Acupuncture for tension-type headache in pregnancy: A prospective, randomized, controlled study

Acupuncture versus tricyclic antidepressants in the prophylactic treatment of tension-type headaches: an indirect treatment comparison meta-analysis

BACKGROUND

Acupuncture showed better improvement than sham acupuncture in reducing attack frequency of tension-type headache (TTH), but its effectiveness relative to first-line drugs for TTH is unknown, which impedes the recommendation of acupuncture for patients who are intolerant to drugs for TTH. We aimed to estimate the relative effectiveness between acupuncture and tricyclic antidepressants (TCAs) through indirect treatment comparison (ITC) meta-analysis.

METHODS

We searched Ovid Medline, Embase, and Cochrane Library from database inception until April 13, 2023. Randomized controlled trials of TCAs or acupuncture in the prevention of TTH in adults were included. The primary outcome was headache frequency. The secondary outcomes were headache intensity, responder rate, and adverse event rate. Bayesian random-effect models were used to perform ITC meta-analysis, and confidence of evidence was evaluated by using the GRADE approach.

RESULTS

A total of 34 trials involving 4426 participants were included. Acupuncture had similar effect with TCAs in decreasing TTH frequency (amitriptyline: mean difference [MD] -1.29, 95% CI -5.28 to 3.02; amitriptylinoxide: MD -0.05, 95% CI -6.86 to 7.06) and reducing TTH intensity (amitriptyline: MD 2.35, 95% CI -1.20 to 5.78; clomipramine: MD 1.83, 95% CI -4.23 to 8.20). Amitriptyline had a higher rate of adverse events than acupuncture (OR 4.73, 95% CI 1.42 to 14.23).

CONCLUSION

Acupuncture had similar effect as TCAs in reducing headache frequency of TTH, and acupuncture had a lower adverse events rate than amitriptyline, as shown by very low certainty of evidence.

Effectiveness of breathing exercise on the duration of labour: A systematic review and meta-analysis

Background

Prolonged labour intensifies labour pain, and failure to address labour pain may lead to abnormal labour and augments the usage of operative interventions. Prolonged labour is common among women, resulting in maternal morbidity, increased caesarean section (CS) rates, and postpartum complications. It may bring forth negative birth experiences that may increase the preference for CS. There is a dearth of evidence concerning the effectiveness of breathing exercises on the duration of labor. As per our knowledge, this is the first systematic review and meta-analysis on the effect of breathing exercises on the duration of labor. This systematic review and meta-analysis aimed to appraise the evidence concerning the effectiveness of breathing exercises on the duration of labour.

Methods

Electronic databases MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Web of Science, SCOPUS, and ClinicalKey were searched for randomized controlled trials, quasi-experimental studies published in the English language between January 2005 to March 2022 that reported on the effectiveness of breathing exercises on the duration of labour. Duration of labour was the primary analysed outcome. The secondary outcomes assessed were anxiety, duration of pain, APGAR scores, episiotomy, and mode of delivery. Meta-analysis was done using RevMan v5.3.

Results

The reviewed trials involved 1418 participants, and the study participants ranged from 70 to 320. The mean gestational weeks of the participants among the reported trials was 38.9 weeks. Breathing exercise shortened the duration of the intervention group's second stage of labour compared with the control group.

Conclusions

Breathing exercise is a beneficial preventive intervention in shortening the duration of second stage of labour.

Registration

The review protocol was registered with PROSPERO (CRD42021247126).

Physical Therapy in Tension-Type Headache: A Systematic Review of Randomized Controlled Trials

(1) Objective: The aim of this study is to synthesize the effects of physical therapy on pain, frequency, or duration management in the short, medium, and long term in adult patients diagnosed with Tension-type headache (TTH). (2) Background: Tension-type headache (TTH) is the most common headache with migraine and its pathophysiology and treatment has been discussed for years without reaching a consensus. (3) Methods: A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review was registered in PROSPERO (CRD42020175020). The systematic search for clinical trials was performed in the databases PubMed, CINAHL, Cochrane Central Register of Controlled Trials, PEDro, Scopus, SciELO and Dialnet. Articles were selected according to the inclusion and exclusion criteria, regarding the effectiveness of physical therapy interventions on adult patients with TTH published in the last 11 years with a score ≥ 6 in the PEDro Scale (Physiotherapy Evidence Database). (4) Results: In total, 120 articles were identified, of which 15 randomized controlled trials were finally included in order to determine the inclusion criteria. Changes in pain intensity, headache frequency or headache duration of individual studies were described (5) Conclusions: This systematic review shows that there is no standardized physical therapy protocol for the approach to tension headache, although all the techniques studied to date address in one way or another the cranio-cervical-mandibular region. The approach to the cranio-cervical-mandibular region reports significant effects in terms of decreasing the intensity of pain and frequency of headache episodes in the short and medium term. More long-term longitudinal studies are needed.

Management of primary headaches during pregnancy, postpartum, and breastfeeding: A systematic review

BACKGROUND

Primary headaches (migraine, tension headache, cluster headache, and other trigeminal autonomic cephalgias) are common in pregnancy and postpartum. It is unclear how to best and most safely manage them.

