NIHR Signal Acupuncture shows promise for preventing episodic migraines

Published on 18 October 2016

Acupuncture was about as effective as long term medication in reducing the number of migraines. There were fewer adverse events amongst people receiving acupuncture (16-17%) compared to drug treatment (34%).

Migraines affect around one in seven people in the UK. Their unpleasant symptoms last between four and 72 hours and can impact on people’s ability to do everyday tasks, such as going to work.

This systematic review looked at acupuncture delivered at least once a week for up to six sessions, similar to the NICE recommendation of up to ten sessions over five to eight - weeks.

Acupuncture may be a preventative treatment option for those willing to have it but NHS provision of acupuncture is variable. This treatment may, in reality, only be available to people living in certain areas or who can afford to pay for treatment themselves.

Acupuncture shows promise for preventing episodic migraines

Why was this study needed?

Migraines are common, affecting around one in five women and one in 15 men. Symptoms include headache, visual disturbances and nausea, which can be severe enough to stop people living their normal daily life. Migraine attacks last anywhere between four and 72 hours and are estimated to cost the UK economy as much as £2 billion a year in lost work.

The cause of migraines remains unclear. Some people can identify triggers such as certain foods, which they can avoid to help prevent migraine attacks. Others take medications to prevent their migraines. Not all migraine sufferers can identify triggers to prevent migraines and they may not want to constantly take medication. Therefore, they may consider other ways to prevent their migraines, such as acupuncture.

This systematic review looked at the effectiveness of acupuncture for preventing migraines.

What did this study do?

This systematic review compared the findings of 22 randomised controlled trials. In the included studies acupuncture was compared to routine care, no treatment, preventive medication or sham acupuncture – which mimics the sensation of acupuncture. The course of acupuncture had to comprise six sessions delivered at least once a week.

This review looked at people who had experienced episodic migraines for over a year. Studies investigating chronic migraine – where people had 15 or more days with a migraine every month – were excluded from the analysis.

The evidence for reducing migraines was graded as moderate quality overall. The review is therefore likely to provide a reasonably close estimate of the true effect.

What did it find?

  • Acupuncture at least halved the frequency of migraines in 41% of people, compared to 17% amongst those receiving no acupuncture (relative risk [RR] 2.40, 95% confidence interval [CI] 2.08 to 2.76) based on four trials including a total of 2519 people.
  • Acupuncture at least halved the frequency of migraines in 50% of those receiving acupuncture compared to 41% receiving sham acupuncture (RR 1.23, 95% CI 1.11 to 1.36) based on 14 trials including a total of 1,825 people.
  • Acupuncture at least halved the frequency of migraines in 57% of people, compared to 46% of those receiving drug treatments after three months (RR 1.24, 95% CI 1.08 to 1.44). There was no difference between acupuncture and drug treatments at six months (RR 1.11, 95% CI 0.97 to 1.26), based on three studies including 743 people at immediate follow-up and 744 at three months.
  • The proportion of people experiencing adverse events associated with their treatment was similar between acupuncture (16%) and sham acupuncture (17%), whereas it was much lower for acupuncture (17%) compared to drug treatment (34%). There was insufficient reporting of adverse events in trials comparing acupuncture with no acupuncture or usual care, so no analysis was possible.

What does current guidance say on this issue?

NICE 2015 guidelines recommend that acupuncture can be used to prevent migraines (with or without aura) when the first choice medications topiramate and propranolol have either been ineffective or are otherwise unsuitable.

NICE recommends a course of up to ten sessions of acupuncture over five to eight weeks. Whether to use preventive treatments and which treatment to use should be discussed with the individual, considering their personal preference and any other medical conditions they may have.

What are the implications?

These findings suggest that acupuncture was more effective at reducing migraines than usual care, sham acupuncture and drug treatments. Fewer adverse events were reported for acupuncture – half the number for migraine medications – suggesting that it is a safe treatment.

