A sham-controlled trial of acupuncture as an adjunct in migraine prophylaxis

Does the outcome of acupuncture differ according to the location of sham needling points in acupuncture trials for migraine? A systematic review and network meta-analysis

Various acupuncture clinical trials have been conducted on migraine; however, the conclusions remain controversial especially when acupuncture was compared with sham acupuncture. Sham acupuncture is sometimes performed at the same acupuncture points used for verum acupuncture despite the evidence on acupuncture point specificity. Four databases were searched for sham acupuncture or waiting list-controlled acupuncture trials for migraine on December 25, 2023. Sham acupuncture was classified according to the needling points: sham acupuncture therapy at verum points (SATV) or at sham points (SATS). Network meta-analysis was performed based on the frequentist framework for headache pain intensity and response rate. A total of 18 studies involving 1936 participants were analyzed. Headache pain intensity and response rate were significantly improved in verum acupuncture compared with SATS. However, there was no significant difference between SATV and verum acupuncture. When comparing SATS and SATV, there was no significant difference in headache pain intensity and response rate; however, the results were in favor of SATV. The effect of the risk of bias on the certainty of evidence between verum and sham acupunctures was judged to be generally low. SATV should not be misused as a placebo control to evaluate the efficacy of acupuncture.

Effect of different non-pharmacologic placebo treatments on migraine prevention: a network meta-analysis of randomized controlled trials

BACKGROUND

Placebo control plays an important role in evaluating the effectiveness of interventions. Specifying differential effects of various placebo controls on migraine prevention would be essential in the explanation of preventive treatment for migraine and the indirect comparison between different prophylactic therapeutics.

OBJECTIVES

To access the impact of different non-pharmacologic placebo types on different outcomes in migraine patients.

METHODS

We searched PubMed, Cochrane Controlled Register of Trials, Embase, and Web of Science databases from the date of creation to June 19, 2023. Randomized controlled trials of migraine that included sham intervention of acupuncture or cognitive behavioural therapy (CBT) or non-invasive Vagus Nerve Stimulation (nVNS) or repetitive Transcranial Magnetic Stimulation (rTMS) or transcranial Direct Current Stimulation (tDCS) were conducted. The primary outcome was the migraine days, and the secondary outcomes were the number of migraine attacks, headache days, headache frequency, and responder's rate. Placebo effects were assessed using five individual placebos for network meta-analysis, using mean differences to measure the relative effect of pair-wise comparisons between interventions.

RESULT

A total of 50 trials with 4880 subjects were included. Twenty-seven trials were evaluated for low risk of bias. The results of indirect comparisons show that sham rTMS and sham tDCS had optimal and similar effects in reducing migraine days; sham acupuncture has the greatest effect on reducing the number of migraine attacks and relieving headache frequency; sham rTMS had a highly significant advantage in reducing headache days compared with the other placebo controls.

CONCLUSION

Based on the network meta-analysis results, we found that sham acupuncture had the greatest effect on migraine prophylaxis. The strong placebo effect of sham acupuncture should be considered when assessing the therapeutic effect.

Effectiveness of Acupuncture for Prophylactic Treatment of Migraine: A Systematic Review and Bayesian Network Meta-Analysis

It is aimed to evaluate the effectiveness and provide evidence-based medical support for acupuncture as a prophylactic treatment for migraines. Randomized controlled trials (RCTs) from inception to April 2022 are included in 14 databases. Pairwise meta-analysis is conducted using STATA software V14.0, while Windows Bayesian Inference Using Gibbs Sampling (WinBUGS V.1.4.3) is applied to generate Bayesian Network Meta-analysis (NMA) using Markov chain Monte Carlo algorithm. Forty RCTs are included, with 4405 participants. The effectiveness of six acupuncture techniques, three types of prophylactic drugs, and psychotherapy are compared and ranked. Acupuncture outperformed prophylactic drugs in terms of diminishing visual analog scale (VAS) score, migraine attack frequency, and days during the treatment and at the 12-week follow-up. At the 12-week follow-up, the effectiveness of various interventions is ranked as follows: manual acupuncture (MA) > electroacupuncture (EA) > calcium antagonists (CA) in reducing VAS score; MA > EA > CA in reducing migraine attack frequency; MA > EA > β-receptor blocker and CA in reducing headache attack days. Acupuncture is a promising treatment for migraine prevention. The best option of acupuncture for improving various migraine outcomes has changed over time. However, the quality of included trials and NMA inconsistency limited the credibility of the conclusion.

