Using Acupuncture to Prevent Recurring Migraine Headaches

Abstract

While acupuncture is recognized as an effective mode of treatment for symptomatic relief of migraines, it is the general understanding among acupuncturists that acupuncture is not significantly effective for reducing recurrences of migraines in the long term. Studies have shown that there is no statistically significant difference between acupuncture based on Traditional Chinese Medicine principles and sham acupuncture. An attempt in this perspective is made to probe into the causes of this apparent lack of effectiveness and present ways to improve the response in patients with chronic recurrent migraine. In modern medicine, the cause of migraine is not well-defined, various theories have been put forward, and genetic and environmental factors have been implicated. Chinese Medicine clearly points to Liver Deficiency as the root cause—a deficiency of Liver Yin or Liver Blood causing Liver Yang to rise, producing the headache. Hence, any treatment aimed at reducing recurrence has to be targeted to the Liver. The common practice of using points to reduce the Liver Excess has the potential to reduce an already Deficient organ further, thus increasing the chances of recurrence. The author prefers a method of diverting this excess to the Son organ (Heart) using the Mother–Son relationship according to the Five-Element system. The Excess is diverted and, thus, the Liver is not reduced. By focusing on the Liver as the primary target, diverting the Excess rather than reducing the Deficient organ, recurrences in migraine can be controlled effectively in the majority of cases.

Introduction

Worldwide, migraine affects more than 10% of the population.¹ In the United States the figures are 18% for men and 43% for women.² A rapid growth in incidence among girls occurs after puberty.^3,4 After menopause, the incidence in women tends to decline and, by the age of 70, the incidence falls to 5% in both men and women. Migraine without aura is almost twice as common as migraine with aura.⁵ Migraine is more common among people with epilepsy and their families⁶ than in the general population.

The term migraine is derived from two Greek words—hemi meaning half and kranion meaning skull.⁷ Migraine is a chronic episodic neurovascular pain syndrome involving the trigeminovascular system, producing inflammation in the cranial vessels and dura mater.⁸ Autonomic symptoms are predominant—such as nausea, photophobia, sonophobia, and osmophobia; symptoms are aggravated by routine activity. Typical attacks last 4–72 hours, may be unilateral or bilateral, and may alternate from one side to the other.

More than 30% of patients receiving acupuncture in Western countries have headaches, and, for these patients, acupuncture is more effective than any other mode of treatment.⁹ Relieving the symptoms is relatively simple, and the response is often dramatic, but prevention of recurrence usually poses problems. Preventing recurrences is the main focus of this article.

Before acupuncture treatment is considered, a modern medicine diagnosis is mandatory for excluding all other causes of headaches, and, once a diagnosis of migraine is established, acupuncture treatment can be offered with confidence, both for symptomatic relief and for prevention of recurrences, provided certain steps are followed.

Most biomedically trained physicians have certain problems with adapting to Chinese ways and principles of treatment. Modern medicine diagnosis and acupuncture treatment sounds like a great idea that captures the best of both worlds, but it is a crossbreed of these worlds—and crossbreeds often have an unpredictable character. Sometimes, they are successful; more often, they are not successful for eradicating chronic constitutional disorders. The current author uses modern medicine diagnosis in all cases. This gives the patient's problem a label; tells us what is curable and what is not; and provides indications regarding prognosis. However, when the question of treatment arises, especially in the case of a complex chronic disorder in which the Ben (the root cause) has to be removed, the treatment has to be guided by Chinese Disharmony Patterns—otherwise known as Chinese Syndromes. Many times, presenters in seminars have said, whether we follow modern medicine diagnosis or Chinese diagnosis, ultimately, we use the same acupoints—but this definitely is not the case for chronic disorders. Some acupuncturists believe and teach that migraine is a Gallbladder disorder. This does not agree with modern medicine or Chinese Medicine. The majority of migraine headaches are projected to the Gallbladder meridian but that does not mean migraine is a Gallbladder disorder.

