Kristen Sparrow • April 26, 2023
Manual acupuncture for migraine
This is from the British Medical Acupuncture Society Blog. It is from 2020 but very pertinent today!
I love the tone of this blog. Lighthearted but fervent! A large portion of my practice is devoted to acupuncture for migraine.
The basic points that he makes are 1. That he was amazed that this article was prominently featured in the prestigious British Medical Journal, double page spread!
2. That the efficacy rate was very high in this sham controlled study. Equal to the results for monoclonal erenumab.
3. The difference in this study is the number of treatments, a whopping 20 treatments in 50 days. This is not difficult to achieve in China, but tougher here in the U.S.
4. The British Medical Journal Editorial Board whined that this would be very expensive to do, ignoring the fact the erenumab costs the patient 5,000 pounds per year. That would buy 50 to 100 acupuncture sessions per year.
It is the first positive sham-controlled trial of acupuncture in migraine prophylaxis.
We have known that acupuncture has efficacy over sham in migraine prophylaxis since Klaus Linde led an update of his Cochrane review, which was published in 2016. This review noted a small but statistically significant effect over sham as well as superiority to drug prophylaxis immediately at the end of treatment…
In terms of RR50 – the responder rate determined by a 50% or greater reduction in days with headache over a 4 week period – the acupuncture group in Xu et al achieved 82.5%. That is considerably greater than in the ART and GERAC migraine trials,[4,5] part of the Modellvorhaben Akupunktur, which achieved 51% and 47% respectively. The RR50 in the sham groups of these three trials was 46%, 53% and 39% respectively. For comparison, the RR50 for a placebo drug was 26.6% in a large trial of a CGRP receptor monoclonal and 23.3% in a large SR.[7,8]
How did Xu et al do so well?..
Could it be the acupuncture, and the length of follow-up? This trial monitored outcomes for 20 weeks, but all the treatment was packed into the first 8. Acupuncture was performed every other day in two courses of 10 sessions separated by just over a week. So, 20 sessions were fitted into about 50 days. Interestingly the effect of sham seemed to peak by the end of the treatment, but then gradually reduced over the next 8 weeks, whereas the effect in the acupuncture group increased slightly.
I guess the total number of treatments may be an important factor. It is the one thing that was highlighted in the IPDM update. The ART and GERAC trials used 12 sessions in 8 weeks (ART) and 10 sessions in 6 week (GERAC), the later with the option of 5 additional sessions for responders.
Now I want to move on to comment on the BMJ editorial that accompanied this research. It was written by a neurologist from the Royal Free called Heather, who has an interest in epilepsy and migraine. Her surname is quite distinctive, so very easy to search on PubMed. I don’t want to be too critical as the overall tone of the piece is very positive, but there are a few aspects that need to be addressed.
The major error that jumped out from this editorial was the suggestion that the new CGRP receptor monoclonals appeared to be substantially better than the effect of acupuncture in this trial. I had a vague memory of reading that the monoclonals reduced the number of days with headache by about 1.5 days, so when Heather quoted a figure of 3.7 days, I was obliged to check her reference. It turns out she had compared the figure for acupuncture vs sham (-2.1 days) from Xu et al, with the change from baseline for the monoclonal erenumab in its highest dose (-3.7 days. The correct figure for comparison was either -1.4 or -1.9 (low and high dose erenumab vs placebo, respectively).
Heather went on to suggest that 10 hours of acupuncture treatment would not be cheap, failing to comment on the eye watering price of drugs such as erenumab, for which the lowest price I could find was $5k per patient per year. $5k will buy you between 50 and 100 sessions of acupuncture in the private sector, which is one session a week for the whole year!