Keywords: Chinese medicine, acupuncture, migraine headache, electroacupuncture

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A migraine is a type of periodic headache that lasts four to 72 hours and is throbbing, moderate-to-severe in intensity, unilateral, worse with exertion, and associated with nausea and vomiting and/or sensitivity to light, sound, or smell. Approximately 24 million Americans have migraines, which may occur at any age. Migraines are a commonly seen complaint by acupuncturists, and one of the first questions acupuncturists are asked by prospective patients is whether or not acupuncture is effective for the treatment of this disorder. To help substantiate the answer to that oft-asked question, I would like to present summaries of a number of Chinese cohort studies and comparative clinical trials that strongly suggest that acupuncture is indeed an effective method of treatment for migraine headaches.

Study 1
This first study, "A Clinical Audit of the Treatment of 207 Cases of Migraine with Acupuncture on Liver-Gallbladder Channel Points," appeared in issue #11, 2002, of the Zhong Yi Za Zhi (Journal of Chinese Medicine). This study was authored by Li Wei et al. from the New Medicine Department of Zhongnan University's Xiang Ya Hospital in Changsha, Hunan and appeared on pages 824-825 of this journal.

Cohort Description
There were a total of 268 migraineurs in this study. Two hundred and seven patients were assigned to the acupuncture treatment group, and 61 were assigned to the Western medicine group. There were also another 30 healthy people in a comparison group. In the acupuncture group, there were 69 males and 38 females aged 18-65 years, with an average age of 31.24 years. These patients had suffered from migraines for three months to 37 years, with average disease durations of 13.26 years. In the Western medicine group, there were 21 males and 40 females aged 19-63, with an average age of 30.82 years. These patients had suffered with migraines from two months to 35 years, with an average disease duration of 12.28 years. In the healthy comparison group, there were 11 males and 19 females whose ages were comparable to the treatment groups.

Treatment Method
All 207 patients in the acupuncture group received electroacupuncture. Fine needles were inserted into the points chosen and then stimulated with a dense disperse wave with a low frequency of 20Hz and a high frequency of 40Hz. The strength of stimulation was as great as the patient could bear. The needles were retained for 30 minutes each session. The points chosen consisted of the following:

• Tai Chong (Liv 3)
• Xing Jian (Liv 2)
• Feng Chi (GB 20)
• Yang Ling Quan (GB 34)

Treatment was given once per day with six treatments equaling one course. Between successive courses, patients were allowed a one-day rest, and four such courses were administered. All 61 patients in the Western medicine group were administered 20 mg t.i.d. of nifedipine and 5 mg of ibuprofen once per evening. At the beginning of an episode, sumatriptan (Imitrex) might be added. These patients took these medicines continuously for four weeks without a break. During this time, both groups received no other therapy except for a multivitamin and vitamin C. They did not receive any other sedative or pain-relieving medications. In addition, serum calcitonin gene-related peptide (CGRP) and substance P (SP), two chemicals associated with expanded blood vessels and neurogenic inflammation, respectively, were analyzed in the normal comparison group and in the acupuncture group before and after treatment.

Study Outcomes
Clinical cure was defined as complete remission of clinical symptoms with no recurrence within one year. Marked effect was defined as remission of clinical symptoms and no recurrence within half a year. Some effect was defined as marked decrease in clinical symptoms or complete disappearance but recurrence soon after cessation of treatment. No effect was defined as inability to stop the pain after one week of beginning treatment. Based on these criteria, 124 patients (54.62%) in the acupuncture group were considered cured, 59 (25.99%) got a marked effect, 32 (14.09%) got some effect, and 12 (5.3%) got no effect. Therefore, the total effectiveness rate in the acupuncture group was 94.7%, and the marked effectiveness in that group was 80.61%. In the Western medicine group, 21 cases (34.43%) were considered cured, 14 (22.95%) got a marked effect, 11 (18.03%) got some effect, and 15 (24.59%) got no effect. Thus, the total effectiveness in that group was only 75.4%, and the marked effectiveness was only 57.38%. This means that the acupuncture protocol was definitely more effective than the Western medical protocol.

In terms of mean CGRP and Sp, in the normal comparison group, CGRP was 5.28 ± 1.21pg/ml and SP was 145.76 ± 50.84Fm/ml. Before treatment with acupuncture, mean CGRP in the acupuncture treatment group was 11.38 ± 1.74pg/ml, and it was only 6.19 ± 1.37pg/ml after treatment. Before treatment, mean SP was 304.83 ± 78.14Fm/ml in the acupuncture treatment group and only 181.15 ± 64.12Fm/ml after treatment. Therefore, there was a definite marked movement towards more normal levels of CGRP and SP in these migraineurs after treatment.