NICE recommends acupuncture for migraine prevention. This review reinforces that recommendation and may help to identify potential candidates for acupuncture – for example people who suffer side effects from medication.

The availability of acupuncture on the NHS varies throughout the UK, therefore any GPs considering recommending acupuncture would have to consider local NHS access and the ability of their patients to pay to access this treatment.

Citation and Funding

Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of episodic migraine. Cochrane Database Syst Rev. 2016;(6):CD001218.

Cochrane UK and the Pain, Palliative and Supportive Care Cochrane Review Group are supported by NIHR infrastructure funding.

Bibliography

NICE. Headaches: Diagnosis and management of headaches in young people and adults. London: National Institute for Health and Care Excellence; 2012.

Migraine Action. Key facts about migraine. Leicester: Migraine Action; 2015.

NHS Choices. Migraine. London: Department of Health; 2016.

NHS Choices. Migraine – treatment. London: Department of Health; 2016.

Why was this study needed?

Migraines are common, affecting around one in five women and one in 15 men. Symptoms include headache, visual disturbances and nausea, which can be severe enough to stop people living their normal daily life. Migraine attacks last anywhere between four and 72 hours and are estimated to cost the UK economy as much as £2 billion a year in lost work.

The cause of migraines remains unclear. Some people can identify triggers such as certain foods, which they can avoid to help prevent migraine attacks. Others take medications to prevent their migraines. Not all migraine sufferers can identify triggers to prevent migraines and they may not want to constantly take medication. Therefore, they may consider other ways to prevent their migraines, such as acupuncture.

This systematic review looked at the effectiveness of acupuncture for preventing migraines.

What did this study do?

This systematic review compared the findings of 22 randomised controlled trials. In the included studies acupuncture was compared to routine care, no treatment, preventive medication or sham acupuncture – which mimics the sensation of acupuncture. The course of acupuncture had to comprise six sessions delivered at least once a week.

This review looked at people who had experienced episodic migraines for over a year. Studies investigating chronic migraine – where people had 15 or more days with a migraine every month – were excluded from the analysis.

The evidence for reducing migraines was graded as moderate quality overall. The review is therefore likely to provide a reasonably close estimate of the true effect.

What did it find?

  • Acupuncture at least halved the frequency of migraines in 41% of people, compared to 17% amongst those receiving no acupuncture (relative risk [RR] 2.40, 95% confidence interval [CI] 2.08 to 2.76) based on four trials including a total of 2519 people.
  • Acupuncture at least halved the frequency of migraines in 50% of those receiving acupuncture compared to 41% receiving sham acupuncture (RR 1.23, 95% CI 1.11 to 1.36) based on 14 trials including a total of 1,825 people.
  • Acupuncture at least halved the frequency of migraines in 57% of people, compared to 46% of those receiving drug treatments after three months (RR 1.24, 95% CI 1.08 to 1.44). There was no difference between acupuncture and drug treatments at six months (RR 1.11, 95% CI 0.97 to 1.26), based on three studies including 743 people at immediate follow-up and 744 at three months.
  • The proportion of people experiencing adverse events associated with their treatment was similar between acupuncture (16%) and sham acupuncture (17%), whereas it was much lower for acupuncture (17%) compared to drug treatment (34%). There was insufficient reporting of adverse events in trials comparing acupuncture with no acupuncture or usual care, so no analysis was possible.

What does current guidance say on this issue?

NICE 2015 guidelines recommend that acupuncture can be used to prevent migraines (with or without aura) when the first choice medications topiramate and propranolol have either been ineffective or are otherwise unsuitable.

NICE recommends a course of up to ten sessions of acupuncture over five to eight weeks. Whether to use preventive treatments and which treatment to use should be discussed with the individual, considering their personal preference and any other medical conditions they may have.

What are the implications?

These findings suggest that acupuncture was more effective at reducing migraines than usual care, sham acupuncture and drug treatments. Fewer adverse events were reported for acupuncture – half the number for migraine medications – suggesting that it is a safe treatment.

