Abstract
For such a ubiquitous symptom, the diagnosis and acupuncture treatment of headache can be surprisingly complex. Clearly, a good history is essential; it should include frequency, position, severity, and associations. Although we divide the main causes of headache into migraine and tension conveniently—for both of which acupuncture is recommended by national authorities such as the National Institute for health and Care Excellence in the United Kingdom—there are multiple relationships and causative factors that may in themselves be amenable to acupuncture.
Cochrane reviews of acupuncture use in both migraine and tension headache report good quality evidence for treating both, but, while sham points appear to be as effective as traditional verum points for migraine, this is not true for tension headache. The researchers suggest that this may be because specific muscle trigger points need to be deactivated when treating tension headache, while migraine responds to more-general acupuncture stimulation.1,2 However, if a patient presents with an acute attack, I find that both types of headache can respond within ∼10 minutes to gentle manual acupuncture or acupressure at LI 4.
Migraine
I like to slip in a needle at LI 4, as a distant point, while I investigate where the migraines usually start and move to, and learn what possible causes may exist. Then, for a migraine originating in the temporal region, I use Taiyang in the temporalis muscle. For frontal-origin migraines, which may involve nerve entrapment by the corrugator supercilii muscle, I use either BL 2 or Yuyao, over the supratrochlear and supraorbital foramina respectively, plus GB 14 or the midline yintang. For an occipital origin, I needle GB 20 or BL 10, whichever seems more tender to palpation. In general, if migraines tend to be on one predominant side, I will needle contralateral points; otherwise I sometimes place needles bilaterally, depending on the sensitivity of the patient.
Although I like to claim good success rate for the prophylactic treatment of migraine, I do warn patients that, sometimes, after a first treatment, the patient could suffer a severe migraine followed by almost complete freedom from migraine symptoms. However, some patients note an occasional aura that does not develop into a full migraine. 3 With this scenario, I wait before giving further treatment, but, for intermittent or menstrual-related migraine, I usually give 4 sessions at weekly intervals and then wait to see what response has occurred.
Migraine is particularly susceptible to precipitating factors that may be countered by lifestyle changes once problematic habits have been identified, but this type of headache may also respond to targeted acupuncture. 4 For migraine with visual symptoms or triggered by flashing lights, I use GB 20 and Taiyang, together with BL 2 or Yuyao. For premenstrual migraine, I treat bilateral SP 6 and teach patients to use acupressure with a finger on the easy-to-identify SP 6 point, which is a hand's-breadth up from the medial malleolus. SP 6 is usually acutely tender around menstrual times. For relationships with allergy or food and drink sensitivity, avoidance is the ideal, but I do add LI 11. Some people seem to worry themselves into migraines, in which case the antistress points GV 20 or Sishencong on the apex of the skull can have a wonderfully calming effect on the anxious personality.5,6
A very common symptom associated with migraine is nausea. If that occurs, I treat at PC 6 and also teach acupressure at that point for use at home. If the migraine actually causes vomiting, then I add a needle to LR 3 as well.
Tension Headache
Causes of bodily tension may be physical or psychologic. Physical tension is often due to poor posture at a computer screen or difficult work conditions, exacerbated by feeling rushed toward a deadline. The visible symptom of this is hunched-up shoulders and tight neck muscles. I teach patients that as soon as they feel shoulders rising in stress, they should formally relax them. Psychologic tension may be related to a poor stress response to situations at home or work that are often difficult to control. Both types of tension result in taut neck and shoulder muscles with activated trigger points referring pain into the scalp.
To treat, I stand behind the seated patient and palpate the upper section of the trapezius muscle and the sternocleidomastoid muscle, gently at first, to find and needle the more-superficial muscle trigger points, and then deeply posteriorly to identify trigger points in the posterior cervical muscles. 7 All of these muscle trigger points have pain- referral patterns giving rise to headaches. It is interesting to note that there are several traditional acupuncture points on the LI, SI, GB, and BL meridians that are identical to common trigger-point sites. I regard the more-important of these to be BL 10, GB 20, and GB 21, so I generally use them even if they are not actively tender. BL 10 and GB 20 can be needled deeply with gentle periosteal tapping. GB 21, however, is within 2 cm of the pleural apex, so I insert my needles horizontally to avoid pneumothorax.
If there is a paucity of active trigger points, I may use the distant points LI 4 and LR 3 in addition, and if there is a psychologic component then, as with migraine treatment, I will use GV 20 or Sishencong to reduce the stress response. I repeat treatment at weekly intervals until a good, lasting response is achieved; this occurs generally between 2 and 5 sessions.
Cluster Headache
The important point to realize about cluster headache is that it is not an exceptionally severe form of migraine, but is one of the trigeminal autonomic cephalgias, more related to trigeminal neuralgia than to the common types of headache. Acupuncture is acknowledged as an effective treatment for trigeminal neuralgia, so using a trigeminal acupuncture method for cluster headache appears a logical approach. 8 Because cluster pain is so excruciating, I encourage patients to continue with their prescribed medications or regimens, including oxygen therapy, during the course of the acupuncture treatment.