The durable effect of acupuncture for episodic migraine: a systematic review and meta-analysis

Background

Migraine is a common and recurrent type of headache. Avoiding trigger factors is not often successful in reducing headache frequency, duration, and severity. Prophylactic medications may be effective but are limited by strict indications and daily medication intake. This review aimed to investigate the durable effect of acupuncture on episodic migraine.

Methods

Seven databases including Medline, Embase, PubMed, etc., were searched for English and Chinese literature from their inception to 23 November 2022. Two independent reviewers screened the retrieved studies and extracted the data. Primary outcomes were monthly migraine days, monthly migraine attacks, and VAS score at 3 months post-treatment. The risk of bias in included studies was assessed using the Cochrane Risk of Bias 2.0 tool. Meta-analysis was conducted where applicable.

Results

Fifteen studies were included in this review. Acupuncture reduced the number of migraine attacks (MD -0.68; 95% CI -0.93, -0.43; p < 0.001), the number of days with migraine (MD -0.86; 95% CI -1.18, -0.55; p < 0.001), and VAS score (MD -1.01; 95% CI -1.30, -0.72; p < 0.001) to a greater degree than sham acupuncture at 3 months after treatment. Significant differences in reducing pain intensity of migraine in favor of acupuncture compared with waitlist (MD -1.84; 95% CI -2.31, -1.37; p < 0.001) or flunarizine (MD -2.00; 95% CI -2.35, -1.65; p < 0.001) at 3 months after treatment were found, and the differences reached the minimal clinically important difference (MCID).

Conclusion

This review found that the durable effect of acupuncture for episodic migraine lasted at least 3 months after treatment. More high-quality studies with longer follow-up periods in the future are needed to confirm the findings.

Circulating exosomal microRNA profiles in migraine patients receiving acupuncture treatment: A placebo-controlled clinical trial

Background

Acupuncture has a long history of being used in Chinese medicine for the treatment of migraine. However, molecular biomarkers for diagnosis and prognosis of migraine and its treatment are lacking. This study aimed to explore whether acupuncture could regulate differentially expressed exosomal miRNAs between patients with migraine without aura (MWoA) and healthy controls (HCs) and to identify diagnostic biomarkers that helped differentiate MWoA patients from HCs and identify prognostic biomarkers that helped to predict the effect of acupuncture.

Methods

Here, we isolated serum exosomes from patients with MWoA and HCs before and after true and sham acupuncture treatment. Then, small RNA sequencing and bioinformatics analysis were performed to screen out key miRNAs specifically responding to acupuncture treatment. Pearson's correlation analysis was used to evaluate the correlation between miRNAs and clinical phenotypes. Finally, we applied a machine learning method to identify diagnostic biomarkers of MWoA patients and identify prognostic biomarkers that helped to predict the effect of acupuncture.

Results

Small RNA sequencing identified 68 upregulated and 104 downregulated miRNAs in MWoA patients compared to those in HCs. Further, we identified eight upregulated and four downregulated miRNAs in migraine patients after true acupuncture treatment (trAMWoA), but not in the sham acupuncture treatment (shAMWoA) or HC group. Among them, has-miR-378a-5p was positively correlated with time unable to work, study, or do housework due to migraine (p < 0.05), whereas has-miR-605-3p was negatively correlated with the restrictive subscale of the migraine-specific quality of life questionnaire (MSQ) (p < 0.05). We then evaluated the diagnostic and prognostic potential of these 12 miRNAs in patients with MWoA. The combination of serum levels of exosomal has-miR-369-5p, has-miR-145-5p, and has-miR-5,010-3p could serve as diagnostic and prognostic biomarkers for MWoA patients following acupuncture treatment.