Discussion
According to Drs. Li et al., in Chinese medicine, migraine headaches may be due to a variety of factors. For instance, external contraction of the six environmental excesses may ascend and attack the vertex and crown, blocking and repressing clear yang. Unregulated drinking and eating or internal damage may result in loss of harmony of the viscera and bowels with qi and blood counterflow and chaos. This may also cause stasis and obstruction in the channels and network vessels of the head with subsequent loss of moistening and nourishment of the brain. At the onset of an attack, there is mainly a repletion pattern. The qi mechanism has lost its regulation, and the blood vessels become static and obstructed. Therefore, treatment should course the liver and rectify the qi, quicken the blood and stop pain. During the remission phase, there is typically a mixture of vacuity and repletion. The liver is depressed, and the spleen is vacuous with qi stagnation and blood stasis. During that phase, treatment should course the liver and fortify the spleen, regulate the qi and quicken the blood. In this protocol, treatment of the liver is the main thing, and the treatment outcomes show that this approach is more effective than standard Western medicine. In patients presenting a repletion pattern, needling liver and gallbladder channel points gets a very good effect for the treatment of migraine. This is because, in Chinese medicine, there is a very close relationship between the liver and migraines.

For those who are skeptical whether acupuncture is capable of effecting changes in the chemical constituents of the human body, the almost normalization of CGRP and SP levels after acupuncture treatment documented by this study should help relieve such doubt.

Study 2
In issue #9, 2003, of Gan Su Zhong Yi (Gansu Chinese Medicine), Du Xiu Xia published "Experiences in the Treatment of 40 Cases of Side Head Pain with Matrix Acupuncture-moxibustion." This article appeared on pages 27-28 of that journal.

Cohort Description
Among the 40 patients included in this study, there were 12 males and 28 females, 16-68 years of age, who had suffered from migraines for durations ranging from one month to 23 years.

Treatment Method
The Matrix Point formula consists of the following:

• Si Zhong Xue (Four Middles Points; these are four extra-channel points located one inch further outside Si Shen Cong, M-HN-1 on the crown of the head)
• Tou Nie Xue (Head Temple Point, an extra-channel point located one inch posterior to Tai Yang, M-HN-9, on the same level as the apex of the ear)
• Feng Chi (GB 20)

This group of eight points (when needled bilaterally) makes up the head region Matrix point formula.

If the headache was most pronounced in the forehead or eye region, these points were combined with Ben Shen (GB 13) and Zan Zhu (Bl 2).

If the headache was vascular in nature, they were combined with Nei Guan (Per 6); while, if they were neurological in nature, they were combined with He Gu (LI 4).

A 1-1.5 inch 28-30 gauge needle was used to needle the first four points with their tips angled toward Bai Hui (GV 20). These points were needled transversely to a depth of one inch. Feng Chi was needled toward the opposite eye to a depth of one inch, while Tou Nie was needled transversely toward Shang Guan (GB 3) to a depth of one inch. After obtaining the qi, the needles were retained for 20-30 minutes. If Zan Zhu was needled, it was inserted with its tip angled upward. If Ben Shen was needled, its tip was angled posterior. If Nei Guan and/or He Gu were needled, they were used with draining technique. Acupuncture was administered once per day, with ten times equaling one course of treatment.

Study Outcomes
Cure was defined as complete disappearance of headaches after one to two courses of treatment and no recurrence within one year. Marked effect was defined as less than five headaches of slight degree within the year after treatment. Patients did not need to take any medicine for these headaches, which remitted spontaneously. No effect meant that, although the headaches decreased in severity after treatment, their incidence was decreased by less than 50%. Based on these criteria, 31 out of 40 cases (77.5%) were labeled cured, seven (17.5%) got a marked effect, and two (5%) got no effect, for a total effectiveness rate of 95%.

Discussion
According to Dr. Du, migraines are due to spasm of the cerebral arteries causing lack of blood and disturbance in function. The Matrix points are chosen based on the saying, "Choose points based on location [of the disease]." The Matrix points regulate the central nervous system and blood vessels in the top and sides of the head. They appear to have a definite effect in the treatment of migraines. However, it should be noted that the treatment frequency and needle technique – and not just the choice of points – may have a lot to do with these outcomes.