NICE recommends acupuncture for migraine prevention. This review reinforces that recommendation and may help to identify potential candidates for acupuncture – for example people who suffer side effects from medication.

The availability of acupuncture on the NHS varies throughout the UK, therefore any GPs considering recommending acupuncture would have to consider local NHS access and the ability of their patients to pay to access this treatment.

Citation and Funding

Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of episodic migraine. Cochrane Database Syst Rev. 2016;(6):CD001218.

Cochrane UK and the Pain, Palliative and Supportive Care Cochrane Review Group are supported by NIHR infrastructure funding.

Bibliography

NICE. Headaches: Diagnosis and management of headaches in young people and adults. London: National Institute for Health and Care Excellence; 2012.

Migraine Action. Key facts about migraine. Leicester: Migraine Action; 2015.

NHS Choices. Migraine. London: Department of Health; 2016.

NHS Choices. Migraine – treatment. London: Department of Health; 2016.

Acupuncture for the prevention of episodic migraine

Published on 29 June 2016

Linde, K.,Allais, G.,Brinkhaus, B.,Fei, Y.,Mehring, M.,Vertosick, E. A.,Vickers, A.,White, A. R.

Cochrane Database Syst Rev Volume 6 , 2016

BACKGROUND: Acupuncture is often used for migraine prevention but its effectiveness is still controversial. We present an update of our Cochrane review from 2009. OBJECTIVES: To investigate whether acupuncture is a) more effective than no prophylactic treatment/routine care only; b) more effective than sham (placebo) acupuncture; and c) as effective as prophylactic treatment with drugs in reducing headache frequency in adults with episodic migraine. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL: 2016, issue 1); MEDLINE (via Ovid, 2008 to January 2016); Ovid EMBASE (2008 to January 2016); and Ovid AMED (1985 to January 2016). We checked PubMed for recent publications to April 2016. We searched the World Health Organization (WHO) Clinical Trials Registry Platform to February 2016 for ongoing and unpublished trials. SELECTION CRITERIA: We included randomized trials at least eight weeks in duration that compared an acupuncture intervention with a no-acupuncture control (no prophylactic treatment or routine care only), a sham-acupuncture intervention, or prophylactic drug in participants with episodic migraine. DATA COLLECTION AND ANALYSIS: Two reviewers checked eligibility; extracted information on participants, interventions, methods and results, and assessed risk of bias and quality of the acupuncture intervention. The primary outcome was migraine frequency (preferably migraine days, attacks or headache days if migraine days not measured/reported) after treatment and at follow-up. The secondary outcome was response (at least 50% frequency reduction). Safety outcomes were number of participants dropping out due to adverse effects and number of participants reporting at least one adverse effect. We calculated pooled effect size estimates using a fixed-effect model. We assessed the evidence using GRADE and created 'Summary of findings' tables. MAIN RESULTS: Twenty-two trials including 4985 participants in total (median 71, range 30 to 1715) met our updated selection criteria. We excluded five previously included trials from this update because they included people who had had migraine for less than 12 months, and included five new trials. Five trials had a no-acupuncture control group (either treatment of attacks only or non-regulated routine care), 15 a sham-acupuncture control group, and five a comparator group receiving prophylactic drug treatment. In comparisons with no-acupuncture control groups and groups receiving prophylactic drug treatment, there was risk of performance and detection bias as blinding was not possible. Overall the quality of the evidence was moderate. Comparison with no acupunctureAcupuncture was associated with a moderate reduction of headache frequency over no acupuncture after treatment (four trials, 2199 participants; standardised mean difference (SMD) -0.56; 95% CI -0.65 to -0.48); findings were statistically heterogeneous (I(2) = 57%; moderate quality evidence). After treatment headache frequency at least halved