Research Notes: Acupuncture and Migraines

/
Acupuncture for Migraine Headaches

Acupuncture as a therapeutic intervention is being embraced by the medical community. This is in part because it is a non-pharmacological therapeutic intervention that is simple to carry out, economical, and has very few side effects (Busse et al. 2017). One area that is being explored is the use of acupuncture to decrease the individual’s headache frequency, intensity, duration and acute medication requirements.

My first recommendation for those who suffer from migraines is to work with a physician to develop strategies to manage symptoms. Then treatment programs should be implemented based on patient-specific assessment findings and patient tolerance.

Acupuncture and Migraines

If a patient is interested in using acupuncture to manage migraine symptoms there is supporting evidence from The Cochrane Collaborative (Linde et al. 2016), Canadian Medical Association (Busse et al. 2017) and other high quality Systematic Reviews (Yang et al. 2016) and Randomized Control Trials (Zhao et al. 2017).

People often assume that acupuncture is synonymous with Traditional Chinese Medicine and that anyone who uses acupuncture does so based on 'qi' or 'meridians'. This is a misconception. Regardless of its theoretical basis, based on the traditional and official definition, the term acupuncture refers to the actual insertion of a needle into the body (Fan et al. 2016).

Acknowledging that traditional narratives outdated, medical acupuncture is an approach that is based upon a theory that is inline current scientific understanding of how the body works. Reframing acupuncture form of peripheral nerve stimulation technique in which acupuncture needles are inserted into anatomically defined sites, and stimulated manually or with electricity (White 2009).

Preferential sites for acupuncture stimulation are associated with areas rich in specialized sensory receptors such as muscle spindles, Golgi tendon organs, ligament receptors, Paciniform and Ruffini’s receptors (joint capsules), deep pressure endings (within muscle belly), and free nerve endings (muscle and fascia). All of these areas are highly innervated and as a result there are a number of physiological responses that help modulate the experience of pain.

Structures to be aware of when treating cervicogenic headaches

A treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. Structures to keep in mind while assessing and treating patients suffering from migraine headaches may include neurovascular structures and investing fascia of:

  • Suboccipitals
  • Upper trapezius
  • Splenius Cervicis
  • Splenius Capitis
  • Levator Scapula
  • Rhomboids
  • Temporalis
  • Occipitofrontalis
  • Corrugator Supercilii
  • Masseter
  • Sternocleidomastoid
  • Temporomandibular Joint
  • Scalene Muscle Group
  • Trigeminovascular Nociceptive Pathway

Mechanism of Action

The British Medical Journal recently published a State of The Art Review looking at the evidence base surrounding acupuncture. It suggests that if you use Occam's razor, the insertion of an acupuncture needle is a form of novel stimuli, that functions by sending anti-nociceptive input to the neuroimmune system. This contributes to a number of physiological changes across different areas of the peripheral and central nervous systems, including peripheral receptors, dorsal horn of the spinal cord, brainstem, sensorimotor cortical areas, and the mesolimbic and prefrontal areas (Chen et al. 2017).

Is Acupuncture a Placebo?

The way we present ourselves and present our techniques is tied to clinical outcomes, the magnitude of a response may be influenced by mood, expectation, and conditioning. In any discussion on therapeutic effect it is important to acknowledge the placebo response.

It is also a within the realm of possibility that when acupuncture needles are inserted into anatomically defined sites, and stimulated manually or with electricity patients have a complex biopsychosocial response that INCLUDES but is not LIMITED to placebo. Several plausible theories attempt to explain how acupuncture works, this includes but is not limited to:
• The Gate Control Theory of Pain (Melzack & Wall 1984)
• The Release of Endogenous Opioids (Chen et al. 2017, Yin et al. 2017)
• The Release of Endogenous Cannabinoids (McPartland et al. 2014, Hu et al. 2017)
• Purinergic Signaling (Sawynok 2016, Tang et al. 2016)
• Interactions Between Non-Neuronal Cells and Neurons (Ji et al. 2016, Zhang et al. 2014)
• The Inflammatory Reflex (Chavan et al. 2014, Lim et al. 2016, Pavlov et al. 2017)
• Neuroplastic Changes Across Different Areas of the Peripheral and Central Nervous System (Chen et al. 2017)
• Sensory-Discriminative and Affective-Social Touch (Chae et al. 2017)
• Mesenchymal Stem Cells (Salazar et al. 2017) 
• Local Changes in Microcirculation (Kaneko et al. 2016)

