Systematic Review

Acupuncture vs Standard Pharmacological Therapy for Migraine Prevention

Niushen Zhang, MD; Tim Houle, PhD; Nada Hindiyeh, MD; Sheena K. Aurora, MD

Disclosures

Headache. 2020;60(2):309-317. 

In This Article

Discussion

An analysis from the American Migraine Prevalence and Prevention (AMPP) Study showed that the vast majority of episodic migraine patients were not able to obtain minimal pharmacologic management.[13] There is growing evidence that acupuncture is just as effective and has fewer side effects than many of the standard pharmaceutical agents that are currently used. In clinical practice, patients frequently ask for guidance on whether or not to try acupuncture and about how frequent and how long they need to try it for. However, we still have very little understanding of the mechanism by which acupuncture works and the data are still limited. Since the publication of the systematic review in 2016 by Linde et al, several new studies have shown that acupuncture is effective in the prevention of migraine when compared to the standard pharmacological treatment.[4] We conducted a focused review of existing randomized controlled trials to study the effectiveness of acupuncture treatment. We also examined the duration and frequency of treatments. Our objective was to use the available data to formulate a practical summary of results for clinicians and their patients.

The heterogeneity and variability of the study protocols bring up the larger question of how the study of acupuncture can be standardized. According to traditional Chinese medicine, migraine is a complex disease and a variety of syndrome diagnoses are possible.[8] Traditionally, treatment is individualized and is not a uniform intervention that can be standardized easily.[4,8] Acupoint selection is extremely variable, as can be seen even in the small collection of studies that we examined. Of these 7 studies, 4 used "part standardization" which involves the use of a set of obligatory points and additional points. The additional points are chosen depending on different syndromes present in the individual patient. Therefore, the absence of standardized approaches to treatment makes it difficult to reproduce studies. Future studies are needed to confirm whether there is a real difference between individualized and standardized acupuncture. The most recent revision of STRICTA (Standard for Reporting Interventions in Clinical Trials of Acupuncture) is intended as a guideline to improve reporting of acupuncture trials and facilitate their interpretation and replication. Of the studies we reviewed, only the studies by Yang et al and Facco et al explicitly mention conformance to STRICTA.

Both the studies from Wang et al and Diener et al employed the use of sham acupuncture. Numerous studies have shown that sham acupuncture is just as effective as true acupuncture for treatment of migraine. In the 2009 review by Linde et al, pooled analyses of 14 studies did not show a statistically significant superiority for true acupuncture compared with sham acupuncture in migraine prophylaxis. But any intervention involving skin penetration cannot be considered an inert placebo.[8,14] Sham acupuncture may still induce a wide range of peripheral, segmental, and central physiological responses to an unpredictable degree.[11] Also, acupuncture-specific non-needle and/or needle components may be retained in sham treatments.[15] Given these reasons, it may be more practical, in future studies, to compare acupuncture with standard therapies rather than comparing it to sham acupuncture.

The tolerability and safety of a treatment are key factors in maximizing compliance. Several large surveys have shown that acupuncture is well tolerated and that serious complications are rare events.[8] In several of the studies that we reviewed, a greater number of patients in the standard therapy group had to withdraw because of adverse effects. Reported side effects of acupuncture included mild bleeding at site of needle insertion, ecchymosis, local pain, sedation, and fatigue. In all of the studies, acupuncture consistently had a lower rate of side effects compared to beta blockers, valproic acid, topiramate, and flunarizine.

Limitations

In the attempt to analyze and compare the data across trials, we encountered tremendous heterogeneity in the study protocols, acupuncture strategies, and outcome measures.

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