Conclusion

This is the first study on the serum exosomal miRNA profiles of migraineurs before and after acupuncture treatment. Our results improve our understanding of the molecular functions of miRNAs in MWoA. More importantly, they expand our view of evaluating the clinical outcomes of migraine patients treated with acupuncture, using exosomal RNA markers.

Clinical Trial Registration

Chinese Clinical Trial Registry, ChiCTR2000034417, July 2020.

Comparative efficacy of acupuncture-related therapy for migraine: A systematic review and network meta-analysis

Background

Migraine is a worldwide disabling chronic brain disorder, some studies suggest acupuncture-related therapy plays an important role in raising efficiency rates and reducing migraine attacks. However, clinical trials comparing the efficacy of different interventions for migraine are limited and controversial. This network meta-analysis (NMA) was performed to review all randomized controlled trials (RCTs) comparing the effects of acupuncture-related therapy for migraine.

Methods

Randomized controlled trials (RCTs) of acupuncture-related therapy for migraine were searched in the following databases from the date of database inception to March 31, 2022, including PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), VIP Database, Wanfang Database, and Chinese Biomedical Database (CBM). The primary endpoint was visual analog scale (VAS) scores. The secondary endpoints were the number of migraine days, duration of migraine, and frequency of migraine attacks. We used Cochrane risk of bias to assess the quality of evidence for outcomes.

Results

Thirty-nine studies involving 4379 patients with 13 different acupuncture-related methods were evaluated. According to surface under the cumulative ranking curve value, acupoint injection was ranked the highest (98.0%) in VAS scores, followed by acupoint implantation (79.0%); electroacupuncture was the optimal intervention method (82.4%) in the number of migraine days, followed by embedding needle therapy (73.1%); embedding needle therapy ranked first (99.9%) in the duration of migraine, followed by acupoint injection (77.4%); acupoint injection was the best intervention (99.3%) in the frequency of migraine attacks, followed by conventional acupuncture plus massage (73.8%).

Conclusion

These results provide preliminary evidence that acupuncture-related therapy could be recommended as one of the effective treatments for migraine. Conventional acupuncture has significant effects on improving VAS scores, the number of migraine days, duration of migraine, and frequency of migraine attacks. However, more high-quality studies should be carried out to verify this finding.

Systematic review registration

https://inplasy.com/, identifier: INPLASY202110035.

Research on electroacupuncture parameters for knee osteoarthritis based on data mining

Background

Knee osteoarthritis, a common degenerative joint disease, has been widely treated by electroacupuncture in recent years. However, there are too many parameters of the treatment currently, resulting in various applications in clinical practice. This study aims to summarize the optimal stimulation parameters of electroacupuncture for knee osteoarthritis in clinical studies by applying data mining techniques.

Methods

Four databases including Pubmed, Cochrane Library, Embase, and Web of Science were searched for clinical studies on electroacupuncture treating knee osteoarthritis from 2012 to 2021. A database was established by Microsoft Excel 2020 and analyzed by R Version 4.1.1.

Results

Forty-six articles were included according to the established criteria. The most used electroacupuncture stimulation parameters were 0.30 mm × 40 mm needle, continuous wave, low frequency of current (mainly 2 Hz), stimulation duration for 30 min per treatment, and frequency of treatment for once a day. Eighteen acupoints were mentioned and the most used ones include Dubi (ST35), Liangqiu (ST34), Neixiyan (EX-LE4), Xuehai (SP10), Yanglingquan (GB34), and Yinlingquan (SP9), and those most generally used acupoints are closely arranged on the Stomach Channel of Foot Yangming. Cluster analysis showed two groups, one for obligatory acupoints and one for adjunctive ones. The association analysis showed the most supported acupoint pair was Liangqiu (ST34) and Xuehai (SP10).

Conclusions

Continuous wave, low frequency of current (2 Hz), 30-min stimulation, and local acupoint selection are frequently used for electroacupuncture treating knee osteoarthritis. Due to the limitations of this study, further research and more standardized, multi-centered, and large-sample clinical trials should be conducted to provide more convincing evidence.