More to Explore

Arendt-Nielsen, L., Castaldo, M., Mechelli, F., & Fernández-De-Las-Peñas, C. (2016). Muscle Triggers as a Possible Source of Pain in a Subgroup of Tension-type Headache Patients? The Clinical Journal of Pain.
https://www.ncbi.nlm.nih.gov/pubmed/26550960

Berchtold, V., Stofferin, H., Moriggl, B., Brenner, E., Pauzenberger, R., Konschake, M. (2017). The supraorbital region revisited: An anatomic exploration of the neuro-vascular bundle with regard to frontal migraine headache. J Plast Reconstr Aesthet Surg.
https://www.ncbi.nlm.nih.gov/pubmed/28712884/

Bonaz, B., Sinniger, V., & Pellissier, S. (2016). Anti-inflammatory properties of the vagus nerve: Potential therapeutic implications of vagus nerve stimulation. The Journal of Physiology.
https://www.ncbi.nlm.nih.gov/pubmed/27059884

Borea, P. A., Gessi, S., Merighi, S., & Varani, K. (2016). Adenosine as a Multi-Signalling Guardian Angel in Human Diseases: When, Where and How Does it Exert its Protective Effects? Trends in Pharmacological Sciences.
https://www.ncbi.nlm.nih.gov/pubmed/26944097

Bove, G. (2013). Lending a hand to migraine. Pain.
https://www.ncbi.nlm.nih.gov/pubmed/23707681

Burstein, R., Noseda, R., Borsook, D. (2015). Migraine: multiple processes, complex pathophysiology. J Neurosci. (OPEN ACCESS)
https://www.ncbi.nlm.nih.gov/pubmed/25926442

Busse, J.W., Craigie, S., Juurlink, D.N, ... Guyatt GH. (2017). Guideline for opioid therapy and chronic noncancer pain. CMAJ.
https://www.ncbi.nlm.nih.gov/pubmed/28483845

Chae, Y., Olausson, H. (2017). The role of touch in acupuncture treatment. Acupunct Med.
https://www.ncbi.nlm.nih.gov/pubmed/28151404

Chen, L., Michalsen, A. (2017). Management of chronic pain using complementary and integrative medicine. BMJ.
https://www.ncbi.nlm.nih.gov/pubmed/28438745

Coeytaux, R. R., & Befus, D. (2016). Role of Acupuncture in the Treatment or Prevention of Migraine, Tension-Type Headache, or Chronic Headache Disorders. Headache.
https://www.ncbi.nlm.nih.gov/pubmed/27411557

Cornelison, L.E., Hawkins, J.L., Durham, P.L. (2016). Elevated levels of calcitonin gene-related peptide in upper spinal cord promotes sensitization of primary trigeminal nociceptive neurons. Neuroscience.
https://www.ncbi.nlm.nih.gov/pubmed/27746346

Courtney, C.A., Fernández-de-Las-Peñas, C., Bond, S. (2017). Mechanisms of chronic pain - key considerations for appropriate physical therapy management. J Man Manip Ther.
https://www.ncbi.nlm.nih.gov/pubmed/28694674

Fernández-de-Las-Peñas, C.. Myofascial Head Pain. (2015). Curr Pain Headache Rep.
https://www.ncbi.nlm.nih.gov/pubmed/26049772

Ferracini, G.N., Florencio, L.L., ... Fernández-de-Las-Peñas, C. (2017). Musculoskeletal disorders of the upper cervical spine in women with episodic or chronic migraine. Eur J Phys Rehabil Med.
https://www.ncbi.nlm.nih.gov/pubmed/28118694

