Is manual acupuncture effective in improving episodic migraine?
Date of publication of the systematic review: June 2016
Design
Systematic review of 22 randomized controlled trials (RCTs).
Participants
4985 participants who had been diagnosed with episodic migraine. The duration of the condition had to be longer than one year. Patients with chronic migraine and chronic daily headache were excluded. The reviewers did not report mean age and gender proportion of the participants.
Intervention
Among included RCTs, manual acupuncture was used as an intervention. Manual acupuncture was described as any treatment involving needle insertion (with or without manual or electrical stimulation) at acupuncture points, pain points or trigger points. The treatment course must consist at least six treatment sessions and was given at least once per week.
Comparator
Comparison 1: Manual acupuncture versus no treatment;
Comparison 2: Manual acupuncture versus sham acupuncture;
Comparison 3: Manual acupuncture versus prophylactic drug treatment.
Major Outcomes
Outcome 1: Headache frequency at completion of treatment;
Outcome 2: The proportion of 'responders' at completion of treatment, response was defined as a reduction in migraine days of at least 50% compared to baseline;
Outcome 3: Number of participants dropping out due to adverse effects;
Outcome 4: Number of participants reporting adverse event or effect.
Settings
All trials were conducted in primary care or outpatient care setting.
Comparison    Manual acupuncture versus no treatment
Main Results
Manual acupuncture was associated with a moderate reduction of headache frequency over no treatment after treatment (pooled standardized mean difference (pooled SMD): -0.56, 95% CI: -0.65 to -0.48). After treatment headache frequency at least halved in 41% of participants receiving manual acupuncture and 17% receiving no acupuncture (pooled risk ratio (pooled RR): 2.40, 95% CI: 2.08 to 2.76).
Comparison 1: Manual acupuncture versus no treatment
Outcomes (units) No. of studies (Total no. of participants) Mean score (SD)/ No. of participants Heterogeneity test (I2) Pooled SMD/RR (95% CI) Overall quality of evidence*
Intervention Comparator
1 (NA) 4 (2199) Not reported/1162 Not reported/1037 57% Pooled SMD: -0.56 ( -0.65 to -0.48) High
2 (NA) 4 (2519) Not reported/1325 Not reported/1194 7% Pooled RR: 2.40 (2.08 to 2.76) High
Keys: SD = standard deviation; SMD = standardized mean difference; RR = risk ratio; CI = confidence interval.
Comparison    Manual acupuncture versus sham acupuncture
Main Results
Manual acupuncture was associated with a small but statistically significant frequency reduction over sham (pooled SMD: -0.18, 95% CI: -0.28 to -0.08) after treatment. Among 14 included trials, post treatment headache frequency halved in 50% of participants receiving true acupuncture and 41% receiving sham acupuncture (pooled RR: 1.23, 95% CI: 1.11 to 1.36). The number of participants dropping out due to adverse effects (pooled odds ratio (pooled OR): 2.84; 95% CI: 0.43 to 18.71) and the number of participants reporting adverse effects (pooled OR: 1.15; 95% CI: 0.85 to 1.56) did not differ significantly between manual acupuncture and sham groups.
Comparison 2: Manual acupuncture versus sham acupuncture
Outcomes No. of studies (Total no. of participants) Mean score (SD)/ No. of participants Heterogeneity test (I2) Pooled SMD/RR/OR (95% CI) Overall quality of evidence*
Intervention Comparator
1 (NA) 12 (1646) Not reported/952 Not reported/694 47% Pooled SMD: -0.18 ( -0.28 to -0.08) High
2 (NA) 14 (1825) Not reported/1055 Not reported/770 48% Pooled RR: 1.23 (1.11 to 1.36) High
3 (NA) 7 (931) Not reported Not reported Not reported Pooled OR: 2.84 (0.43 to 18.71) High
4 (NA) 4 (1414) Not reported Not reported Not reported Pooled OR: 1.15 ( 0.85 to 1.56) High
Keys: SD = standard deviation; SMD = standardized mean difference; pooled RR = pooled risk ratio; OR = odds ratio; CI = confidence interval.
Comparison    Manual acupuncture versus prophylactic drug treatment
Main Results
Manual acupuncture reduced migraine frequency significantly more than drug prophylaxis after treatment (pooled SMD: -0.25, 95% CI: -0.39 to -0.10). Participants receiving manual acupuncture were less likely to drop out due to adverse effects (pooled OR: 0.27, 95% CI: 0.08 to 0.86) and to report adverse effects (pooled OR: 0.25, 95% CI: 0.10 to 0.62) than participants receiving prophylactic drugs.
Comparison 3: Manual acupuncture versus prophylactic drug treatment
Outcomes No. of studies (Total no. of participants) Mean score (SD)/ No. of participants Heterogeneity test (I2) Pooled SMD/ OR (95% CI) Overall quality of evidence*
Intervention Comparator
1 (NA) 3 (739) Not reported/431 Not reported/308 0% Pooled SMD: -0.25 ( -0.39 to -0.10) High
3 (NA) 4 (451) Not reported Not reported Not reported Pooled OR: 0.27 (0.08 to 0.86) High
4 (NA) 5 (931) Not reported Not reported Not reported Pooled OR: 0.25 (0.10 to 0.62) High
Keys: SD = standard deviation; SMD = standardized mean difference; OR = odds ratio; CI = confidence interval.
Comparison    Manual acupuncture versus no treatment
Main Results
Manual acupuncture was associated with a moderate reduction of headache frequency over no treatment after treatment (pooled standardized mean difference (pooled SMD): -0.56, 95% CI: -0.65 to -0.48). After treatment headache frequency at least halved in 41% of participants receiving manual acupuncture and 17% receiving no acupuncture (pooled risk ratio (pooled RR): 2.40, 95% CI: 2.08 to 2.76).