Study 3
On page 20 of issue #11, 2005, of Zhen Jiu Lin Chuang Za Zhi (Clinical Journal of Acupuncture & Moxibustion), Sun Bo published "The Acupuncture Treatment of 68 Cases of Migraine Headache."

Cohort Description
All 68 cases enrolled in this study were treated as outpatients. Among them, there were 26 males and 42 females 18-60 years of age, with an average age of 35 years. The disease duration ranged from one month to more than six years. Forty-eight patients took medicines regularly to control their migraines. The other 20 did not. Thirty-four cases had a family history of migraines.

Treatment Method
The main points used in this trial were as follows:

• Feng Chi (GB 20)
• Tai Chong (Liv 3)
• Xing Jian (Liv 2)

The auxiliary points were as follows:

• Tai Yang (M-HN-9)
• Tou Wei (St 8)
• Shuai Gu (GB 8)
• A shi points

After disinfection, Feng Chi was needled with a 1.5-inch needle with even supplementing-even draining technique. Tai Chong and Xing Jian were needled with strong stimulation for one to three minutes. Shuai Gu was needled through to Tou Wei with a two-inch needle. Then small amplitude twisting and turning draining technique was used for one to three minutes. Tai Yang and a shi points were bled three to five drops with a three-edged needle. The needles were retained for 30 minutes and re-stimulated one time during treatment. One treatment was given per day, and ten treatments equaled one course. A three- to four-day rest was allowed between successive courses. Outcomes were analyzed after two courses of treatment.

Study Outcomes
Cure was defined as complete absence of headache with no other associated symptoms and no recurrence on follow-up after one month. Marked effect was defined as a marked decrease in headaches and other associated symptoms and no disturbance to daily work or other life activities. No effect meant that there was no obvious improvement in the headaches or associated symptoms and patients experienced daily disturbances in their work and lives. Based on these criteria, 26 cases (38.2%) were cured, 39 cases (57.4%) got a marked effect, and three cases (4.4%) got no effect for a total effectiveness rate of 95.6%.

Discussion
According to Dr. Sun, migraines fall under the traditional Chinese disease categories of headache and head wind. They are mostly due to wind evil invasion and attack, ascendant liver yang hyperactivity, phlegm turbidity obstructing the network vessels, and/or blood stasis obstructing the network vessels. However, external contraction and internal damage are the two main types. Dr. Sun believes that treatment of this condition should mainly be addressed to the hand and foot shao yang channels in order to course and free the flow of the shao yang qi mechanism, free the flow of the channels and quicken the network vessels, transform stasis and stop pain. This is based on the saying, "If there is pain, there is no free flow; if there is free flow, there is no pain." Within the above formula, Feng Chi is a meeting point of the foot shao yang and yang linking vessel. It can scatter wind and resolve the exterior as well as settle head pain. Because the liver and gallbladder have a mutual interior-exterior relationship, this point can also level and repress the yang qi of the liver and gallbladder. Tai Chong and Xing Jian both clear and drain liver fire. Bleeding Tai Yang and any a shi points transforms stasis and frees the flow of the network vessels. When all these points are used together, their effect is to level the liver and extinguish wind.

Study 4
In issue #2, 2002, of Zhong Guo Zhen Jiu (Chinese Acupuncture & Moxibustion), Lei Jing-he et al. published "Clinical Observations on the Treatment Efficacy of Acupuncture on 126 Cases of Vascular Headache Treated by Selecting Acupoints Via the Channels." This article appeared on pages 87-88 of this journal.

Cohort Description
All the patients in this study were outpatients on their first visit to the Chinese authors' hospital, and all were diagnosed as suffering from migraine based on the International Criteria for Classification and Diagnosis of Headache, published by the International Association of Headache in 1998. Blood analysis, liver function, electrocardiogram (ECG), electroencephalogram (EEG), CT scan of the head, and routine examination of the nervous system were carried out, and patients who tested positive for neurological disorders were excluded. After testing and diagnosis, patients were randomly assigned to two groups: a so-called acupuncture group and a comparison group. There were 126 cases in the acupuncture group of whom 54 were male and 72 were female, aged 18.5-69 years, with a median age of 38.9 ± 5.4 years. The shortest duration of illness was three months, and the longest was 18.5 years, with an average disease duration of 5.8 ± 2.2 years. Ninety-one of these cases mainly suffered temporal pain, 13 cases mainly suffered frontal pain, four cases mainly suffered occipital pain, while the other 18 cases experienced generalized head pain.