Giamberardino, M.A., Tafuri, E., ... Mezzetti, A. (2007). Contribution of myofascial trigger points to migraine symptoms. J Pain.
https://www.ncbi.nlm.nih.gov/pubmed/17690015

Horwitz, S., Stewart, A. (2015). An Exploratory Study to Determine the Relationship between Cervical Dysfunction and Perimenstrual Migraines. Physiother Can.
https://www.ncbi.nlm.nih.gov/pubmed/25931651

Iyengar, S., Ossipov, M.H., Johnson, K.W. (2017). The role of calcitonin gene-related peptide in peripheral and central pain mechanisms including migraine. Pain.
https://www.ncbi.nlm.nih.gov/pubmed/28301400

Jacobs, B., & Dussor, G. (2016). Neurovascular contributions to migraine: Moving beyond vasodilation. Neuroscience.
https://www.ncbi.nlm.nih.gov/pubmed/27312704

Ji, R.R., Chamessian, A., Zhang, Y.Q. (2016). Pain regulation by non-neuronal cells and inflammation. Science.
https://www.ncbi.nlm.nih.gov/pubmed/27811267

Langevin, H. M. (2014). Acupuncture, Connective Tissue, and Peripheral Sensory Modulation. Critical Reviews in Eukaryotic Gene Expression.
https://www.ncbi.nlm.nih.gov/pubmed/25072149

Li, Z., Zeng, F., ... Kong, J. (2017). Acupuncture modulates the abnormal brainstem activity in migraine without aura patients. Neuroimage Clin. (OPEN ACCESS)
https://www.ncbi.nlm.nih.gov/pubmed/28580293

Lim, H., Kim, M., Lee, C., & Namgung, U. (2016). Anti-Inflammatory Effects of Acupuncture Stimulation via the Vagus Nerve. PLoS ONE.  (OPEN ACCESS)
http://www.ncbi.nlm.nih.gov/pubmed/26991319

Linde, K., Allais, G., Brinkhaus, B., Fei, Y., Mehring, M., Vertosick, E. A., . . . White, A. R. (2016). Acupuncture for the prevention of episodic migraine. Cochrane Database of Systematic Reviews.
https://www.ncbi.nlm.nih.gov/pubmed/27351677

Luedtke, K., Boissonnault, W., Caspersen, N., Castien, R., Chaibi, A., Falla, D., . . . May, A. (2016). International consensus on the most useful physical examination tests used by physiotherapists for patients with headache: A Delphi study. Manual Therapy.
http://www.ncbi.nlm.nih.gov/pubmed/27183831

Luedtke, K., Starke, W., May, A. (2017). Musculoskeletal dysfunction in migraine patients. Cephalalgia.
https://www.ncbi.nlm.nih.gov/pubmed/28641450

MacPherson, H., Vickers, A., Bland, M., Torgerson, D., Corbett, M., Spackman, E., ..., Watt, I. (2017). Acupuncture for chronic pain and depression in primary care: a programme of research. Southampton (UK): NIHR Journals Library.
https://www.ncbi.nlm.nih.gov/pubmed/28121095

Millstine, D., Chen, C., Bauer, B. (2017). Complementary and integrative medicine in the management of headache. BMJ.
https://www.ncbi.nlm.nih.gov/pubmed/28512119

Murakami, M., Fox, L., Dijkers, M.P. (2017). Ear Acupuncture for Immediate Pain Relief-A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Pain Med.
https://www.ncbi.nlm.nih.gov/pubmed/28395101

Nahin, R. L., Boineau, R., Khalsa, P. S., Stussman, B. J., & Weber, W. J. (2016). Evidence-Based Evaluation of Complementary Health Approaches for Pain Management in the United States. Mayo Clinic Proceedings.
https://www.ncbi.nlm.nih.gov/pubmed/27594189

