Community pharmacists can join forces with acupuncturists to treat migraine, as Mark Bovey explains…
Acupuncture is a therapy in which thin needles are inserted into the skin at particular points. It originated in China and is now used in many countries to treat people with migraine.
It is one of the best studied, most effective and best tolerated treatments for migraine and can be recommended to members of the public who are interested. Some studies have shown that acupuncture is even more effective than pharmaceuticals in treating migraine.
Community pharmacists are well-placed to promote acupuncture either by referring patients to a local British Acupuncture Council-registered acupuncturist or even by using the services of an acupuncturist in the pharmacy itself.
With migraine we are in the happy position where clinical results and experiences are reflected in the evidence base.
The most recent Cochrane review included 25 randomised controlled trials and nearly 5,000 participants. Whether compared to no other prophylactic intervention, or to sham, acupuncture was significantly superior for reducing headache frequency.
The advantage over sham is small, but then sham is simply a diluted form of the real thing, not a placebo, so this is to be expected. Perhaps more useful for clinicians and patients is the comparison with prophylactic drugs.
Acupuncture was slightly more effective and with fewer adverse events. At the three-month mark there were 57% responders (i.e. ≥50% frequency reduction) versus 46% with medication.
Other systematic reviews have similar findings, cost effectiveness has been established, and acupuncture is recommended by NICE: up to 10 sessions as a back-up to topiramate or propanolol.
More recent trials provide support for longer, as well as shorter-term, benefits and confirm that acupuncture is a more desirable option than botulinum injection. As well as prevention it may also alleviate symptoms in acute attacks, and as well as relieving symptoms it can also increase coping mechanisms.
The migraine evidence fits exactly into the general picture with acupuncture for chronic pain. For headache, backache, osteoarthritis and shoulder pain acupuncture is consistently and significantly superior to either usual care or sham, based on high class evidence from 31 trials with over 20,000 patients. It also fits with the safety profile established by two very large surveys published in the BMJ in 2001 (see here and here) and an even larger German one.
The risk of a serious adverse reaction is extremely low, and minor side effects, such as dizziness or bruising around the needle point, are mild and self-correcting.
There’s an array of research on acupuncture mechanisms, with numerous biochemical and biophysical possibilities, generally linked to neurological models. The importance of endorphins and other neurohumoral factors for acupuncture analgesia was noted in the 1970s but increasingly sophisticated brain imaging techniques can be used now.
Acupuncture may reduce migraine pain through changes in brain biochemistry and functional connectivity demonstrated in this study, published this year and this study, published in 2017.
Some of the other possible mechanisms in respect of migraine are to reduce inflammation, reduce cortical spreading depression, reduce calcitonin gene–related peptide in the central nervous system, modulate cranial blood flow and regulate serotonin levels.
This wealth of evidence supports calls by many that acupuncture is a viable healthcare choice for people experiencing migraine. Pharmacists are often the first point of contact for patients and are therefore in a perfect position to help alleviate pressures on our stretched NHS by making the most of this treatment either by referring on or by employing the services of an acupuncturist to work in-house.
The following two case studies highlight how acupuncture works in different people.
A woman in her 30s consults a traditional acupuncturist about her migraines, which are characterised by severe headaches above the right eye, with no aura but often nausea.
They are provoked particularly by computer screens. She can’t tolerate prophylactic medication but takes half a sumatriptan to try to prevent slight headaches developing further.
A woman in her 50s also consults the practitioner about right-sided migraines. These come with an aura but no nausea. The frequency escalated recently from a few per year to several per month following a severe illness. She does take preventive medication.
In Chinese medicine terms the diagnoses were entirely different in these two cases. For one, it is a very typical diagnosis for people with migrainous headaches. For the other, diagnosis and treatment are focused more on improving the patient’s whole constitution, rather than explicitly ‘chasing’ the symptoms.
The relative emphasis in such ‘root’ and ‘branch’ approaches will vary from person to person and also change over a course of treatment.
In practical terms this may mean different points are needled (mostly leg and foot for patient 1; arm and hand for patient 2. Interestingly, points on the head scarcely featured for either of them), the needles are inserted/manipulated differently, and different lifestyle advice is offered.
The first patient immediately noticed a much-reduced frequency of migraines. She still gets slight headaches and takes the sumatriptan but has had only five full migraines in 18 months. She soon reduced treatment frequency to six-weekly, and then sporadic.
The second also responded well but wished to continue acupuncture at regular intervals, slowly increasing from 2 up to 6 weeks. She has had no migraine now for 11 months and has reduced her medication dose.
Even though some diagnoses and treatments are more likely than others there is no one formula that is best, no magic points, and traditional acupuncturists will look at each person individually and try to treat them holistically.
Any comorbidities will tend to be addressed at the same time, by the same practitioners. Most traditional acupuncturists are generalists. You can find specialists in paediatrics or obstetrics but not in headaches: everyone treats those.
Professional acupuncturists operate largely outside of the NHS and they see on average three times as many patients as their orthodox medical colleagues.
Traditional acupuncture is practised by members of the British Acupuncture Council; hence they belong to a Professional Standards Authority accredited register, providing guarantees of safety, education and continuing development.
Mark Bovey is head of research at the British Acupuncture Council.