OBJECTIVE

We conducted a systematic review (SR) of interventions to prevent or treat primary headaches in women who are pregnant, attempting to become pregnant, postpartum, or breastfeeding.

METHODS

We searched Medline, Embase, Cochrane CENTRAL, CINAHL, ClinicalTrials.gov, Cochrane Database of SRs, and Epistemonikos for primary studies of pregnant women with primary headache and existing SRs of harms in pregnant women regardless of indication. No date or language restrictions were applied. We assessed strength of evidence (SoE) using standard methods.

RESULTS

We screened 8549 citations for studies and 2788 citations for SRs. Sixteen studies (mostly high risk of bias) comprising 14,185 patients (total) and 26 SRs met the criteria. For prevention, we found no evidence addressing effectiveness. Antiepileptics, venlafaxine, tricyclic antidepressants, benzodiazepines, β-blockers, prednisolone, and oral magnesium may be associated with fetal/child adverse effects, but calcium channel blockers and antihistamines may not be (1 single-group study and 11 SRs; low-to-moderate SoE). For treatment, combination metoclopramide and diphenhydramine may be more effective than codeine for migraine or tension headache (1 randomized controlled trial; low SoE). Triptans may not be associated with fetal/child adverse effects (8 nonrandomized comparative studies; low SoE). Acetaminophen, prednisolone, indomethacin, ondansetron, antipsychotics, and intravenous magnesium may be associated with fetal/child adverse effects, but low-dose aspirin may not be (indirect evidence; low-to-moderate SoE). We found insufficient evidence regarding non-pharmacologic treatments.

CONCLUSIONS

For prevention of primary headache, calcium channel blockers and antihistamines may not be associated with fetal/child adverse effects. For treatment, combination metoclopramide and diphenhydramine may be more effective than codeine. Triptans and low-dose aspirin may not be associated with fetal/child adverse effects. Future research should identify effective and safe interventions in pregnancy and postpartum.

Effect of Acupuncture on Pregnancy-Related Insomnia and Melatonin: A Single-Blinded, Randomized, Placebo-Controlled Trial

OBJECTIVE

The aim of the current study is to evaluate the efficacy and safety of acupuncture on sleep quality and overnight melatonin secretion, measured as urinary 6-sulfatoxymelatonin, in pregnant women.

PATIENTS AND METHODS

This randomized, parallel, single-blinded (participant), controlled trial was conducted on 72 pregnant women with insomnia. Study participants were randomly assigned to either the intervention, 10 sessions of acupuncture treatment over a 3-week period, or control group by block randomization (1:1). Patients in both groups were evaluated at baseline and post-treatment (third week) using the Pittsburgh Sleep Quality Index (PSQI) score (as the primary outcome) and urinary 6-sulfatoxymelatonin.

RESULTS

Fifty-five of 72 participants completed the study. There was no statistically significant difference regarding PSQI score and 6-sulfatoxymelatonin level between intervention and control groups at the baseline (P=0.169 and P=0.496). At the end of the study period, treatment with acupuncture significantly improved the PSQI score (P<0.001) with a large effect size of 3.7, as well as 6-sulfatoxymelatonin level (P=0.020) with a medium effect size of 0.6 as compared to the control group. No adverse effects were noted during acupuncture sessions and follow-up visits.

CONCLUSION

Acupuncture was shown to significantly improve the sleep quality in pregnant women, possibly through increasing melatonin secretion, and could be recommended as a low-cost and low-risk alternative treatment to pharmacological therapies.

Using Forbidden Points in Pregnancy: Adverse Outcomes and Quality of Evidence in Randomized Controlled Trials-A Systematic Narrative Review

Objective: Pregnancy is a complex physical and hormonal condition. Many women experience back and pelvic pain, reflux, and headaches during pregnancy. There has been a significant rise in the popularity of acupuncture for pain conditions in pregnancy, wherein nonpharmacologic options are important. Concerns have been raised by both traditional and medical acupuncturists about using "forbidden points" during pregnancy and the risk of preterm contractions (PTC), as this could limit women's and practitioners' willingness to continue treatment during pregnancy. There is also a risk of bias introduced into clinical trials when participants are highly selected or they drop out of studies due to adverse outcomes. This review examined randomized controlled trials (RCTs) of acupuncture using forbidden points prior to 37 weeks of pregnancy to treat pain conditions, with the primary outcome of PTC. Methods: A database search identified RCTs, including trials of penetrating acupuncture that used forbidden points in their protocols to treat pregnancy-related pain conditions. STRICTA [Standards for Reporting Interventions in Clinical Trials of Acupuncture] and GRADE [Grades of Recommendation, Assessment, Development, and Evaluation] criteria were used to assess the quality of evidence. This review includes 8 RCTs reporting on 713 women. Results: Only 2 studies reported on the primary outcome of PTC, and there were insufficient data to perform a primary analysis. In these 2 studies, 6 participants withdrew due to PTC. No study was at a low risk of bias for all GRADE domains, and 3 studies were at high or unclear risk of bias in all domains. Conclusions: PTC is an important clinical outcome and should be reported routinely. The strength of evidence to date is insufficient to recommend using forbidden points prior to 37 weeks of pregnancy. Highly selected patient populations, risk of bias in study design, and participant withdrawal rates, suggest that high-quality trials are required.

