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With Comments from Russell H. Greenfield, MD
Acupuncture for Chronic Headache
Source: Vickers AJ, et al. Acupuncture for chronic headache in primary care: Large, pragmatic, randomized trial. BMJ 2004; 328:744-750.
Goal: To compare policies of "use acupuncture" vs. "avoid acupuncture" for people with chronic headaches on headache, health status, days lost from work, and use of resources over one year.
Design: Randomized, controlled trial.
Subjects: A total of 401 patients with chronic headaches (mainly migraines) were drawn from general practices in England and Wales (data from 301 subjects were included in analysis).
Methods: Suitable subjects were identified from within general practices and sent letters describing the study. Recruitment and screening followed. Twelve separate sites were included, each consisting of a single acupuncture practice together with 2-5 local general practices. Eligible patients completed a four-week headache diary, and were then randomized to "use acupuncture" (usual care plus up to 12 acupuncture treatments over a three-month period), or to "avoid acupuncture" (usual care). Headache severity was recorded four times daily using a Likert scale, while headache score (primary endpoint), SF-36 health status, and medication usage were assessed at baseline, three months, and 12 months. Resource utilization was assessed every three months. One year after randomization, subjects were contacted to provide a global assessment of headache severity, current and baseline, on a scale from 1-10.
Results: Mean headache score at 12 months was significantly lower in the acupuncture group than in controls, falling 34% and 16%, respectively. Those randomized to acupuncture used 15% less medication, made 25% fewer office visits, and took 15% fewer days off from work due to illness. Data extrapolation showed that subjects in the acupuncture group experienced 22 fewer days of headache per year compared with members of the control group. SF-36 data revealed superiority of acupuncture over usual care, but only for physical role functioning, energy, and change in health.
Conclusion: Acupuncture leads to persistent, clinically important benefits for people with chronic headaches, especially migraines, referred from primary care clinics. Expansion of acupuncture services under the auspices of the NHS should be considered.
Study strengths: Close follow-up; diversity of patients; subjects were coached about bias; sample size; only three subjects reported receiving acupuncture outside the study.
Study weaknesses: Significant attrition (the authors had anticipated a 25% dropout rate—161/186 completed the 12-month assessment in the acupuncture group, while 140/193 completed the assessment at one year) in the avoid acupuncture group; lack of blinding; no subjects received sham acupuncture.
Of note: All acupuncturists in the study had completed at least 250 hours of training and had practiced acupuncture for a median of 12 years; most subjects experienced migraines, with but a small number having tension-type headaches; treatment was individualized to each patient, and subjects received a median of one treatment per week; there was a larger treatment effect in those with more severe symptoms, even after controlling for regression to the mean.
We knew that: In an average week, up to 10% of English general practitioners either refer patients for acupuncture or practice it themselves; prior studies have suggested improvements in both severity and frequency of migraine headaches following a course of acupuncture.
Clinical import: Despite the increasing availability of effective medical therapy like triptans, many people with migraine headaches continue to experience discomfort that disrupts their daily activities. The situation often leads to a search for viable alternatives, of which acupuncture appears to be one. An article in the same edition of the BMJ evaluated the cost of providing such treatment to the chronic headache patients in this study, and found that acupuncture improved health-related quality of life at minimal additional cost. With relative prowess within reach of practitioners after only 250 hours of training, perhaps it is time for more of us to learn this ancient healing art.
What to do with this article: Keep a hard copy in your files.