Comparison of Acupuncture and Sham Acupuncture in Migraine Treatment: An Overview of Systematic Reviews

BACKGROUND

Acupuncture is widely used for treating migraine; however, evidence of its efficacy when compared with sham acupuncture is equivocal. This study aimed to compare the evaluate efficacy of acupuncture versus sham acupuncture in migraine treatment.

METHODS

We searched PubMed, the Cochrane Library, Web of Science, and EMBASE databases from their inception to April 25, 2021, for randomized controlled trials. The outcome measurement included response rate, migraine days, intensity, and frequency.

RESULTS

Twenty randomized controlled trials involving 2725 patients were included. Pooled data suggested that acupuncture was superior to sham acupuncture [mean difference (MD)=-0.52, 95% confidence interval (CI): -0.71 to -0.34, P<0.00001] in reducing the migraine frequency after treatment and follow-up (MD=-0.51, 95% CI: -0.70 to -0.32, P<0.00001). In reducing Visual Analog Scale, acupuncture was superior to sham acupuncture (MD=-0.72, 95% CI: -1.17 to -0.27, P=0.002) after treatment, and also superior to sham acupuncture (MD=-0.82, 95% CI: -1.31 to -0.33, P=0.001) on the follow-up. As for responder rate, acupuncture's efficacy was better than sham acupuncture (relative risk=1.28, 95% CI: 1.00-1.64, P=0.05). However, the reduction of migraine days in the acupuncture group was not significantly different from that in the sham acupuncture group after treatment (MD=-0.62; 95% CI: -1.31 to 0.08; P=0.08) and on the follow-up (MD=-0.68; 95% CI: -1.52 to 0.17; P=0.12).

CONCLUSIONS

Acupuncture appears to be an effective treatment modality for migraine. Compared with sham acupuncture, acupuncture had greater improvements in migraine frequency, Visual Analog Scale, and responder rate, but there was no statistically significant difference for the number of migraine days.

Scientific Knowledge Graph of Acupuncture for Migraine: A Bibliometric Analysis from 2000 to 2019

OBJECTIVE

This study aims to explore the trend and knowledge mapping of acupuncture for migraine through bibliometrics.

METHODS

It retrieved the literature on acupuncture for migraine in the Web of Science database from 2000 to 2019, and then resorted to CiteSpace to conduct bibliometric analysis to attain the knowledge mapping.

RESULTS

The total number of publications each year has increased year by year, and the average annual growth rate from 2000 to 2009 was 15.57%, while from 2010 to 2019 was 6.35%, with a faster growth rate from 2000 to 2009. According to the cluster analysis of institutions, authors, cited references, and keywords, 10, 7, 12, and 10 categories were gained from 2000 to 2019. The most productive countries, institutions, and authors are the USA and China, Technical University of Munich and Beijing University of Chinese Medicine, Linde K and Liang FR from 2000 to 2019, whose frequency is 119/103, 28/24, and 28/24, respectively. However, the most important of them are Canada, Sichuan University, and Witt CM. Owing to their highest centrality, they are 0.86, 0.54, and 0.27 separately. Moreover, cited references that contributed to the most co-citations are Linde K (2005), yet, the most vital cited reference is Karst M (2001). Keywords such as migraine, acupuncture, headache, pain, and randomized controlled trial are the most frequently used. However, needle acupuncture is the crucial keyword. In the cluster analysis of institutions, authors, cited references, and keywords from 2000 to 2019, the largest cluster categories are #0 migraine prophylaxis, #1 randomized controlled trial, #0 episodic migraine, and #0 topiramate treatment. Then, randomized controlled trials of acupuncture prevention and treatment of migraine are the most important research content in this field.

CONCLUSION

Through the bibliometric analysis of the research on acupuncture for migraine in the Web of Science database in the past 20 years, the trends and the Knowledge Graph of the country, institution, author, cited reference, and the keyword are acquired, which have an important guiding significance for quickly and accurately positioning the key information in the field.

