Acupuncture (real or fake it doesn’t matter) good for headaches and migraines

Two new Cochrane Systematic Reviews have just been published (January 2009) looking into the prophylactic effects of acupuncture on tension-type headaches [1], and migraines [2]. Klaus Linde (famous for his research in Complementary and Alternative Medicine, CAM) was the lead investigator in both studies. So let’s have a quick look at the results of these studies, while waiting for Orac and the people over at Science-based Medicine to take notice of the reviews.

In the first review on tension type headaches, the results were positive for real acupuncture as a prophylactic measure when compared to basic treatment of acute episodes (usually with painkillers and of course without blinding of any type!) or routine care (which is what?). When compared to sham acupuncture though, there was a small statistically significant (but probably clinically insignificant) difference in the patients’ responses.

Eleven trials with 2317 participants (median 62, range 10 to 1265) met the inclusion criteria. Two large trials compared acupuncture to
treatment of acute headaches or routine care only. Both found statistically significant and clinically relevant short-term (up to 3 months)
benefits of acupuncture over control for response, number of headache days and pain intensity. Long-term effects (beyond 3 months)
were not investigated. Six trials compared acupuncture with a sham acupuncture intervention, and five of the six provided data for
meta-analyses. Small but statistically significant benefits of acupuncture over sham were found for response as well as for several other
outcomes. Three of the four trials comparing acupuncture with physiotherapy, massage or relaxation had important methodological
or reporting shortcomings. Their findings are difficult to interpret, but collectively suggest slightly better results for some outcomes in
the control groups.

The second review, dealt with acupuncture as a prophylactic measure against migraines. Results here were very similar to the first paper: acupuncture as a prophylaxis had a better response than no treatment or routine care (again, what is this?). Interestingly, fourteen trials that compared real and sham acupuncture, found no overall statistically significant difference -or else, hello placebo effect, goodbye Chinese magic! Finally, it also seems that acupuncture achieves a marginal win over typical prophylactic drug treatment -which says a lot perhaps about the power of placebo*) especially considering that comparing acupuncture to real drug treatment, certainly means that blinding is not involved!

Twenty-two trials with 4419 participants (mean 201, median 42, range 27 to 1715) met the inclusion criteria. Six trials (including
two large trials with 401 and 1715 patients) compared acupuncture to no prophylactic treatment or routine care only. After 3 to 4
months patients receiving acupuncture had higher response rates and fewer headaches. The only study with long-term follow up saw no
evidence that effects dissipated up to 9 months after cessation of treatment. Fourteen trials compared a ’true’ acupuncture intervention
with a variety of sham interventions. Pooled analyses did not show a statistically significant superiority for true acupuncture for any
outcome in any of the time windows, but the results of single trials varied considerably. Four trials compared acupuncture to proven
prophylactic drug treatment. Overall in these trials acupuncture was associated with slightly better outcomes and fewer adverse effects
than prophylactic drug treatment. Two small low-quality trials comparing acupuncture with relaxation (alone or in combination with
massage) could not be interpreted reliably.

It is important to mention a few more things regarding both reviews.

  • First, there was no statistically significant difference (or a small and probably clinically irrelevant in the headache review) between “real” acupuncture and sham acupuncture. This can only mean one thing: that the traditional Chinese mysticism surrounding acupuncture, with the highly dubious concepts of Qi, energy flows, meridians etc. is just what every skeptic and scientist has been saying all along: magical woo woo. Magical energies just do not exist in reality…

    Further, it also means that there is a very strong placebo response associated with acupuncture (especially since sham acupuncture didn’t not even involve actual needling in some cases, which pretty much rules out any physiological response).

  • Second, the conditions studied, headaches and migraines, are semi-self-limiting conditions in the sense that pain is a very subjective issue, and psychological conditions play a hugely important role in controlling pain -hence a very fertile ground for the placebo effect to act on. Studies on acupuncture in more “objectively” measured conditions have shown that acupuncture does not work over placebo (references to come soon -I have them stored somewhere!).

  • Finally, on both reviews, acupuncture was only studied as a prophylactic measure. One cannot assume that it will be effective during actual migraine or acute headache episodes.


With the results of the reviews available, we can perhaps conclude that acupuncture may provide a seemingly effective prophylactic method to control such conditions as headaches and migraines even if the placebo effect or other non-specific needling effects are the causative agents -OK, some ethical issues might arise here, but one can argue that they can be sidestepped (can they?) since the evidence show a possible positive effect.

Having said that, we need to further qualify this statement with two important observations: one cannot extrapolate from these reviews and generalize that acupuncture is an efficient treatment. It has only been *possibly* effective as a prophylactic in very specific pain-related conditions, namely headaches and migraines. Any generalization that includes serious conditions is not only unwarranted but dangerous too -especially when we have such strong indications that the placebo effect is in action here!

Also, to all new age mystics and proponents of ancient Chinese wisdom: please, do not bother us again with energy flows, Qis, meridians, and other such nonsense. It’s magical crap in their most primitive and naive form.

Despite the actual contents of the reviews, previous experience suggests that the media will distort the scientific reality once again to declare that “hey, acupuncture is so good, that even is fake version works!” Poor Ben Goldacre will be very busy in the coming days…

I am sure I missed the subtle points in these reviews, since it was a hasty reading. I will try to keep this post updated with links to posts by Orac, SBM, or any other more experienced and qualified blogger. In all probability they will have a very thorough discussion on these reviews. Let’s wait and see…

UPDATES (22nd Jan)

Steven Novella discusses the reviews with a very tasteful introduction :-)

– “Acupuncture ‘works for headaches’” declares BBC, and only later qualifies with “but so is a sham form”…

– The Guardian and the Telegraph have done better jobs with their headlines

UPDATES (23rd Jan)

Further discussion by Steven Novella where he touches some of the ethical issues and the non-specific effects of acupuncture:

It is unscientific to conclude that a specific intervention (acupuncture in this case) works because of non-specific effects.

[…]
What this means is that we should eliminate acupuncture entirely from the equation. Any benefit from the ritual of acupuncture can be derived by using the non-specific elements stripped away from the pseudoscience of acupuncture itself.

which gives me more confidence to answer the question I made above: “OK, some ethical issues might arise here, but one can argue that they can be sidestepped (can they?)“. And the answer is: no. No reason to do so and keep pseudoscience on the table.



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Footnotes:
  1. * (Granted, acupuncture might have a plausible physiological mechanism, some non-specific needling effects, that elicits such pain-killing results. I am not sure though, how sticking needles through one’s skin can achieve that result. Further research might reveal something (or have I missed something relevant?) []


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References:
  1. Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR, “Acupuncture for tension type headache,” Cochrane Database of Systematic Reviews 2009, Issue 1 []
  2. Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR, “Acupuncture for migraine prophylaxis,” Cochrane Database of Systematic Reviews 2009, Issue 1 []