Headaches and Migraines

Acupuncture Treatment for Migraine Headaches

Tim H. Tanaka, Ph.D.

Director,

Toronto, Ontario, Canada

Visiting Research Fellow, School of Health Sciences, Tsukuba University of Technology, Ibaragi, Japan

(Original version published in June 2003, Updated in August 2006)

 

There are two different categories of headaches: primary and secondary. A primary headache is an actual clinical condition and not a symptom caused by another disorder. Primary headaches include tension-type headaches, migraines, and cluster headaches. Secondary headaches are caused by other medical conditions such as sinus disease, allergies, dental disorders, head injury, or brain tumors.

Here, I will discuss the mechanisms, unique characteristics, and treatment of disabling headaches ? migraines, and how they can be treated with acupuncture.

Characteristics of the two most common primary headaches

(Based on the International Headache Society Guidelines [1])

 

Tension-type headaches (muscle-contraction headaches)

• Recurrent headaches lasting from 30 minutes to 7 days.
• A dull pressure type of pain, which is mild or moderate in severity.
• Pain is located on both sides of the head.
• Mild or moderate intensity (may inhibit but does not prohibit activities).
• No nausea or vomiting.
• The most common type of headache. Many individuals will experience this type of headache once in a while.

Migraine headaches (vascular headaches)

• Population-based studies have consistently shown that approximately 18% of women and 6% of men suffer from migraine in the United States [2, 3].
• Pain can be so intense that it interferes with one?s physical ability to function, sometimes requiring bed rest.
• Patients experience pulsating or throbbing types of pain. The pain is limited to one side of the head, however, in about a third of patients, it is bilateral [4].
• May be associated with nausea and/or vomiting, as well as sensitivity to light, noise, and/or odors.
• Some patients experience auras prior to the onset of a migraine (the headache sufferer sees little flashes of light, waves of lights, or changes in their vision). An aura is a neurological symptom that typically develops gradually over a period of several (5-20) minutes.

 

 

 

What is the relationship between the autonomic nervous system and headaches?

The function of all our internal organs is regulated by an involuntary nervous system known as the autonomic nervous system (ANS). There are two main divisions of the ANS ? the sympathetic and the parasympathetic nervous systems. The sympathetic nervous system is responsible for eliciting the ?fight or flight? response that is characteristically activated during periods of stress. The parasympathetic system opposes this response by activating the restful state, thus causing a relaxation response.

When our bodies are subjected to prolonged periods of stress, a chronic dominant state of sympathetic activity and/or suppressed parasympathetic response results. This occurs because the body shifts to an increased sympathetic response to deal with the stress appropriately. Eventually this can lead to the development of symptoms such as neck and upper back stiffness, heaviness behind the eyes, and tension-type headaches. In addition, other symptoms may include anxiety, palpitations, irritability, and digestive problems such as bloating or constipation. During the development of this chronically sympathetic-dominant state, circulation is minimized to the internal organs including those carrying blood to the head, due to the constriction of the blood vessels.

When local vasoconstriction becomes excessive, the body responds by releasing specific neuropeptides (CGRP, substance P, and neurokinin A), causing a rebound dilation in the segments of these overly constricted arteries. This sudden rebound dilation is a natural defensive mechanism of our body to compensate for extended periods of blood deprivation. These arteries are wrapped with sensitive pain receptors and are being activated due to dilation of arteries, thus causing migraine pain. The migraine pain is often localized because over-dilation occurs in a limited area. It is often throbbing and stabbing because each time the heart pumps blood into the artery, there is an expansion of the artery which aggravates the pain. When the heart rests, the artery partially constricts resulting in a relief of pain. The entire cycle produces throbbing pain.[5]

Is a migraine part of a healing reaction?

As explained above, chronic states of sympathetic dominance result in constriction of blood vessels. Many patients with migraine complain about cold hands and feet, which are one of the typical signals of a lack of circulation due to stress. Compromised circulation, due to constriction of blood vessels, not only occurs in hands and feet, but also in those carrying blood to the head and internal organs. If this situation is prolonged, the body enters into a sudden emergency state due to oxygen and nutrient deprivation to the internal organs (especially the brain). The body seeks to compensate for this by creating a rebound response. This is a natural, innate recovery response. In fact, a group of prominent Japanese MDs now view and treat migraine as a healing pain [6]. Sudden recovery process following psychological stress is known as vagal (parasympathetic) rebound (i.e, acute slow down of heart rate following racing of heart).[7] Prof. Abo at the Niigata University Medical School believes that migraines are a necessary recovery process from the compromised circulation due to chronic stress, and considers it to be a part of the vagal (parasympathetic) rebound response.