in 41% of participants receiving acupuncture and 17% receiving no acupuncture (pooled risk ratio (RR) 2.40; 95% CI 2.08 to 2.76; 4 studies, 2519 participants) with a corresponding number needed to treat for an additional beneficial outcome (NNTB) of 4 (95% CI 3 to 6); there was no indication of statistical heterogeneity (I(2) = 7%; moderate quality evidence). The only trial with post-treatment follow-up found a small but significant benefit 12 months after randomisation (RR 2.16; 95% CI 1.35 to 3.45; NNT 7; 95% 4 to 25; 377 participants, low quality evidence). Comparison with sham acupunctureBoth after treatment (12 trials, 1646 participants) and at follow-up (10 trials, 1534 participants), acupuncture was associated with a small but statistically significant frequency reduction over sham (moderate quality evidence). The SMD was -0.18 (95% CI -0.28 to -0.08; I(2) = 47%) after treatment and -0.19 (95% CI -0.30 to -0.09; I(2) = 59%) at follow-up. After treatment headache frequency at least halved in 50% of participants receiving true acupuncture and 41% receiving sham acupuncture (pooled RR 1.23, 95% CI 1.11 to 1.36; I(2) = 48%; 14 trials, 1825 participants) and at follow-up in 53% and 42%, respectively (pooled RR 1.25, 95% CI 1.13 to 1.39; I(2) = 61%; 11 trials, 1683 participants; moderate quality evidence). The corresponding NNTBs are 11 (95% CI 7.00 to 20.00) and 10 (95% CI 6.00 to 18.00), respectively. The number of participants dropping out due to adverse effects (odds ratio (OR) 2.84; 95% CI 0.43 to 18.71; 7 trials, 931 participants; low quality evidence) and the number of participants reporting adverse effects (OR 1.15; 95% CI 0.85 to 1.56; 4 trials, 1414 participants; moderate quality evidence) did not differ significantly between acupuncture and sham groups. Comparison with prophylactic drug treatmentAcupuncture reduced migraine frequency significantly more than drug prophylaxis after treatment ( SMD -0.25; 95% CI -0.39 to -0.10; 3 trials, 739 participants), but the significance was not maintained at follow-up (SMD -0.13; 95% CI -0.28 to 0.01; 3 trials, 744 participants; moderate quality evidence). After three months headache frequency at least halved in 57% of participants receiving acupuncture and 46% receiving prophylactic drugs (pooled RR 1.24; 95% CI 1.08 to 1.44) and after six months in 59% and 54%, respectively (pooled RR 1.11; 95% CI 0.97 to 1.26; moderate quality evidence). Findings were consistent among trials with I(2) being 0% in all analyses. Trial participants receiving acupuncture were less likely to drop out due to adverse effects (OR 0.27; 95% CI 0.08 to 0.86; 4 trials, 451 participants) and to report adverse effects (OR 0.25; 95% CI 0.10 to 0.62; 5 trials 931 participants) than participants receiving prophylactic drugs (moderate quality evidence). AUTHORS' CONCLUSIONS: The available evidence suggests that adding acupuncture to symptomatic treatment of attacks reduces the frequency of headaches. Contrary to the previous findings, the updated evidence also suggests that there is an effect over sham, but this effect is small. The available trials also suggest that acupuncture may be at least similarly effective as treatment with prophylactic drugs. Acupuncture can be considered a treatment option for patients willing to undergo this treatment. As for other migraine treatments, long-term studies, more than one year in duration, are lacking.

Expert commentary

This good systematic review echoes what is known about pain: If you do nothing (waiting list), then few people have a good result. If you do something (placebo of any sort, including fake acupuncture), then more people do better.

This is also the case for reducing the number of migraine attacks by at least 50% a month, an outcome considered useful by patients, and one known to improve quality of life. Success rates were about 2 in 10 with doing nothing (waiting list), 4 in 10 with fake acupuncture, 4-6 in 10 with real acupuncture, and 5 in 10 with drugs. Acupuncture as practiced by an authentic method is possibly helpful, but to only about 1 in 10 people more than fake acupuncture.

Professor Andrew Moore, Pain Research, University of Oxford

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  •   Complementary and alternative therapies, Nervous system disorders