In the comparison group, there were 72 cases, 28 males and 44 females, 15.5-73 years of age, with a median age of 39.4 ± 3.9 years. These patients had suffered from migraines from five months to 21 years, with a mean disease duration of 5.2 ± 3.0 years. Fifty-two of these cases mainly suffered temporal pain, five cases mainly suffered frontal pain, three cases mainly suffered vertex pain, four cases mainly suffered occipital pain, and eight cases suffered generalized head pain. Therefore, in terms of sex, age, disease conditions, and disease duration, there were no marked statistical differences between these two groups.

Treatment Method
In the acupuncture treatment group, acupoints were selected along the channel(s) that traversed the site(s) of pain.

For temple pain, Jiao Sun (TB 20), Tai Yang (M-HN-9), Zhong Zhu (TB 3), and Zu Lin Qi (GB 41) were selected as the main points, while Wai Guan (TB 5), Yang Fu (GB 38), and a shi points were selected as auxiliary points.

For frontal pain, Shen Ting (GV 24), Yin Tang (M-HN-3), Tou Wei (St 8), He Gu (LI 4), and Xian Gu (St 43) were selected as the main points, and Qu Chi (LI 14) and Jie Xi (ST 41) were chosen as auxiliary points.

For occipital pain, Yu Zhen (Bl 9), Tian Zhu (Bl 10), Hou Xi (SI 3), and Shen Mai (Bl 62) were selected as the main points, and Wan Gu (SI 4) and Kun Lun (Bl 60) were chosen as auxiliary points.

For generalized head pain, Bai Hui (GV 20), Jiao Sun (TB 20), Tou Wei (St 8), Yin Tang (M-HN-3), and Tian Zhu (Bl 10) were selected as the main points, and Feng Chi (GB 20), He Gu (LI 4), Hou Xi (St 41), Zu Lin Qi (GB 41), and Jie Xi (St 41) were selected as auxiliary points.

During the acute stage, strong manipulation was applied to create the strongest needling sensation the patient could bear. The needles were retained for ten to 15 minutes, and treatment was given once or even twice each day for patients suffering severe pain. During remission, even supplementing-even draining method was applied, with treatment given once per day and the needles retained for 30 minutes. Six days equaled one course of treatment, and one day's rest was allowed between successive courses. Treatment outcomes were assessed after four such courses.

Members of the control group mainly received oral administration of analgesics and Valium (diazepam) during the acute stage, and Prilue (identification unknown), 20 mg t.i.d., and Nimotop (nimodipine), 30 mg t.i.d., administered orally during remission. Six days equaled one course of treatment in this group as well, with an interval of one day between courses. Likewise, treatment outcomes were assessed after four courses.

Study Outcomes
Initial assessments of severity of pain and final outcomes were based on the Visual Analogue Scale, which patients used to self-assess the degree of their pain. On a scale of 0-10, 0 meant that the patient felt no pain, and 10 meant that the patient felt the most severe pain imaginable. Cure was defined as a pain scale rating of zero after treatment. Some effect was defined as a pain scale rating, which was decreased by more than three units or stages from before to after treatment. No effect meant that the pain scale rating was decreased by less than three units or stages from before to after treatment. Comparison of cumulative scores of pain between the two groups indicated that there was no statistically significant difference (P > 0.05) before treatment. However, after treatment, there was a significant difference (P < 0.01) between these two groups. Comparison of the cumulative scores before and after treatment in the two groups showed that both acupuncture and Western medicine were able to decrease the cumulative pain score but that acupuncture treatment was superior to Western medicine in analgesic effect. In the acupuncture treatment group, the cure rate was 61.11%, the rate for some effect was 25.40%, and the total amelioration rate was 86.51%. In the comparison group, the cure rate was 38.89%, the rate for some effect was 31.94%, and the total amelioration rate was 70.83%. Thus, there were significant differences between these two groups in terms of the cure and the total amelioration rates (P < 0.01).

Discussion
Unfortunately, it is not clear what the first prophylactic Western medicine is in the above study. Nimodipine is a calcium channel blocker that is sometimes used for migraine prophylaxis. Typically, in the West, it is used for at least two to three months before evaluating its effectiveness. It is also a clinical fact that no Western prophylactic therapy is effective until or unless the patient has effected a major reduction in analgesic use, but there is no discussion of this in this study. Therefore, it seems to me that there may be some shortcomings with the Western medical arm of this study. Nevertheless, the acupuncture arm of this study appears quite standard to me. A combination of local (or main) points is used with distant (or auxiliary) points on the channel that traverses the primary area of pain. Such a combination of local and distant points is characteristic of contemporary Chinese acupuncture and should be familiar to every practitioner who has studied this style.

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