This theory explains the many unique characteristics of migraine attacks which often develop when one is relieved from a situation of prolonged stress (an increased sympathetic state shifted to a rebound type of parasympathetic dominant state). For example, many migraine sufferers often develop migraines on weekends, the first day of vacation, following a relaxing dinner at the end of a stressful day, or after sleeping-in on Sunday mornings.

Many migraine sufferers also experience attacks in low air pressure environments such as rainy weather, airplane trips, or climbing to high mountains. This phenomenon can also be explained by the parasympathetic rebound theory described above. It is known that the body is shifted more towards the sympathetic dominant state when in high air pressure (i.e; sunny days) and shifted to the parasympathetic dominant state during low air pressure such as on rainy days and in high altitude. Many sufferers also note the occurrence of migraines when they skip meals. It is known that the autonomic nervous system sharply inclines toward sympathetic mode during the state of hunger. The sharp inclination towards the sympathetic nervous system by skipped meals can induce a parasympathetic rebound response (this is evident by the fact that some individuals experience stomach pain or cramps before meals, due to increased gastric acid secretions and digestive motility by enhanced vagal/parasympathetic stimulation). It should also be noted that the autonomic nervous system closely interacts with female hormones. Many women with migraines often experience more headache episodes around the time of menstruation. Contraceptive pills are one common known trigger for migraines occurrences.

The migraine theory, based on an exaggerated autonomic nervous system reaction, known as parasympathetic rebound, can be applied to other various health conditions such as asthma, irritable bowel syndrome (IBS) and eczema. For example, a study indicated that among asthmatic patients, there were actually less airway obstructions during stress visits than non-stress control visits. Further, an exacerbation of asthma is often not during stress, but following severe stress events. [8]. Over the years in my practice, I have been intrigued to observe that many migraine patients concurrently have one or more of these conditions.

Many sufferers also experience some of their most intense migraine episodes following a massage treatment. This is not surprising considering that massage and many other natural therapies including acupuncture can trigger the healing reaction by eliciting a relaxation response and enhancing circulation. On the other hand, it should be kept in mind that when it comes to migraine, any therapy that provides some immediate pain relief may not necessarily be the best treatment for long-term management of migraine.

Although, in most cases, the pain due to relaxation and enhanced circulation is a positive response from a physiological perspective, it is certainly not a pleasant experience for patients. Experienced practitioners, who understand the unique physiological mechanism of migraines, would alter the treatment protocol accordingly depending on the patient?s condition on that day, with consideration of both short and long-term treatment goals.

 

 

 

 

What is the pharmacological approach to a migraine?

Two different types of medications are often prescribed: Medication to relieve acute migraine pain and medication to prevent migraines. The actions of the two medication types are quite different.

For acute attacks, medications such as Imitrex, Maxalt, Zomig, and ergotamine (Cafegot) are often prescribed. These medications have a potent vasoconstricting action (constricting blood vessels) and patients are instructed to take them during or at the onset of a migraine. This approach can provide excellent relief of symptoms, but the effect is temporary and will not prevent the recurrence of migraines.

For migraine prevention, beta-adrenergic receptor blockers (which inhibit part of the sympathetic nerve activity) such as metoprolol, atenolol, propranol, calcium channel blockers such as flunarizine, or antidepressive agents such as amitriptyline are often prescribed. Most medications for migraine prevention would produce a general relaxation effect.

Both types of migraine medications are not without side-effects. Vasoconstrictor medications to treat acute migraine can have serious detrimental effects particularly for patients with cardiovascular risk [9]. In addition, frequent use of these pain medications can create further grounds to more frequently induce migraine episodes. It should be noted that many commonly used over the counter headache medications (NSAIDs) can also create a sympathetic dominant state and inhibit peripheral circulation, thus leading to a rebound headache. Beta blockers are most commonly used to treat high blood pressure. Beta blockers are contraindicated in patients with asthma, chronic obstructive pulmonary disease, insulin-dependent diabetes mellitus, heart block or failure, or peripheral vascular disease [10]. Common side effects associated with them include fatigue, dizziness, gastrointestinal discomfort and decreased sexual ability. Preventative medications cannot be expected to work immediately, some take 12 months to work, especially calcium-channel blockers [10].