Pareja, J.A., López-Ruiz, P., Cuadrado, M.L. (2017). Supratrochlear Neuralgia: A Prospective Case Series of 15 Patients. Headache.
https://www.ncbi.nlm.nih.gov/pubmed/28833061

Pavlov, V.A., Tracey, K.J. (2017). Neural regulation of immunity: molecular mechanisms and clinical translation. Nat Neurosci.
https://www.ncbi.nlm.nih.gov/pubmed/28092663

Perry, C.J., Blake, P., Buettner, C., Papavassiliou, E., Schain, A.J., Bhasin, M.K., Burstein, R. (2016). Upregulation of inflammatory gene transcripts in periosteum of chronic migraineurs: Implications for extracranial origin of headache. Ann Neurol. (OPEN ACCESS)
https://www.ncbi.nlm.nih.gov/pubmed/27091721

Qiao, L.N., Liu, J.L., Tan, L.H., Yang, H.L., Zhai, X., Yang, Y.S. (2017). Effect of electroacupuncture on thermal pain threshold and expression of calcitonin-gene related peptide, substance P and γ-aminobutyric acid in the cervical dorsal root  ganglion of rats with incisional neck pain. Acupunct Med.
https://www.ncbi.nlm.nih.gov/pubmed/28600329

Ranoux, D., Martiné, G., Espagne-Dubreuilh, G., Amilhaud-Bordier, M., Caire, F., Magy, L. (2017). OnabotulinumtoxinA injections in chronic migraine, targeted to sites of pericranial myofascial pain: an observational, open label, real-life cohort study. J Headache Pain.
https://www.ncbi.nlm.nih.gov/pubmed/28733943

Sawynok, J. (2016). Adenosine receptor targets for pain. Neuroscience.
https://www.ncbi.nlm.nih.gov/pubmed/26500181

Schwedt, T. J. (2014). Chronic migraine. BMJ. 
https://www.ncbi.nlm.nih.gov/pubmed/24662044

Tang, Y., Yin, H., Rubini, P., & Illes, P. (2016). Acupuncture-Induced Analgesia: A Neurobiological Basis in Purinergic Signaling. The Neuroscientist.
http://www.ncbi.nlm.nih.gov/pubmed/27343858

Vickers, A. J., Cronin, A. M., Maschino, A. C., Lewith, G., Macpherson, H., Foster, N. E., . . . Collaboration, F. T. (2012). Acupuncture for Chronic Pain. Archives of Internal Medicine.
https://www.ncbi.nlm.nih.gov/pubmed/22965186

Volkow, N.D., McLellan, A.T. (2016). Opioid Abuse in Chronic Pain--Misconceptions and Mitigation Strategies. N Engl J Med.
https://www.ncbi.nlm.nih.gov/pubmed/27028915

Waki, H., Suzuki, T., Hisajima, T. (2017). Effects of electroacupuncture to the trigeminal nerve area on the autonomic nervous system and cerebral blood flow in the prefrontal cortex. Acupunct Med.
https://www.ncbi.nlm.nih.gov/pubmed/28765118

Watson, D. H., & Drummond, P. D. (2012). Head Pain Referral During Examination of the Neck in Migraine and Tension-Type Headache. Headache: The Journal of Head and Face Pain.
https://www.ncbi.nlm.nih.gov/pubmed/22607581

Yang, Y., Que, Q., Ye, X., Zheng, G.h. (2016). Verum versus sham manual acupuncture for migraine: a systematic review of randomised controlled trials. Acupunct Med.
https://www.ncbi.nlm.nih.gov/pubmed/2671800  

Yin, C., Buchheit, T.E., Park, J.J. (2017). Acupuncture for chronic pain: an update and critical overview. Curr Opin Anaesthesiol.
https://www.ncbi.nlm.nih.gov/pubmed/28719458

Zhao et al. (2017). The Long-term Effect of Acupuncture for Migraine Prophylaxis A Randomized Clinical Trial. JAMA Intern Med.
https://www.ncbi.nlm.nih.gov/pubmed/28241154