Cluster headache is normally unilateral, regularly originating from the same periorbital or temporal regions, with referral of pain down the side and front of the face. As with any neuralgia, stimulation into the neuralgic area can precipitate pain, so I place my needles into the contralateral side and use few points with minimal stimulation.
I select standard ophthalmic-division trigeminal-acupuncture points, notably either BL 2 or Yuyao above the eye for the headache origin, and within the maxillary division, I use Taiyang over the temple for the alternative headache origin, with ST 2 over the infraorbital foramen for the area of pain referral. 8 As distant points, I use the traditional LI 4 or LR 3. I treat on alternate days during a cluster headache episode, but avoid acupuncture during times of remission unless prodromal symptoms have emerged.
Footnotes
1.
Linde K, Allais G, Brinkhaus B, et al. Acupuncture for migraine prophylaxis. Cochrane Database Syst Rev. 2009;1:CD001218.
2.
Linde K, Allais G, Brinkhaus B, et al. Acupuncture for tension-type headache. Cochrane Database Syst Rev. 2009;1:CD007587.
3.
Hayhoe S. Acupuncture for chronic pain. In: Filshie J, White A, Cummings M, eds. Medical Acupuncture: A Western Scientific Approach, 2nd ed. Edinburgh: Elsevier; 2016:315–344.
4.
Hayhoe S. Acupuncture. In: Varley P, ed. Complementary Therapies in Dental Practice. Oxford: Butterworth-Heinemann; 1998:141–173.
5.
Lloret L, Hayhoe S. A tale of two foxes: Case reports. Acupunct Med. 2005;23(4):190–195.
6.
Hayhoe S. How do you boost resilience during the current COVID-19 pandemic in your practice? Med Acupunct. 2020;32(4):241–242.
7.
Baldry PE. Myofascial Pain and Fibromyalgia Syndromes. Edinburgh: Churchill Livingstone; 2001.
8.
Hayhoe S. Acupuncture for episodic cluster headache: A trigeminal approach. Acupunct Med. 2016;34(1):55–58.
Address correspondence to:
Simon Hayhoe, MSc, MBBS, MRCA, DA
Pain Management Department
University Hospital, Turner Road
Colchester CO4 5JL
United Kingdom
E-mail:
Migraine headaches affect 16% of the population and are more common in women, especially associated with menses. 1 Despite the many treatments available for both prophylaxis and treatment, ranging from over-the-counter medications to the highly expensive antibody and botulinum toxin treatments, few patients experience complete cures. 1 A simple 2-point auricular acupuncture treatment, using Shen Men and Point Zero with gold Aiguille Semi-Permanente® (ASP®) needles left in place for up to 7 days, can serve as an effective and efficient headache treatment and prophylaxis. This is illustrated in 2 different cases wherein auricular acupuncture treatment was provided on a drop-in basis, as both patients were hospital staff members.
Headache is a common complaint in our daily practice and at the hospital where we work. The majority of patients have primary headache disorders, but these can be difficult to diagnose. Headache treatment is usually individualized because it varies according to each individual's needs.
Acupuncture can be used with significant therapeutic effect to reduce pain and headache frequency. The treatment according to Chinese Medicine, following a clinical and physical evaluation, can include 1 of these 2 combinations for the following conditions:
For symptoms classified through syndromes: (A) Tension pain has Cold, Heat (infectious, or not) characteristics that involve heavy pain, which is a Qi Stasis Syndrome or Phlegm. The points are LI 4, SI 3, TE 3, ST 36, and LR 3. (B) Pain with throbbing characteristics is a Heat Syndrome (infection). The points are LI 4, LR 3, ST 7, TE 17, LI 20, GB 20. Pain caused by internal factors, usually of emotional origin, family problems, and other causes: (A) Throbbing pain is a Heart or Liver Fire Syndrome. The points are PC6, LR 3, and TE 6 with GB 34. (B) Pain with a heaviness pattern, associated with faintness, nausea, and depression. The points are PC6, CV 12, BL 18, and BL 15.
We begin by comparing areas of pain with meridian pathways as follows:
We also evaluate patients according to Western Medicine diagnoses. Many patients whose conditions do not respond to pharmacologic treatment may present with mixed headache syndromes, characterized by combinations of both migraine and muscle contractions or cervicogenic pain.
Muscle tension and taut bands may be present in the neck, contributing to the headache with referred pain. Acupuncture can be used to treat Ah Shi points or active myofascial trigger points in the head (temporal and occipital regions) and cervical and upper-back muscles.
In practice, acupuncture is aimed at treatment for general well-being: using the meridian points in the head area as analgesics and the points on the body based on Syndrome concepts aimed at general well-being, thus, preventing emotional causes or other causes, such as sinusitis or tension of the cervical and masticatory muscles.
In general, 12 sessions per week are given initially. After 2 sessions, we can add electric stimulation or cupping to improve pain management. For chronic pain, a 30–40-minute session is recommended 1–2 times per week for the next 6–8 weeks.