Natural headache treatment using acupuncture

Tension-type headaches are often associated with chronic neck and upper back muscle tension. In fact, a research study of tension-type headache sufferers showed a strong correlation between headache intensity and the degree of upper trapezius muscle tension as measured by electromyography[11]. Since acupuncture treatments can induce potent muscle relaxation effects (both general and local), most patients experience relief during, or immediately after the acupuncture session as demonstrated in our study[11].

Compared to tension-type headaches, treatment during migraine attacks requires extra care and consideration. The relaxation response typically induced by the therapy may trigger or intensify the migraine for the reasons previously discussed. For migraine treatment, it is rather important to shift our focus to prevention by avoiding accumulating stress and minimizing the continuous hyperexcitation of the sympathetic nervous system in order to prevent eliciting the exaggerated parasympathetic rebound response. Theoretically, if the predevelopment stage of the migraine involving excessive vasosconstriction can be prevented, the entire headache episode can be avoided all together.

Irrespective of using conventional or natural alternatives, it is important to note that treatments that are only focused on immediate pain relief are the least likely aid to decrease and eliminate future migraines. It is important that both the patient and the practitioner understand the true cause and physiological mechanism behind the migraine for long-term success.

See the illustrations below, which explain the migraine development mechanisms (Fig.1) and how successful stress management can lead to a decrease in the frequency or intensity of migraine or eliminate future migraine episodes(Fig.2).

The acupuncture Treatment for Headache and Migraine at The Pacific Wellness Institute

• Our treatment is targeted to prevent future migraines. Ideally, most sessions are done in between migraine episodes. When we consider that the onset of a migraine is close, we may use a more selective approach to minimize the vasodilation type of reaction (e.g., treatment in the sitting position, which maintains a higher vasomotor tone). If patients are in the midst of a moderate to severe migraine episode, it may be advised for them to stay at home and take the acute pain management medication recommended by their doctor. Application of ice on the pain region can constrict local blood vessels and may help ease some pain.
• To help prevent future migraine episodes, it is essential to keep stress level and sympathetic activity under control and release chronic muscle tension. Acupuncture and moxibustion treatment is used to induce a general relaxation response and relieve muscle stiffness and spasms, especially in the neck and shoulder regions.
• Acupuncture is applied to the entire body including points on the back, head, abdomen, arms and legs. This is important since migraines are vascular in nature involving systemic imbalances and hormonal dysfunctions.
• Many migraine patients are highly stressed individuals, who often unknowingly tense their muscles as a result of mental stress and anxiety. We often use an innovative biofeedback approach called the Acupuncture and Sound Assisted Autonomic Modulation Technique. This technique helps to maintain balance of autonomic tone between acupuncture sessions.

  Research & Articles of Interest

  About.Com An Acupuncturist’s Perspective on Migraine by Tim H. Tanaka, Ph.D. of The Pacific Wellness Institute.

  References:

• Committee, The International Classification of Headache Disorders: 2nd edition. Cephalalgia, 2004. 24 Suppl 1: p. 9-160.
• Stewart, W.F., et al., Prevalence of migraine headache in the United States. Relation to age, income, race, and other sociodemographic factors. Jama, 1992. 267(1): p. 64-9.
• Lipton, R.B., et al., Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache, 2001. 41(7): p. 646-57.
• Lance, J.W. and M. Anthony, Some clinical aspects of migraine. A prospective survey of 500 patients. Arch Neurol, 1966. 15(4): p. 356-61.
• biofeedback, A.f.A.P.a., Autonomic Nervous System Intervention, BCIA Certification Text.
• Abo, T., Kusuriwo Yameruto Byouki ha Naoru (Spontaneous recovery of diseases upon discontinuation of pharmaceutical drugs). 2004, Tokyo: Makino Publishers.
• Mezzacappa, E.S., et al., Vagal rebound and recovery from psychological stress. Psychosom Med, 2001. 63(4): p. 650-7.
• Klinnert, M.D., Evaluating the effects of stress on asthma: a paradoxical challenge. Eur Respir J, 2003. 22(4): p. 574-5.
• Mikhail, G.W., F. Airoldi, and A. Colombo, Acute myocardial infarction following the use of antimigraine therapy. J Invasive Cardiol, 2004. 16(10): p. 602-3.
• Pryse-Phillips, W.E., et al., Guidelines for the diagnosis and management of migraine in clinical practice. Canadian Headache Society. Cmaj, 1997. 156(9): p. 1273-87.
• Tanaka, T.H., G. Leisman, and K. Nishijo, The physiological responses induced by superficial acupuncture: a comparative study of acupuncture stimulation during exhalation phase and continuous stimulation. Int J Neurosci, 1997. 90(1-2): p. 45-58.

