham treatment at nonacupuncture points).Theanalysis included 476 patients in China with a mean age 36.9 years and onset ofmigraine before age 50 years, who had experienced acute migraine attacks formore than a year and had experienced 2 or more attacks per month during theprevious 3 months. They had not taken prophylactic migraine medication duringthe previous month. The patients were randomly assigned to 1 of the 4 groups.During a4-week period, patients received 20 electrostimulation treatments. Acupuncturewas applied unilaterally, alternating between the left and right sides. Thegoal was to elicit a de qi sensation, or sensations typically generated byinserting a needle into an acupuncture point and then manipulating it, in the 3acupuncture groups, but not in the sham group.Duringweeks 5 to 8, the study's primary endpoint, there were no significantdifferences in the number of days with a migraine between any of the acupuncturegroups compared with the sham group, or between any of the 3 acupuncturegroups.However,there was a significant difference during weeks 13 to 16 in all treatmentgroups compared with the control group.Table. Change in Days With Migraine (Weeks 13 - 16) WithAcupuncture vs Sham Acupuncture Acupuncture Type Change (Days) P Shaoyang-specific−1.06.003Shaoyang-nonspecific−1.22< .001Yangming-specific0.91.011Researcherswere somewhat surprised that the differences between real and sham acupuncturewere not more significant, said Dr. Liang. This might be a result of theprotocol used, or the placebo effect may be larger than previously thought, hesaid.The findingsraise question of whether the effects would have increased even more with alonger follow-up period. This, said Dr. Liang, " needs to be studied. " Shaoyang-specificacupuncture proved to have an edge over control treatment on a number ofmeasurements. " It was superior to sham in reducing the number of days withmigraine during 13 to 16 weeks, and the frequency of migraine attacks and[visual analogue scale] score during 5 to 8 weeks and during 13 to 16weeks, " said Dr. Liang. " It was also better than Shaoyang-nonspecificacupuncture and Yangming-specific acupuncture in reducing pain intensity ofmigraine attack. " Thefinding that secondary outcomes, including pain intensity, are more improvedwith Shaoyang-specific acupuncture " confirmed that acupuncture points areeffective for migraine management, " said Dr. Liang.Overall,the study demonstrates that acupuncture treatments have a significant effect onmigraine, said Dr. Liang. " At baseline, patients had an average of 6.3headache days a month, and at 13 to 16 weeks after study inclusion, the averageof headache days was 2.2 days, so acupuncture removes 65% of headachedays. " Althoughthe electrostimulation occurring with acupuncture contributes to part of theeffect, it does not explain it all. This issue is complex, said Dr. Liang. " The effect may be composed of several factors, including acupunctureeffect, placebo effect, good doctor–patient relationship, and patients'expectation of the treatment. " Resultsof the study may be difficult to generalize to Western populations. For onething, said Dr. Liang, North Americans may not be keen on receiving 20acupuncture treatments within a 4-week period.The studyhad a relatively short follow-up period. Other limitations were that physicianswere not blinded to treatment assignments, patients in the Shaoyang-specificacupuncture group reported the highest number of days with a migraine atbaseline (and the greatest effect after treatment), and the number ofacupuncture points used was small.Body of Evidence In an accompanyingeditorial, Albrecht Molsberger, MD, from Ruhr University Bochum in Germany, and from the Center for SensoryDisorders at the University of North Carolina, Chapel Hill,points out that unlike other alternative therapies for migraine, acupuncturenow has a body of evidence from trials of sound methodology. Evidence from morethan 20 trials involving 4419 patients with migraines was summarized in a 2009 Cochrane review, concluding thatthere is benefit from acupuncture for migraine prophylaxis, he points out.However,many of these trials have also failed to find a difference between " true " and " sham " acupuncture, he writes. The finding hasfuelled debate on the role of placebo effects in these findings, but it alsosolves the problem to some degree of which school or acupuncture or particularset of pressure points provides benefit, Dr. Molsberger writes. " Onthe basis of the existing evidence, acupuncture should be an option for thefirst-line treatment of migraine to supplement other nonpharmacologic treatmentoptions, " he concludes. " Itis at least as effective as prophylactic drug therapy, has longer lastingeffects, is safe, seems to be cost-effective, and reduces drug intake withpossibly severe unwanted effects, " he adds. " All of this can beachieved even if point selection is not as dogmatic and precise as proposed bythe Chinese system. " Asked tocomment on the findings, A. Whelan, MD, a retired neurologist from NewYork City, and a member of the American Academy of Neurology, said the studywas " somewhat imperfect, " as it was not double-blind. " That'sa potential bias, but it probably would bias things in the direction offavoring the acupuncture treatment, and in fact, there were no significantdifferences found between the control group and the treated group, so thatargues that acupuncture is not an effective treatment for preventingmigraine, " she told Medscape MedicalNews.Dr.Whelan noted that the purpose of the study was to determine whether acupuncturereduces the number of attacks, not whether it relieves migraine.Thestudy was supported by the National Basic Research Program of China. Theauthors have disclosed no relevant financial relationships.CMAJ.Published online January 9, 2012. 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