Causes Of Migraine

Western Biomedical View

In modern medicine, the cause of migraine is not precisely known.^1,10 Several theories have been offered. Patients with migraine have a definite genetic predisposition for this problem. A recent study found three areas of the human genome that are associated with common forms of migraine,¹¹ either with or without auras. It is possible that disturbances in the glutamate-signaling pathway are a causative factor. The affected genes are LRP1, TRPM8 (both associated with migraine only) and PRDM16 (associated with both migraine and nonmigraine headaches). The entity known as Familial Hemiplegic Migraine (FHM) is found to be associated with mutations in CACNAIA (FHM1), ATP1A2 (FHM2), and SCNIA (FHM3).¹²

Common triggering factors are stress, hunger, and fatigue. The evidence is against tyramine¹³ and monosodium glutamate¹⁴ as triggers. Menstruation is definitely a triggering factor¹⁵ as well as oral contraceptive usage.¹⁶

Cortical spreading depression,¹⁷ is a phenomenon in which neurological activity is initially activated and then depressed; this is thought to cause release of inflammatory mediators, leading to irritation of nerve roots—especially the trigeminal nerve. Additional factors include:

• Vascular factors—An aura coincides with intracranial vasoconstriction, and this is followed by extracranial vasodilation,¹⁸ producing the headache; dilated vessels allow leakage of fluids, which cause irritation, leading to inflammation.

• Serotonin—Low levels of this substance (a communication chemical) in the brain can trigger migraine, and this is the basis for therapeutic use of triptans, which are serotonin agonists.

• Substance P—When certain nerves or the brainstem become irritated, chemicals such as substance P are released; they send pain signals to the brain; and these substances also cause further irritation to the nerves and blood vessels.

• Dopamine—Most symptoms of migraine can be induced by dopaminergic stimulation; dopamine–receptor antagonists are effective therapeutic agents for treating migraine.

It is not clear whether migraine is a vascular or a neurological disorder—perhaps it is both. Stress causes changes in the brain; these cause serotonin and/or histamine to be released; blood vessels constrict and dilate; and chemicals are released, including substance P, which irritate blood vessels and nerves, causing inflammation and pain—this is a unified theory.

Traditional Chinese Medicine View

According to Traditional Chinese Medicine (TCM), migraine headaches are caused by blockage of Qi (as all painful syndromes are) in the Yang channels of the head and this is the result of disturbances in the internal organs, especially of the Liver. For all practical purposes, it can be said that migraine is a Liver disorder—an Excess of Liver Yang rising to the head, caused by Liver Yin/Liver Blood Deficiency. A weak motor has to rotate faster and, in that process, more heat is generated.

Acupuncture is a holistic system of medicine, and in that system, every chronic disorder has a root and a manifestation (Ben and Biao, respectively, in Chinese). Treating the Biao is simple; painkillers can do that; it is controlling the Ben that is complex, and that is where the skill and expertise of the acupuncturist become involved.

Qi contains a harmonious mixture of Yin and Yang. When Yin is Deficient Yang is in Excess, or, in other words, Yin is too weak to control the Yang, which rises, causing the blockage of Qi and hence the headache. Yin Deficiency of the Liver is the Ben, and the headache caused by the Yang Excess is the Biao. If there is any hope of eradicating the disease, or reducing recurrences, treatment has to be directed to the Liver—to correct the Yin/Blood Deficiency. Any other approach is a “band-aid” treatment.

Symptoms

Symptoms in migraine can be projected to:

• The Gallbladder channel around GB 14, GB 13, GB 20, GB 5, and GB 8; this accounts for 40%–50% of all migraines⁹

• The Stomach channel, with maximum pain around St 8

• The Urinary Bladder channel with pain around UB 2 (between the eyebrows) or around UB 10 in the upper neck and occiput

• The Governing Vessel presenting as a headache in the vertex around GV 20; this is caused by the internal pathway of the Liver Channel connecting to the Governing Vessel at GV 20; some acupuncturists call it Liver Channel Manifestation of Migraine; treatment in these cases is directed to the Liver channel.