Research: Acupuncture Treatment Provided Significant Relief for Migraine and Tension Headache Sufferers
Tim H. Tanaka, Ph.D.
Director

Two recent studies have suggested that acupuncture is an effective treatment for migraine and tension-type headaches. These studies are randomized, multi-center trials and two of the largest and most rigorous studies which have examined efficacy of acupuncture. The findings from these studies, however, were somewhat controversial and open the door for interpretations and discussions.

The first study, which was published in the May 4, 2005 issue of the Journal of the American Medical Association, randomly assigned 302 migraine patients to three study groups¹. Group one underwent 12 acupuncture sessions (traditional Chinese style acupuncture, involving deep needling) over eight weeks; group two had “minimal” acupuncture; and group three had no treatment. The “minimal” (sham) acupuncture group underwent treatment as frequently as the real acupuncture group, but fewer needles were used and the needles were inserted only superficially into the skin.

The results of this study established 51% of patients who had “true” acupuncture experienced at least a 50% reduction in the number of headache days while only 15% among those waiting for treatment experienced the same reduction. The difference between the acupuncture group and the no treatment group was large enough to conclude that acupuncture was effective for migraine headache. However, this finding was complicated by the fact that 53% of those patients who underwent “minimal acupuncture” (which was given with an intention to simulate acupuncture) also experienced at least a 50% reduction in the number of headache days.

In a second study, which appeared in the August, 2005 issue of the British Medical Journal, researchers utilized similar study protocol as the migraine trial, but tested the efficacy of acupuncture on 270 patients with tension-type headache². The results were strikingly similar to the outcomes of the migraine study. It demonstrated that the number of days with headache decreased by 7.2 days in the acupuncture group, the minimal acupuncture group followed closely with 6.6 days, while the no treatment group managed an improvement of 1.5 headache-free days. Authors of the study stated, “An intriguing finding of our trial is the strong and lasting response to minimal acupuncture. The improvement over, and differences compared with the waiting list group are clearly clinically relevant” ².

Some acupuncturists believe that it is essential to deeply insert the needle and manipulate it vigorously in order to achieve a beneficial effect by acupuncture. This more is better American concept does not necessarily apply to acupuncture treatment. Traditionally, many Japanese practitioners have been using an extremely gentle superficial needling technique and producing excellent results in their patients’ conditions. In our practice, it is not an uncommon event to encounter a noticeable change in a patient’s condition upon a single small needle insertion just under the skin. Human skin contains a number of receptors that trigger powerful physiological reactions. The efficacy of this superficial needling technique has been studied in Japanese and Canadian research facilities. A study conducted at The Pacific Wellness Institute demonstrated that a single superficial acupuncture treatment provided instant reduction of pain among patients with tension-type headache³. The significant pain reduction, however, occurred only when superficial acupuncture was applied in synchronization with patient’s respiratory rhythm.

More studies are certainly needed to elucidate how exactly acupuncture works and what types of acupuncture techniques can be most effective for each condition or individual. In clinical practice, experienced acupuncturists consider not only acupuncture point location but also various other factors such as needling depth, intensity of stimulation, respiration, and patient position, in attempt to produce the most consistent results. Our goal at The Pacific Wellness Institute is to deliver highly effective treatment while providing a safe and comfortable treatment experience.

1. Linde, K. et al. Acupuncture for patients with migraine: A randomized controlled trial. JAMA, 2005; 293(17):2118-25.
2. Melchart, D. et al. Acupuncture in patients with tension-type headache: Randomized controlled trial. BMJ, 2005; 331(7513):376-82.
3. Tanaka, T.H. et al. The physiological responses induced by superficial acupuncture: A comparative study of acupuncture stimulation during exhalation phase and continuous stimulation. Int J Neurosci 1997; 90(1-2):45-58.