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Review
. 2016 Jun 28;2016(6):CD001218.
doi: 10.1002/14651858.CD001218.pub3.

Acupuncture for the prevention of episodic migraine

Klaus Linde  1 , Gianni Allais, Benno Brinkhaus, Yutong Fei, Michael Mehring, Emily A Vertosick, Andrew Vickers, Adrian R White
Affiliations
Review

Acupuncture for the prevention of episodic migraine

Klaus Linde et al. Cochrane Database Syst Rev. .

Abstract

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 We searched the World Health Organization (WHO) Clinical Trials Registry Platform to February 2016 for ongoing and unpublished trials.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.

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Conflict of interest statement

This review includes trials in which some of the reviewers were involved, as follows: Allais 2002 ‐ Gianni Allais; Jena 2008 ‐ Benno Brinkhaus; Linde K 2005 ‐ Benno Brinkhaus and Klaus Linde; Streng 2006 ‐ Klaus Linde; and Vickers 2004 ‐ Andrew Vickers. These trials were reviewed by at least two other members of the review team.

Gianni Allais, Benno Brinkhaus, Yutong Fei, and Michael Mehring use acupuncture in their clinical work. Adrian White has used acupuncture in the past but has retired from clinical practice.

Within the last three years (June 2013 to May 2016): Gianni Allais received fees for teaching acupuncture in private schools; Klaus Linde once received a fee from the German Medical Acupuncture Society for speaking about research at a conference; Benno Brinkhaus has received fees for presenting research findings at meetings of acupuncture societies in various countries; Adrian White is employed by the British Medical Acupuncture Society as a journal editor and has received fees for lecturing on acupuncture on several occasions.

Emily Vertosick's and Andrew Vickers' contribution to this review was supported by the NIH grant R01AT006794 (see Sources of support).

Figures

1
1
Flow diagram
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study. Note: for trials including both a comparison with sham and a no‐acupuncture control/prophylactic drugs (Diener 2006, Facco 2008, Linde K 2005) blinding was assessed for the comparisons with sham. For the comparisons with no acupuncture/prophylactic drugs the risk of bias is high (no blinding).
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
4
4
Forest plot of comparison: 1 Acupuncture vs. no acupuncture, outcome: 1.1 Headache frequency
5
5
Forest plot of comparison: 1 Acupuncture vs. no acupuncture, outcome: 1.2 Response (at least 50% frequency reduction)
6
6
Forest plot of comparison: 2 Acupuncture vs. sham interventions, outcome: 2.1 Headache frequency
7
7
Forest plot of comparison: 2 Acupuncture vs. sham interventions, outcome: 2.2 Response (at least 50% frequency reduction)
8
8
Forest plot of comparison: 3 Acupuncture vs. prophylactic drug treatment, outcome: 3.1 Headache frequency
9
9
Forest plot of comparison: 3 Acupuncture vs. prophylactic drug treatment, outcome: 3.2 Response (at least 50% frequency reduction)
1.1
1.1. Analysis
Comparison 1 Acupuncture vs. no acupuncture, Outcome 1 Headache frequency.
1.2
1.2. Analysis
Comparison 1 Acupuncture vs. no acupuncture, Outcome 2 Response (at least 50% frequency reduction).
1.3
1.3. Analysis
Comparison 1 Acupuncture vs. no acupuncture, Outcome 3 Headache frequency (various measures).
1.4
1.4. Analysis
Comparison 1 Acupuncture vs. no acupuncture, Outcome 4 Response.
1.5
1.5. Analysis
Comparison 1 Acupuncture vs. no acupuncture, Outcome 5 Migraine attacks.
1.6
1.6. Analysis
Comparison 1 Acupuncture vs. no acupuncture, Outcome 6 Migraine days.
1.7
1.7. Analysis
Comparison 1 Acupuncture vs. no acupuncture, Outcome 7 Headache days.
1.8
1.8. Analysis
Comparison 1 Acupuncture vs. no acupuncture, Outcome 8 Headache intensity.
1.9
1.9. Analysis
Comparison 1 Acupuncture vs. no acupuncture, Outcome 9 Analgesic use.
1.10
1.10. Analysis
Comparison 1 Acupuncture vs. no acupuncture, Outcome 10 Headache scores.
1.11
1.11. Analysis
Comparison 1 Acupuncture vs. no acupuncture, Outcome 11 Safety/acceptability.
2.1
2.1. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 1 Headache frequency.
2.2
2.2. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 2 Response (at least 50% frequency reduction).
2.3
2.3. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 3 Headache frequency (various measures).
2.4
2.4. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 4 Response.
2.5
2.5. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 5 Migraine attacks.
2.6
2.6. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 6 Migraine days.
2.7
2.7. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 7 Headache days.
2.8
2.8. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 8 Headache intensity.
2.9
2.9. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 9 Analgesic use.
2.10
2.10. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 10 Headache scores.
2.11
2.11. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 11 Frequency after treatment ‐ subgroup analysis 1: Adequacy of concealment.
2.12
2.12. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 12 Frequency follow‐up ‐ subgroup analysis 1: Adequacy of concealment.
2.13
2.13. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 13 Response after treatment ‐ subgroup analysis 1: Adequacy of concealment.
2.14
2.14. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 14 Response at follow‐up ‐ subgroup analysis 1: Adequacy of concealment.
2.15
2.15. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 15 Frequency after treatment ‐ subgroup analysis 2: Sample size.
2.16
2.16. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 16 Frequency follow‐up ‐ subgroup analysis 2: Sample size.
2.17
2.17. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 17 Response after treatment ‐ subgroup analysis 2: Sample size.
2.18
2.18. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 18 Response at follow‐up ‐ subgroup analysis 3: Number of treatment sessions.
2.19
2.19. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 19 Frequency after treatment ‐ subgroup analysis 3: Number of treatment sessions.
2.20
2.20. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 20 Frequency follow‐up ‐ subgroup analysis 3: Number of treatment sessions.
2.21
2.21. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 21 Response after treatment ‐ subgroup analysis 3: Number of treatment setssions.
2.22
2.22. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 22 Response at follow‐up ‐ subgroup analysis 2: Sample size.
2.23
2.23. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 23 Frequency after treatment ‐ subgroup analysis 4: Type of sham.
2.24
2.24. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 24 Frequency follow‐up ‐ subgroup analysis 4: Type of sham.
2.25
2.25. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 25 Response after treatment ‐ subgroup analysis 4: Type of sham.
2.26
2.26. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 26 Response at follow‐up ‐ subgroup analysis 4: Type of sham.
2.27
2.27. Analysis
Comparison 2 Acupuncture vs. sham interventions, Outcome 27 Safety/acceptability.
3.1
3.1. Analysis
Comparison 3 Acupuncture vs. prophylactic drug treatment, Outcome 1 Headache frequency.
3.2
3.2. Analysis
Comparison 3 Acupuncture vs. prophylactic drug treatment, Outcome 2 Response (at least 50% frequency reduction).
3.3
3.3. Analysis
Comparison 3 Acupuncture vs. prophylactic drug treatment, Outcome 3 Headache frequency (various measures).
3.4
3.4. Analysis
Comparison 3 Acupuncture vs. prophylactic drug treatment, Outcome 4 Response.
3.5
3.5. Analysis
Comparison 3 Acupuncture vs. prophylactic drug treatment, Outcome 5 Migraine attacks.
3.6
3.6. Analysis
Comparison 3 Acupuncture vs. prophylactic drug treatment, Outcome 6 Migraine days.
3.7
3.7. Analysis
Comparison 3 Acupuncture vs. prophylactic drug treatment, Outcome 7 Headache days.
3.8
3.8. Analysis
Comparison 3 Acupuncture vs. prophylactic drug treatment, Outcome 8 Headache intensity.
3.9
3.9. Analysis
Comparison 3 Acupuncture vs. prophylactic drug treatment, Outcome 9 Analgesic use.
3.10
3.10. Analysis
Comparison 3 Acupuncture vs. prophylactic drug treatment, Outcome 10 Headache scores.
3.11
3.11. Analysis
Comparison 3 Acupuncture vs. prophylactic drug treatment, Outcome 11 Safety/acceptability.
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References

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Qin 2006 {published data only}
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References to studies awaiting assessment

Giannini 2015 {published and unpublished data}
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References to ongoing studies

Chen 2013 {published data only}
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Liang 2013 {published data only}
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References to other published versions of this review

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