Diagnosis

Manifestation

Diagnosis of the manifestation (Biao) is made by the examining the patient's history of chronic episodic primary headaches, lasting 4–72 hours. These headaches may (but not always) be unilateral, throbbing, and worse with exertion. They may be accompanied by autonomic disturbances, such as nausea and vomiting (which often bring relief); sensitivity to light, noise, or odors; and, in some cases, auras (visual, paresthesiae, numbness, speech disturbances, brainstem–thalamic disturbances etc.). Migraine must be differentiated from tension headache—the most common primary headache seen in clinical practice. Migraine is associated with features as given above; tension headache is featureless.¹² Disabling headaches are usually migraines.

Migraines can manifest as vertigo without headache—this is called vestibular migraine. It has the same pathophysiology as other migraines.

Internal Disturbances

Diagnosis of internal disturbances (Chinese Syndromes) may appear to be complex but is, in fact, quite simple. The pathology is Excess Liver Yang. This can be caused by Liver Yin Deficiency per se or by Kidney Yin Deficiency producing Liver Yin Deficiency (with the Kidney being the Mother of Liver in the Five-Element system), or Liver Blood Deficiency (which is more likely to be the case in women).

Diagnosis of these syndromes can be made from the symptoms and simple tongue signs; pulse signs are mentioned for the sake of providing complete coverage, but we can make a diagnosis without them.

All Yin Deficiencies, irrespective of the organs involved, have some features in common—fatigue, weakness, restlessness, nervousness, agitation, insomnia, dreaming, and a pale lustreless complexion with malar flush. Because the Yin cannot control the Yang, Yang goes into Excess, producing Heat, as shown by the patient's warm hands and soles, dry eyes, dry mouth, dry nose (heat dries tissues), and spontaneous sweating. The tongue is red because of Heat and has a thin coating. The pulse is rapid because of Heat and is thin because of Deficiency. To this general Yin deficiency picture, we add:

• For the Liver—Problems include blurred vision (the Liver opens to the eyes), tingling, and cramps (the Liver controls the tendons and muscles), ridged nails (the Liver is responsible for nail health), menstrual irregularities (the Liver controls the flow of Qi to uterus), insomnia, dreaming (the Liver houses the Ethereal Soul).

• For the Kidney—Problems include poor memory, dizziness, weak bones (the Kidney produces marrow and, hence, affects brain and bone health), deafness (the Kidney opens to the ears), low-back pain, degenerative arthritis (as noted the Kidney controls bone health), baldness (the Kidney is responsible for hair health in the scalp), and impotence (the Kidney influences reproductive function).

• For Liver Blood Deficiency—Symptoms are the same as in Liver Yin Deficiency; the distinguishing features are a pale face (no malar flush) and a pale tongue showing Blood Deficiency; a choppy pulse showing Blood Deficiency may be added, if one is keen on pulse diagnosis.

The diagnosis is as simple as that.

Treatment

Acupuncture Points

It is most important to treat the manifestation (Biao) first and deal with the root (Ben) only when the symptoms are totally controlled. This is because, if the Yin Deficiency is corrected by stimulating the organ (either the Liver or Kidney), both Yin and Yang will go up, and Yang (being more volatile than Yin) will go up much more and intensify the headache. Also, any treatment, even if directed to relieve symptoms only, should be of weak intensity.

The steps for treatment of manifestations (Biao) are to identify the involved channel (GB, UB, ST, or LR); stimulate Ting Well points bilaterally (Reinforcement Method); stimulate (reinforce) the source point or tonification point on the side where the pain is located; reinforce the meeting points on both sides; reduce all AhSHI points (look for them diligently)¹⁹; and, most importantly, look specifically for BL 2, GB 9, GB 8, and GB 6. The relevant points are provided in Table 1.

Table 1.

Points Used for Symptomatic Relief of Headache (Muscle Meridian Points)

Channel	Tingwell points	Tonification/source points	Meeting points
GB	GB 44	GB 40	ST 7
ST	ST 45	ST 41	ST 7
BL	BL 67	BL 64	ST 7
LR	LR 1	LR 8	CV 3

The pathology is blockage of Qi in the Yang channels of the head; thus, the treatment has to be channel-based. Use is made of muscle channels, and points are situated in relation to those channels. If the headache is in the vertex (Liver channel) tonification of LR 8 (the tonification point) may aggravate the pain. Concomitant use of HT 9 will alleviate this problem (see below). Treating these points will deblock the affected channels and provide the patient with symptomatic relief. Once the symptoms are totally relieved, treatment of the root is carried out.