Acupuncture also reduces medication-use effects, particularly in headaches caused by medication overuse. Acupuncture is also important for preventing migraine attacks and reducing their frequency.
Lifestyle and diet changes should also be incorporated to eliminate possible underlying headache causes. Patient education and referral to a neurologist might be important for reducing headaches caused by medication overuse. Practitioners should focus on treatments that address both the Eastern and Western diagnoses.
Marcus Yu Bin Pai, MD, PhD §
Hong Jin Pai, MD PhD
§Address correspondence to:
Pain Center, University of São Paulo
Aveneida Dr. Enéas de Carvalho Aguiar 255
São Paulo, SP, Brazil
E-mail:
Pearls for treating headaches begin with listening to each patient's history and doing a careful neuromusculoskeletal examination of the whole patient, especially of the head and neck. Review the patient's records and imaging studies. For acute headaches, exclude serious conditions, such as meningitis, arteritis, and subarachnoid hemorrhage (including sentinel events).
Most benign recurring headaches are combinations of vascular and tension-type headaches. If your palpation uncovers neuromusculoskeletal sites that reproduce the patient's symptoms, you can let your palpation direct the initial, local treatment. Commonly used regional acupuncture points include:
Sometimes, use of a single needle will completely relieve a persistent headache when there are discrete identifiable symptom-reproducing points revealed on palpation.
For occipital neuralgia, needle BL 10, GB 20, and SI 16, along with the Huato Jiaji points at the highest cervical level. For posterior axial and spondylogenic headaches, an energetic approach works with the Governor Vessel points GV 24, GV 20 through GV 16, GV 14 and any tender interspinous ligaments from C-2–C-7, adding local Huato Jiaji points as needed. For posterior paraxial symptomatology, with a more-neuromuscular type of presentation use the Yang Qiao Mo: BL 62/SI 3/BL 59. For headaches between the eyes where Yin Qiao Mo and Yang Qiao Mo meet, treat with KI 6/LU 7 and BL 62/SI 3, adding KI 8 for the Depleted state or BL 59 for the Excess state. For patients with vertex headaches, combine Jue Yin with Yang Wei Mo/Shao Yang. Open with LR 3 and/or LR 2 as needed before completing the circuit with TE 5, GB 41, and either PC 6 for Depletion or GB 39 for Excess presentations.
When the neck problem is the source of the head problem, choose Yin Qiao Mo. Open with KI6 and LU 7, because LU 7 is influential in the neck. Activate with KI 8, for Depleted Kidney Yin and pair it with an appropriate Yang axis, (Yang Qiao, Du, Yang Wei, or Tai Yang). For patients with anterior facial presentation of their headaches, treat with Chong Mo–Yang Ming, ST 5, ST 6, ST 7, and ST 8 if tenderness exists. For patients with the global headache of Kidney Depletion, Chong Mo is helpful.
Migraine sufferers usually have positive familial histories of migraine. Many women experience catamenial exacerbations. Think Yuan Qi. Treat migraines with Chong Mo–Yang Wei Mo: SP 4/PC 6 + KI 3; TE 5/GB 41 or SP 4/PC 6; or TE 5/GB 41 + BL 63/GB 35. Add BL 10, GB 20, LI 18, SI 16, and TE 16 points as needed This approach to migraines is useful for managing well-controlled migraines in patients who must abandon their medications during pregnancy or prepregnancy.
A systematic palpatory examination for tender Window of the Sky points yields a surprising benefit beyond straightforward relief of musculoskeletal discomfort. This may be related to the major presence of Window points along the sternocleidomastoid and upper trapezius muscles. Their innervation by the spinal accessory nerve brings them into connection with the vagal nerve complex and its role in modulating affect. Simple deactivation of tender Window points in 1–2 minutes each or as part of a larger treatment will consistently improve a patient's response. If a Window point remains tender, add the Yuan point of that channel.
Auricular treatments are useful for initiating treatment with acupuncture or for adding a potentiating microsystem. Scan and needle the Anti-Tragus for frontal, temporal, and occipital headaches at their somatotopic projection sites, additionally scanning just off the cartilaginous ridge at the junction of the lobe for signs of soft-tissue involvement.
The Battlefield Acupuncture protocol is helpful for managing acute head pain. The Auricular Trauma Protocol has proven to be a potent alternative, especially if a patient's symptoms appear to be stress-driven. These auricular treatments are meant for downrange use and do not replace the local neuromusculoskeletal and energetic work that remains to be managed.
To summarize, my usual approach involves a global energy-moving needle pattern to regulate and improve constitutional balance. Local needles are applied to points on the head, neck, face, and shoulders that reproduce symptoms and/or address areas that are tender on examination. The treatment is completed by using the auricular microsystem with straight needles and/or indwelling semipermanent needles to potentiate and extend the treatment effect beyond the clinical setting.
Address correspondence to:
Mitchell Elkiss, DO, FACN, FAAMA, CSPOMM
Department of Neurology
Michigan State University College of Osteopathic Medicine
Helms Medical Institute
Rather, Berkeley, CA, USA
E-mail: