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 []

12 Responses to this post
[...] unknown wrote an interesting post today onHere’s a quick excerptTwo 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 … [...]
I was very interested to learn about these recent studies. I have been suffering from migraines for about 15 years. I have been to several specialists, had every diagnostic test and scan available and have been prescribed every drug available. I have even participated in experimental drug studies. None of the medication had good results. My doctors literally shrugged their shoulders and asked “you’ve had them all which one did you like the best?” Finally, in desperation I tried acupuncture. I was extremely skeptical and have always relied on science over “magic” but figured I didn’t have anything to lose.

My acupuncturist warned me that I would require a lot of frequent treatments in the beginning to have a good response. So, for the first three months I had a 30-45 minute session twice a week, then slowly tapered back the treatments over the past two years to my current routine of once every three weeks.

My migraine attacks were 4-5 per week, each lasting 1-3 days and I would consistently rate my pain level at a 7. Since my acupuncture treatments I now have a migraine about once a week lasting 12-24 hours and my pain level is about a 3.

It appears the studies are either point to a strong placebo effect or a connection to stimulating the nervous system with needles in general has an effect. But because of my own positive results I can’t help but wonder if there is more that these studies are not revealing.

One question I would be curious to see studied is a comparison of the sham method versus Chinese and Japanese style acupuncture. My practitioner is trained in the Japanese style and from what I understand there is a greater focus on very specific needle placement than with Chinese. Also, the Japanese style uses much finer needles (with no pain). I also wonder if the studies are long enough and intense enough to see the full effect of acupuncture treatments. As I mentioned earlier, it took a lot of initial treatments, followed by sustained routine for me to achieve the results I have seen. Is the placebo effect lasting or does it typically fade?
Hi Gregg, thanks for sharing. It’s good that you keep a cautious approach even after your positive results -the vast majority of people would immediately attribute treatment to ancient Chinese wisdom…

But because of my own positive results I can’t help but wonder if there is more that these studies are not revealing

I do not think so. There have been really many studies and trials on acupuncture, the majority of which point to the placebo effect and other non-specific effects from the needling -which you mention as well.

One question I would be curious to see studied is a comparison of the sham method versus Chinese and Japanese style acupuncture.

But the reviews mention a large number of trials that compare “real” to fake acupuncture and they didn’t discover a difference! No matter where you put the needles, or even if you do not penetrate the skin, it makes no difference!

Keep in mind that chronic conditions provide the most fertile ground for alternative treatments for a variety of reasons: regression to the mean and cyclic nature; placebo effect; the very subjective (and easily manipulated psychologically) nature of pain etc.
I had dinner with the former publicity person for the British Acupuncturist Association yesterday evening. Shame I did not read this article yesterday. I would then have remembered to make the point about sham acupuncture.

Any positive benefits of acupuncture surely have to be due to sticking needles in people rather than pre-scientific notiions of Qi, Yin and Yang or whatever.
I would then have remembered to make the point about sham acupuncture.” -that ought to have been interesting :-)

Any positive benefits of acupuncture surely have to be due to sticking needles in people rather than pre-scientific notiions of Qi, Yin and Yang or whatever.” -well, that’s certainly what the reviews have shown! And you don’t even have to stick the needles anywhere! It’s simply an elaborate placebo.

And as Steven Novella has pointed out, it is not right to say that acupuncture works at all!
6. sciencebitches
“Shame I did not read this article yesterday. I would then have remembered to make the point about sham acupuncture.”

Oh damn, that would have been fun to watch!
Perhaps a trial could be done sticking pencils or keyrings in to people? Would that count as acupuncture?
8. sciencebitches
LeeT, go on! you seem to have stumbled upon a very interesting idea. Shall we design such a trial?

What else can we possibly stick to people?
That’s cool. We can call it “alternative alternative medicine” :-)
Apologies, but I have just had a look at Ernst and Singh’s Trick or Treatment. Acupuncture is to do with Ch’i not Qi, Yin or Yang. The Ch’i a vital life force flow through meridians.

So if anyone claims acupuncture works they need to explain what Ch’i and meridians are.

I am waiting ….
LeeT, I think Qi and Ch’i it’s the same thing just spelled differently… It’s supposed to be that life energy flow as you say. None has any base in reality of course :-)

By the way, Singh’s book is high on my list. Any initial thoughts?
You need to read it if you want to become an expert on the evidence base for alternative remedies. Where there is evidence for some “alternative” remedies - e.g St Johns Wort and some types of osteopathy - Ernst and Singh are not afraid to say so
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