Points usually recommended for eradicating the root (Ben) include:

• LR 3—Widely recommended as the main distal point for migraine, because this point reduces Liver Yang most effectively)—reduce

• TE 5—Reduces Liver Yang and is quite useful for headache in the Gallbladder channel, and this is caused by the “axis relationship” between GB and TE channels (Shao Yang Axis)—reduce

• LI 4—Subdues Liver Yang—reduce

• PE 6—Calms the mind and reduces Liver Yang—reduce

• GB 43—Main distal point for headache around the eyes and temple—reduce

GB 20—Useful for occipital headache—reduce

• GB 38—Very effective for all migraines—reduce

• GV 20, SISHENCONG, SI 6, and GB 34—All quite useful for Liver Yang Excess—reduce

• HT 9—Not widely recommended, but the author finds it most useful—reinforce.

Points for Liver Blood Deficiency include SP 6, LR 8, and ST 36 (to nourish Liver Blood), which are reinforced.

Points for Kidney Yin Deficiency include KI 3, KI 6, and KI 10, which are reinforced.

Diet

In addition to just treating migraine with acupuncture, one has to reduce strain on the Liver. Thus, red meat, alcohol, excess spices, dairy products, and fried foods should be kept to a minimum.

Psychological Factors

The most common cause of migraine is suppressed anger.²⁰ This applies not only to the aggressive and assertive Yang types, but also to the fearful, disgusted, suppressive Yin types. Meditation is often recommended. However, it is often difficult, and, in the author's experience, self-hypnosis is easier and more effective. Two half-hour sessions can train a patient.

Acupuncture is a most effective form of treatment for all Excess, Stagnant and, Rebellious conditions, and even in Deficiency involving Qi.²⁰ However, when it comes to Yin Deficiency, when the organ is Deficient, acupuncture is not that effective; it often needs help, especially in chronic recurrent cases. The famous Chinese physician Sun Su Mo stated: “Those who apply acupuncture or herbs are not brilliant physicians; a brilliant doctor uses both.”²¹ It is not intended to introduce Chinese herbal medicine here, but concomitant use of simple supplements such as milk thistle (Silybum marianum) helps to improve the results in a large percentage of cases involving Liver Yin Deficiency.

Battlefield Acupuncture using auricular points—the cingulate gyrus, thalamus, omega 2, point zero, and ear Shenmen often aborts an attack of migraine and other painful syndromes within seconds.²² Auricular points have reflex healing capacity,²³ and repeated use can reduce the frequency of attacks and may eventually eradicate them altogether.

Hemicrania continua is a variant of migraine, in which there is chronic constant headache, fixed in one location. No etiology is offered by modern medicine; Chinese Medicine considers this type of headache similar to migraine with additional Blood Stagnation. Treatment involves additional use of Extra Meridians. Space in this article does not permit any discussion on these fascinating meridians.

Discussion

Acupuncture is unquestionably effective for reducing the symptoms of an attack of migraine, but, when it comes to reduction of recurrences, the picture is not that encouraging. Studies have shown that acupuncture based on TCM principles is no more effective than sham acupuncture.^24,25 Over the years, the author has been studying ways to improve this situation and has learned some major lessons.

Lesson One: The Cause of Pain in Migraines

Pain in migraines is caused by blockage of Qi in the Yang channels of the head. The principal meridians exert their influence in the peripheral parts of the body through muscle meridians, and any treatment directed to unblock Qi in these meridians using muscle meridian points is, in the experience of the author, the most effective treatment—not only for symptomatic relief of pain, but also for reducing recurrences. The reduction in recurrences is possibly the result of more-effective deblocking of channels. Points described in the treatment section of this article are directed toward that goal.