A Bibliometric Analysis of Research Trends of Acupuncture Therapy in the Treatment of Migraine from 2000 to 2020

BACKGROUND

Migraine is the second-leading cause of disability worldwide. It is often characterized by attacks of severe, mostly unilateral, pulsating headache associated with symptoms such as photophobia, phonophobia, nausea, vomiting, and cutaneous allodynia. Acupuncture therapy has been used worldwide for the treatment of migraine. However, no visual bibliometric analysis has been conducted on the effects of acupuncture on migraine over the past 20 years. Therefore, this study aimed to explore the current status and trends on the use of acupuncture in the treatment of migraine from 2000 to 2020.

PURPOSE

The objective of this study is to identify the current status and emerging trends of the global use of acupuncture on migraine from 2000 to 2020 using CiteSpace and VOSviewer.

METHODS

Web of Science databases were searched for publications related to acupuncture therapy for treating migraine between 2000 and 2020. CiteSpace and VOSviewer were used to analyze the number of publications per year, countries, institutions, authors, journals, references, and keywords.

RESULTS

A total of 572 publications were included in the final analysis. The total number of publications has continued to increase with some fluctuations over the past 20 years. The most productive country and institution in this field were the USA, and Chengdu University of Traditional Chinese Medicine, respectively. The most active and cited authors were Liang FR and Linde K, respectively. Cephalalgia was the most productive, cited, and co-cited journal. The Linde K (2005) had the highest co-citation, citation number and centrality. The keywords "migraine" ranked first in frequency. The common type of migraine (tension-type headache), research method (randomized controlled trial, multicenter, double-blind), acupuncture's role (prophylactic, quality of life, pain), and evaluation (meta-analysis, systematic review) were the hotspots and frontier trends of acupuncture therapy on migraine between 2000 and 2020.

CONCLUSION

The present study examined the research-related trend in acupuncture therapy on migraine using bibliometric methods and identified the statement and research frontiers over the past two decades. This may help researchers to identify potential hotspots and new directions for future research in this field.

The reporting quality and risk of bias of randomized controlled trials of acupuncture for migraine: Methodological study based on STRICTA and RoB 2.0

OBJECTIVES

To investigate the reporting quality and risk of bias of randomized controlled trials (RCTs) of acupuncture for migraine, to facilitate and improve the quality of RCTs of acupuncture for migraine.

METHODS

The Cochrane Library, PubMed and EMBASE were searched from inception to June 11, 2019 using a comprehensive search strategy. The reporting quality and risk of bias of included RCTs were independently evaluated by two investigators using STRICTA and RoB 2.0. Any disagreement was resolved by a third investigator.

RESULTS

A total of 28 eligible RCTs were published in 24 academic journals from 1994 to 2018. Based on STRICTA, four sub-items including "details of other interventions'' (1/28, 4 %), "setting and context of treatment" (9/28, 32 %), "the extent to which treatment was varied" (11/28, 39 %), and "number of needle insertions per subject per session" (13/28, 46 %), showed low reporting quality. A total of 32 different outcomes were reported in 28 RCTs, and based on RoB 2.0, nine (9/28, 32 %) RCTs were judged to be high RoB, three of which were owing to deviations from intended interventions; 11(11/28, 39 %) RCTs elicited some concerns; and eight (8/28, 29 %) RCTs were low RoB for their outcomes.

CONCLUSIONS

The reporting quality and risk of bias of RCTs of acupuncture for migraine remain suboptimal. Therefore, all stakeholders should make a contribution to improve the quality of RCTs of acupuncture for migraine using STRICTA and RoB 2.0, while not limiting this approach solely to studies on migraine, using STRICTA and RoB 2.0 tools.

Acupuncture versus Various Control Treatments in the Treatment of Migraine: A Review of Randomized Controlled Trials from the Past 10 Years

BACKGROUND

Migraine is defined as a recurrent headache of moderate to severe intensity that seriously affects the quality of life. Recent clinical trials have confirmed that acupuncture is effective in treating migraine. We aimed to review the effectiveness of acupuncture in the treatment of migraine by comparing treatment and various control groups in accordance with the newly published guidelines for systematic reviews.