Comparison 1: Manual acupuncture versus no treatment
Outcomes (units) 1 (NA) 2 (NA)
No. of studies (Total no. of participants) 4 (2199) 4 (2519)
Mean score (SD)/ No. of participants Intervention Not reported/1162 Not reported/1325
Comparator Not reported/1037 Not reported/1194
Pooled SMD/RR (95% CI) Pooled SMD: -0.56 ( -0.65 to -0.48) Pooled RR: 2.40 (2.08 to 2.76)
Overall quality of evidence* High High
Keys: SD = standard deviation; SMD = standardized mean difference; RR = risk ratio; CI = confidence interval.
Comparison    Manual acupuncture versus sham acupuncture
Main Results
Manual acupuncture was associated with a small but statistically significant frequency reduction over sham (pooled SMD: -0.18, 95% CI: -0.28 to -0.08) after treatment. Among 14 included trials, post treatment headache frequency halved in 50% of participants receiving true acupuncture and 41% receiving sham acupuncture (pooled RR: 1.23, 95% CI: 1.11 to 1.36). The number of participants dropping out due to adverse effects (pooled odds ratio (pooled OR): 2.84; 95% CI: 0.43 to 18.71) and the number of participants reporting adverse effects (pooled OR: 1.15; 95% CI: 0.85 to 1.56) did not differ significantly between manual acupuncture and sham groups.
Comparison 2: Manual acupuncture versus sham acupuncture
Outcomes 1 (NA) 2 (NA) 3 (NA) 4 (NA)
No. of studies (Total no. of participants) 12 (1646) 14 (1825) 7 (931) 4 (1414)
Mean score (SD)/ No. of participants Intervention Not reported/952 Not reported/1055 Not reported Not reported
Comparator Not reported/694 Not reported/770 Not reported Not reported
Pooled SMD/RR/OR (95% CI) Pooled SMD: -0.18 ( -0.28 to -0.08) Pooled RR: 1.23 (1.11 to 1.36) Pooled OR: 2.84 (0.43 to 18.71) Pooled OR: 1.15 ( 0.85 to 1.56)
Overall quality of evidence* High High High High
Keys: SD = standard deviation; SMD = standardized mean difference; pooled RR = pooled risk ratio; OR = odds ratio; CI = confidence interval.
Comparison    Manual acupuncture versus prophylactic drug treatment
Main Results
Manual acupuncture reduced migraine frequency significantly more than drug prophylaxis after treatment (pooled SMD: -0.25, 95% CI: -0.39 to -0.10). Participants receiving manual acupuncture were less likely to drop out due to adverse effects (pooled OR: 0.27, 95% CI: 0.08 to 0.86) and to report adverse effects (pooled OR: 0.25, 95% CI: 0.10 to 0.62) than participants receiving prophylactic drugs.
Comparison 3: Manual acupuncture versus prophylactic drug treatment
Outcomes 1 (NA) 3 (NA) 4 (NA)
No. of studies (Total no. of participants) 3 (739) 4 (451) 5 (931)
Mean score (SD)/ No. of participants Intervention Not reported/431 Not reported Not reported
Comparator Not reported/308 Not reported Not reported
Pooled SMD/ OR (95% CI) Pooled SMD: -0.25 ( -0.39 to -0.10) Pooled OR: 0.27 (0.08 to 0.86) Pooled OR: 0.25 (0.10 to 0.62)
Overall quality of evidence* High High High
Keys: SD = standard deviation; SMD = standardized mean difference; OR = odds ratio; CI = confidence interval.
Conclusion
Benefits
Compared to no treatment, sham acupuncture and prophylactic drug treatment, manual acupuncture showed significant reduction of migraine frequency. For all outcomes, the overall quality of evidence is high. Further research is unlikely to have an important impact on our confidence in this estimate of effect.
Harms
In the comparison between manual acupuncture versus no acupuncture, one trial reported the number of participants with adverse events but details were not mentioned; six trials mentioned the number of participants with adverse events in the comparison between manual acupuncture versus sham interventions (pooled odds ratio (pooled OR): 1.29, 95% CI: 0.43 to 3.83); and three trials comparing manual acupuncture to prophylactic drug treatment reported the number of participants with adverse events. Adverse events were reported in 7 of 313 participants receiving manual acupuncture compared to 4 of 307 participants receiving prophylactic drugs (pooled OR: 1.33, 95% CI: 0.38 to 4.73).
Link to Original Article
https://www.ncbi.nlm.nih.gov/pubmed/27351677
The synopsis is based on the following article:
Linde K, Allais G, Brinkhaus B, Fei Y, Mehring M, Vertosick EA, et al. Acupuncture for the prevention of episodic migraine. Cochrane Database Syst Rev. 2016 Jun 28;(6):CD001218.


* Interpretation of quality assessment results:
• Very low: Further research is most likely to have an important impact on our confidence in this estimate of effect.
• Low: Further research is likely to have an important impact on our confidence in this estimate of effect.
• Moderate: Further research is fairly likely to have an important impact on our confidence in this estimate of effect.
• High: Further research is unlikely to have an important impact on our confidence in this estimate of effect.
• Very high: Further research is most unlikely to have an important impact on our confidence in this estimate of effect.

Details of assessment method can be found at Chung VC, Wu XY, Ziea ET, Ng BF, Wong SY, Wu JC. Assessing internal validity of clinical evidence on effectiveness of CHinese and integrative medicine: Proposed framework for a CHinese and Integrative Medicine Evidence RAting System (CHIMERAS). European Journal of Integrative Medicine. 2015 Aug 31;7(4):332-41.