Lesson Two: The LR 3 Point

LR 3 is often acclaimed as the most effective point for treating migraine. No doubt LR 3 will reduce Liver Yang and will relieve the headache quite effectively, but it is important to remember that the fundamental pathology is Liver Yin/Blood Deficiency, and each time the Liver is reduced using LR 3, or any other point for that purpose, this reduces an already-Deficient organ. This applies especially to long-established cases in which Liver Deficiency is deeply rooted. Mild cases may not pose a problem initially. One might reduce the headache but each time the Liver is reduced, we are sowing the seeds of recurrence. The next time such a patient gets a headache, that patient's Liver is a bit more Deficient, and the headache could be more severe. One might argue that LR 3 produces a neutralizing effect. That may be true, but the capacity of acupuncture in general is such that Excess is brought down efficiently, but, for addressing a Yin Deficiency, acupuncture is not that efficient. Moreover, reducing an Excess organ is a waste of precious energy. Thus, it is better to divert the Excess energy to another organ, and the best way to do that is to stimulate the Son (in the Five-Element System). The author does not mean to imply that LR 3 should not be used in migraine; everyone's views and experiences have to be respected. But the author seldom uses this point except in situations of intractable pain, and then, only once or twice—definitely not repeatedly for the reasons given above. The Son will suck the Excess energy from the Mother. Heart (Fire) is the Son of Liver (Wood); thus, we will not waste energy and we will not reduce a Deficient organ. Every organ has its own Five-Element points within itself; in the case of a Yin organ, the first point is the Wood point; and, because Wood is the Mother of Fire, the first point in the Heart channel (HT 9) is the Mother point, or tonification point. Reinforce HT 9 and the headache will lessen. We can use that point any number of times; there is no waste of energy, and we are not reducing Liver. In the author's experience, which spans over more than 48 years, HT 9 is the most effective point in migraine, both for symptomatic relief and to reduce recurrence. The points mentioned for symptomatic relief should be used in addition to deblock channels, and also other points mentioned in the treatment according to indications.

Lesson Three: The Electronic Point Stimulator

Despite a doctor's most meticulous efforts, there will be some patients in almost every practice, whose conditions fail to respond. Teaching these patients how to stimulate HT 9 using an electronic point stimulator will be quite useful. The patient learns to stimulate HT 9 bilaterally using the Reinforcement Method, and this often aborts the attack quite effectively. A stimulator is most efficient if used when the patient gets warning signs of an impending attack, thus, preventing a recurrence. LI 4 can be stimulated in addition, if required, using the Reduction Method. This is a general analgesic point; stimulating it will reduce pain but will not reduce recurrences. Thus, this will provide temporary relief from all forms of headaches; HT 9 will only relieve headaches caused by Liver Yang Excess.

The equipment used is the Pointer Excel II–Electronic Stimulator (Lhasa Oms Inc., Weymouth, MA), using 9V batteries, with an output of 0–22 mA a pulse width of 220 microseconds, and a continuous biphasic square wave. This equipment has a polarity reversal switch. The duration of stimulation is 25 seconds, and treatments are twice per week when patients are asymptomatic (for prevention of recurrence) and daily or on alternate days when patients are symptomatic. The total number of treatments is 16. Further treatment is performed as and when needed. Please refer to manufacturer's instructions regarding contraindications and restrictions.

Conclusions

Acupuncture is a most useful modality of treatment for all forms of migraines—perhaps the most effective modality—both for acute attacks and for preventing or reducing recurrences. While modern medicine diagnosis is an absolute must for all chronic headaches (to give such headaches a “label”), it cannot offer cures or reduce recurrences of migraines because their precise etiology is not well-understood. Any hope of reducing recurrences lies in correcting the Liver disharmony, and for achieving this, acupuncture is quite effective. Diet, management of anger, supplements to support the Liver, and acupuncture—especially the use of HT 9—all play important roles, both in symptomatic relief of migraines and in reducing recurrences—comprising a multipronged approach.

Footnotes

Disclosure Statement

The author has not received any financial grants, and there are no conflicts of interest.

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