MATERIALS AND METHODS

The following databases were searched for relevant articles published from January 1, 2010 to December 31, 2019: Embase, PubMed, Medline, Cochrane Library, and four Chinese databases. The present review included randomized controlled trials in which acupuncture was the sole treatment or an adjunctive treatment for migraine. Two researchers independently conducted the study selection, data extraction, and quality assessment processes. Disagreements between reviewers were solved by discussion and data reanalysis. The quality of each included study was evaluated using the Cochrane Collaboration risk-of-bias assessment method and the Standards for Reporting Interventions in Controlled Trials of Acupuncture (STRICTA) checklist.

RESULTS

Forty-nine studies were analyzed and ranked based on the latest STRICTA and Cochrane Collaboration risk-of-bias assessment standards. The analysis revealed that acupuncture reduced headache frequency compared with no treatment (mean difference [MD] = -1.80, P < 0.00001, 95% confidence interval [CI] -2.34 to -1.26) and western medicine (MD = -1.75, P = 0.003, 95% CI -2.91 to -0.58). Headache frequency did not significantly differ between patients who received real acupuncture versus those who received sham acupuncture (MD = -0.64, P = 0.24, 95% CI -1.70 to 0.42).

CONCLUSION

The present review evaluated the current research on the use of acupuncture for migraine, compared with various control treatments. The evidence for the effectiveness of acupuncture in controlling migraine is still limited due to the low quality of the published studies.

A Systematic Review and Meta-analysis of the Therapeutic Effect of Acupuncture on Migraine

Background: Migraine is an intractable headache disorder, manifesting as periodic attacks. It is highly burdensome for patients and society. Acupuncture treatment can be beneficial as a supplementary and preventive therapy for migraine. Objectives: This systematic review and meta-analysis aimed to investigate the efficacy and safety of acupuncture for migraine, and to examine transcranial doppler changes after acupuncture. Methods: Reports, conference, and academic papers published before March 15, 2019 in databases including PubMed, Cochrane library, Embase, China National Knowledge Infrastructure, WANFANG Database, Chinese journal of Science and Technology, and China Biomedical were searched. Randomized controlled trials (RCTs) involving acupuncture, sham acupuncture, and medication in migraine were included. The Cochrane Collaboration software, RevMan 5.3, was used for data processing and migration risk analysis. Results: Twenty-eight RCTs were included. 15 RCTs included medication only, 10 RCTs included sham acupuncture only, and 3 RCTs included both. The study included 2874 patients, split into 3 groups: acupuncture treatment group (n = 1396), medication control group (n = 865), and sham acupuncture control group (n = 613). The results showed that treatment was more effective in the acupuncture group than in the sham acupuncture group (MD = 1.88, 95% CI [1.61, 2.20], P < 0.00001) and medication group (MD = 1.16, 95% CI [1.12, 1.21], P < 0.00001). Improvement in visual analog scale (VAS) score was greater in the acupuncture group than in the sham acupuncture group (MD = -1.00, 95% CI [-1.27,-0.46], P < 0.00001; MD = -0.59, 95% CI [-0.81,-0.38], P < 0.00001), and their adverse reaction rate was lower than that of the medication group (RR = 0.16, 95% CI [0.05, 0.52], P = 0.002). The improvement of intracranial blood flow velocity by acupuncture is better than that by medication, but the heterogeneity makes the result unreliable. Conclusions: Acupuncture reduced the frequency of migraine attacks, lowered VAS scores, and increased therapeutic efficiency compared with sham acupuncture. Compared with medication, acupuncture showed higher effectiveness with less adverse reactions and improved intracranial blood circulation. However, owing to inter-study heterogeneity, a prospective, multicenter RCT with a large sample is required to verify these results.

Antagonism of Cannabinoid Receptor 1 Attenuates the Anti-Inflammatory Effects of Electroacupuncture in a Rodent Model of Migraine

Background

The anti-nociceptive effects of electroacupuncture (EA) in migraine have been documented in multiple randomised controlled trials. Neurogenic inflammation plays a key role in migraine attacks, and the anti-inflammatory effects of acupuncture have been associated with the type 1 cannabinoid (CB1) receptor.

