From Evidence to Practice: Importance of Developing Guidelines for Clinical Practice in Migraine Prophylaxis with Acupuncture
Received Date: December 31, 2020; Published Date:February 05, 2021
In acupuncture practice, emphasis was focused on episodic migraine treatment, but the evidence-based practice revealed that acupuncture in migraine prophylaxis is superior to conventional medicine which is significant to clinical practice. Body constitution, syndrome differentiation, acupoints selection, needle techniques, stimulation modality, and treatment plan are the factors to be considered for developing guidelines of clinical practice for acupuncture in migraine prophylaxis.
Keywords:Acupuncture; Guidelines of Clinical Practice; Migraine; Prophylaxis
As one of the primary headache disorders, migraines are a common neurological condition which has caused tremendous burdens to patients and society. It was estimated that 1-year prevalence of incident migraine was 2.2% (1.5% in men and 3.1% in women) and declined with age and approximately 21% of people with migraine had reported a diagnosis by a health care provider, and close to 12% were found to have severe disability related to migraines . Acupuncture, an important modality of nonpharmacological pain management, has demonstrated its efficacy and safety in the treatment of migraines without aura. Acupuncture has been an effective treatment for episodic migraines, with recent evidence indicating that acupuncture is, in fact, superior to conventional medicine in migraine prophylaxis [2-8]. The evidence is acquired from high quality clinical trial design in randomized double-blind trials, but the majority of acupuncture treatment plan is aimed to a research purpose which is standardized with less points and no differentiation for individual patients [9,10]. It is quite different compared to the real world of clinical practice so it is important to develop guidelines for clinical practice in migraine prophylaxis which was emphasized in the previous textbooks or practical protocols.
In 2014, China Association of Acupuncture & Moxibustion revised the “Evidence-Based Guidelines of Clinical Practice with Acupuncture & Moxibustion: Migraine”  which emphasized the recommendation of episodic migraine treatments such as bleeding technique, electro-acupuncture and even a pyro-acupuncture. For the clinical reliving period of migraine, the guidelines strongly recommended a comprehensive acupuncture-moxibustion treatment, which includes acupoints selection based on channel syndromes, mainly Shaoyang Channel, and Zang-fu organs syndromes differentiation which assisted with modalities of scalp acupuncture, electro-acupuncture, warming-needle moxibustion and bleeding technique, etc. It is important to develop clinical practice guidelines which aim to migraine prophylaxis since it is a significant outcome of evidence-based practice. The following is the considerations.
In traditional Chinese medicine (TCM) practice, individual body constitution is an important factor to identify during comprehensive body assessment before treatment. For chronic migraine patient, certain type of body constitution is the main reason which causes repeated episodes. According to current survey and statistical analysis, migraine patients are more likely presenting Qi Stagnation Constitution, Blood Stasis Constitution, and Yin deficiency Constitution [12,13]. So, the migraine prophylaxis should consider this constitutional factor which follows the “treating the root” principle in traditional Chinese medicine.
It refers to the current status of the patient who suffered from frequent migraine episodes by overall analysis at approaches of TCM way of assessment such as: general body discomfort, symptoms, signs of tongue features, and pulse phenomenon, etc. It is a way to explore the pathogenesis and to determine syndrome differentiation either in a catalog of Zang-fu Organ syndromes or Channel syndromes, the later one also depends on the outcome of palpation, local area or in a distance. Mostly those patients are identified as syndrome of the Liver-related system and/or Shaoyang Channel. Blood stasis and phlegm accumulation are main pathogenesis of migraine.
Since the body constitution and syndrome differentiation are determined, it is not difficult for an acupuncturist to select appropriate points. As an experienced acupuncturist, palpation on the channels and certain acupoints (spots) to explore tender points (spots) is a key of efficacy. During each visit, those tender points (spots) could be various on the location and severity of tenderness. Some empirical points are also very effective . A PET-CT study on the specificity of acupoints through acupuncture treatment in migraine patients demonstrated that higher brain metabolism showed after inserting needles on acupoints like Waiguan (SJ 6), Yanglingquan (GB 34) and Fengchi (GB 20) . Such scientific study report is also kind a clue for acupoints selection.
Applying specific needle techniques are ways to enhance therapeutic effect according to patient’s syndrome differentiation. The practitioners should perform those needle techniques carefully and gently to make patient not uncomfortable during the treatment session.
Besides traditional body acupuncture methods, other acupuncture-related modalities are also used for migraine prophylaxis which include ear acupuncture, scalp acupuncture, dry needling techniques, and electro-acupuncture [16-21]. So, we can choose appropriate methods especially when one method failed during practice.
Based on some clinical trials data, prophylaxis of episodic migraine needs repeat treatment for about 20 sessions, in a mode of every other day for 10 sessions with 9-day break or in a mode of two acupuncture sessions per week continuous for 3 months [4,22]. For women who experienced episodic associated with menstrual cycle, frequency of visits should be adjusted accordingly. Affordability and insurance reimbursement allowance are also the considerations to adjust the plan for acupuncture treatment sessions.
Although evidence of acupuncture in migraine prophylaxis is confirmed, guidelines of clinical practice are necessary to develop aim to therapeutic outcome.
Conflict of Interest
Author declares no conflict interest.
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