Acupuncture for the prevention of tension-type headache

BACKGROUND

Acupuncture is often used for prevention of tension-type headache but its effectiveness is still controversial. This is an update of our Cochrane review originally published in Issue 1, 2009 of The Cochrane Library.

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 other interventions in reducing headache frequency in adults with episodic or chronic tension-type headache.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE and AMED to 19 January 2016. We searched the World Health Organization (WHO) International Clinical Trials Registry Platform to 10 February 2016 for ongoing and unpublished trials.

SELECTION CRITERIA

We included randomised trials with a post-randomisation observation period of at least eight weeks, which compared the clinical effects of an acupuncture intervention with a control (treatment of acute headaches only or routine care), a sham acupuncture intervention or another prophylactic intervention in adults with episodic or chronic tension-type headache.

DATA COLLECTION AND ANALYSIS

Two review authors checked eligibility; extracted information on participants, interventions, methods and results; and assessed study risk of bias and the quality of the acupuncture intervention. The main efficacy outcome measure was response (at least 50% reduction of headache frequency) after completion of treatment (three to four months after randomisation). To assess safety/acceptability we extracted the number of participants dropping out due to adverse effects and the number of participants reporting adverse effects. We assessed the quality of the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation).

MAIN RESULTS

Twelve trials (11 included in the previous version and one newly identified) with 2349 participants (median 56, range 10 to 1265) met the inclusion criteria.Acupuncture was compared with routine care or treatment of acute headaches only in two large trials (1265 and 207 participants), but they had quite different baseline headache frequency and management in the control groups. Neither trial was blinded but trial quality was otherwise high (low risk of bias). While effect size estimates of the two trials differed considerably, the proportion of participants experiencing at least 50% reduction of headache frequency was much higher in groups receiving acupuncture than in control groups (moderate quality evidence; trial 1: 302/629 (48%) versus 121/636 (19%); risk ratio (RR) 2.5; 95% confidence interval (CI) 2.1 to 3.0; trial 2: 60/132 (45%) versus 3/75 (4%); RR 11; 95% CI 3.7 to 35). Long-term effects (beyond four months) were not investigated.Acupuncture was compared with sham acupuncture in seven trials of moderate to high quality (low risk of bias); five large studies provided data for one or more meta-analyses. Among participants receiving acupuncture, 205 of 391 (51%) had at least 50% reduction of headache frequency compared to 133 of 312 (43%) in the sham group after treatment (RR 1.3; 95% CI 1.09 to 1.5; four trials; moderate quality evidence). Results six months after randomisation were similar. Withdrawals were low: 1 of 420 participants receiving acupuncture dropped out due to adverse effects and 0 of 343 receiving sham (six trials; low quality evidence). Three trials reported the number of participants reporting adverse effects: 29 of 174 (17%) with acupuncture versus 12 of 103 with sham (12%; odds ratio (OR) 1.3; 95% CI 0.60 to 2.7; low quality evidence).Acupuncture was compared with physiotherapy, massage or exercise in four trials of low to moderate quality (high risk of bias); study findings were inadequately reported. No trial found a significant superiority of acupuncture and for some outcomes the results slightly favoured the comparison therapy. None of these trials reported the number of participants dropping out due to adverse effects or the number of participants reporting adverse effects.Overall, the quality of the evidence assessed using GRADE was moderate or low, downgraded mainly due to a lack of blinding and variable effect sizes.

AUTHORS' CONCLUSIONS

The available results suggest that acupuncture is effective for treating frequent episodic or chronic tension-type headaches, but further trials - particularly comparing acupuncture with other treatment options - are needed.

The safety of acupuncture during pregnancy: a systematic review

Objective

Although there is a growing interest in the use of acupuncture during pregnancy, the safety of acupuncture is yet to be rigorously investigated. The objective of this review is to identify adverse events (AEs) associated with acupuncture treatment during pregnancy.

Methods

We searched Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED) and five Korean databases up to February 2013. Reference lists of relevant articles were screened for additional reports. Studies were included regardless of their design if they reported original data and involved acupuncture needling and/or moxibustion treatment for any conditions in pregnant women. Studies of acupuncture for delivery, abortion, assisted reproduction or postpartum conditions were excluded. AE data were extracted and assessed in terms of severity and causality, and incidence was determined.

Results

Of 105 included studies, detailed AEs were reported only in 25 studies represented by 27 articles (25.7%). AEs evaluated as certain, probable or possible in the causality assessment were all mild/moderate in severity, with needling pain being the most frequent. Severe AEs or deaths were few and all considered unlikely to have been caused by acupuncture. Total AE incidence was 1.9%, and the incidence of AEs evaluated as certainly, probably or possibly causally related to acupuncture was 1.3%.

Conclusions

Acupuncture during pregnancy appears to be associated with few AEs when correctly applied.