Objective

To investigate whether CB1 receptors mediate the anti-inflammatory effects of EA on migraine attacks.

Methods

A migraine model was produced in Sprague-Dawley rats by unilateral electrical stimulation of the trigeminal ganglion (TGES). Rats received EA daily on the 5 days preceding TGES with (TGES+EA+SR141716 group) or without (TGES+EA group) intraperitoneal injections of the CB1 receptor antagonist SR141716. Another group of TGES rats (TGES+MA group) and a non-TGES sham-operated group of rats (Sham+MA group) received minimal acupuncture (MA). Calcitonin gene-related peptide (CGRP) and prostaglandin E2 (PGE2) concentrations were determined in serum obtained from the ipsilateral jugular vein at initiation of TGES and 5 min after. Postmortem interleukin (IL)-1β and cyclooxygenase (COX)2 protein levels in the trigeminal ganglion (TG) and plasma protein extravasation (PPE) in the dura mater were assessed.

Results

TGES induced increases in serum CGRP and PGE2 levels (TGES+MA vs baseline and vs Sham: all p<0.001), as well as IL-1β and COX2 protein expression in the TG, and neurogenic PPE levels (TGES+MA vs Sham+MA: all p<0.001). EA attenuated TGES-induced increases in the levels of these proteins (TGES+EA vs TGES+MA: all p<0.001). CB1 receptor antagonism reversed the effects of EA (TGES+EA+SR141716 vs TGES+EA: all p<0.05).

Conclusions

CB1 receptors appear to mediate anti-inflammatory effects of EA in a rat model of migraine.

Current Treatment Options: Headache Related to Menopause-Diagnosis and Management

PURPOSE OF REVIEW

Menopause is a life-changing event in numerous ways. Many women with migraine hold hope that the transition to the climacteric state will coincide with a cessation or improvement of migraine. This assumption is based mainly on common lay perceptions as well as assertions from many in the healthcare community. Unfortunately, evidence suggests this is far from the rule. Many women turn to a general practitioner or a headache specialist for prognosis and management. A natural instinct is to manipulate the offending agent, but in some cases, this approach backfires, or the concern for adverse events outweighs the desire for a therapeutic trial, and other strategies must be pursued. Our aim was to review the frequency and type of headache syndromes associated with menopause, to review the evidence for specific treatments for headache associated with menopause, and to provide management recommendations and prognostic guidance.

RECENT FINDINGS

We reviewed both clinic- and population-based studies assessing headache associated with menopause. Headache in menopause is less common than headache at earlier ages but can present a unique challenge. Migraine phenotype predominates, but presentations can vary or be due to secondary causes. Other headache types, such as tension-type headache (TTH) and cluster headache (CH) may also be linked to or altered by hormonal changes. There is a lack of well-defined diagnostic criteria for headache syndromes associated with menopause. Women with surgical menopause often experience a worse course of disease status than those with natural menopause. Hormonal replacement therapy (HRT) often results in worsening of migraine and carries potential for increased cardiovascular and ischemic stroke risk. Estrogen replacement therapy (ERT) in patients with migraine with aura (MA) may increase the risk of ischemic stroke; however, the effect is likely dose-dependent. Some medications used in the prophylaxis of migraine may be useful in ameliorating the vasomotor and mood effects of menopause, including venlafaxine, escitalopram, paroxetine, and gabapentin. Other non-medication strategies such as acupuncture, vitamin E, black cohosh, aerobic exercise, and yoga may also be helpful in reducing headache and/or vasomotor symptoms associated with menopause. The frequency and type of headache associated with menopause is variable, though migraine and TTH are most common. Women may experience a worsening, an improvement, or no change in headache during the menopausal transition. Treatment may be limited by vascular risks or other medical and psychiatric factors. We recommend using medications with dual benefit for migraine and vasomotor symptoms including venlafaxine, escitalopram, paroxetine, and gabapentin, as well as non-medication strategies such as acupuncture, vitamin E, black cohosh, aerobic exercise, and yoga. If HRT is pursued, continuous (rather than cyclical) physiological doses should be used, transdermal route of administration is recommended, and the patient should be counseled on the potential for increased risk of adverse events (AEs). Concomitant use of a progestogen decreases the risk of endometrial hyperplasia with ERT. Biological mechanisms are incompletely understood, and there is a lack of consensus on how to define and classify headache in menopause. Further research to focus on pathophysiology and nuanced management is desired.

Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis

Despite wide use in clinical practice, acupuncture remains a controversial treatment for chronic pain. Our objective was to update an individual patient data meta-analysis to determine the effect size of acupuncture for 4 chronic pain conditions. We searched MEDLINE and the Cochrane Central Registry of Controlled Trials randomized trials published up until December 31, 2015. We included randomized trials of acupuncture needling versus either sham acupuncture or no acupuncture control for nonspecific musculoskeletal pain, osteoarthritis, chronic headache, or shoulder pain. Trials were only included if allocation concealment was unambiguously determined to be adequate. Raw data were obtained from study authors and entered into an individual patient data meta-analysis. The main outcome measures were pain and function. An additional 13 trials were identified, with data received for a total of 20,827 patients from 39 trials. Acupuncture was superior to sham as well as no acupuncture control for each pain condition (all P < .001) with differences between groups close to .5 SDs compared with no acupuncture control and close to .2 SDs compared with sham. We also found clear evidence that the effects of acupuncture persist over time with only a small decrease, approximately 15%, in treatment effect at 1 year. In secondary analyses, we found no obvious association between trial outcome and characteristics of acupuncture treatment, but effect sizes of acupuncture were associated with the type of control group, with smaller effects sizes for sham controlled trials that used a penetrating needle for sham, and for trials that had high intensity of intervention in the control arm. We conclude that acupuncture is effective for the treatment of chronic pain, with treatment effects persisting over time. Although factors in addition to the specific effects of needling at correct acupuncture point locations are important contributors to the treatment effect, decreases in pain after acupuncture cannot be explained solely in terms of placebo effects. Variations in the effect size of acupuncture in different trials are driven predominantly by differences in treatments received by the control group rather than by differences in the characteristics of acupuncture treatment.

PERSPECTIVE

Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Treatment effects of acupuncture persist over time and cannot be explained solely in terms of placebo effects. Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain.

Acupuncture for the prevention of episodic migraine

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 (I² = 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 (I² = 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; I² = 47%) after treatment and -0.19 (95% CI -0.30 to -0.09; I² = 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; I² = 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; I² = 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 I² 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.

Verum versus sham manual acupuncture for migraine: a systematic review of randomised controlled trials

BACKGROUND

Manual acupuncture (MA) is commonly used as a treatment for migraine in China. However, its specific clinical effects have been challenged on the basis that some of its effects may relate to psychological or 'placebo' mechanisms.

OBJECTIVE

To identify the effectiveness of verum MA compared with sham acupuncture for the treatment of migraine.

METHODS

Eight electronic databases were searched for randomised controlled trials (RCTs) evaluating the effect of verum versus sham MA on migraine. The quality of included trials was assessed using the 'risk of bias' tool provided by the Cochrane Handbook for Systematic Review of Intervention. RevMan 5.2 software was used for data analysis.

RESULTS

Ten trials with 997 participants were included. Most trials had high methodological quality and were at low risk of bias. Meta-analysis showed superior effects of verum MA over sham acupuncture on the total effective rate, reflected by a reduction in the 'not effective' rate (relative risk (RR) 0.24, 95% CI 0.15 to 0.38; p<0.0001, four trials) and a reduced recurrence rate (RR 0.47, 95% CI 0.28 to 0.81; p=0.006, two trials), but no significant differences in headache intensity, frequency or duration, accompanying symptoms and use of medication. No severe adverse events related to acupuncture occurred during treatment with either verum or sham MA.

CONCLUSIONS

Current clinical evidence suggests that verum acupuncture is superior to sham acupuncture in migraine, reflected by a higher total effective rate and decreased recurrence rate. Nevertheless, further large-scale RCTs with a rigorous design are required to confirm these findings in view of the relative paucity of eligible RCTs and small sample sizes of those included.