Letter: Comments on “Acupuncture Treatment for Chronic Post-Traumatic Headache in Individuals with Mild Traumatic Brain Injury: A Pilot Study”

To the Editor:

We read with great interest the article by Herrmann et al. titled “Acupuncture Treatment for Chronic Post-Traumatic Headache in Individuals with Mild Traumatic Brain Injury: A Pilot Study” published in the Journal of Neurotrauma. ¹ The authors conducted a well-designed pilot study to explore the effects of low-dose (once weekly) versus high-dose (twice weekly) acupuncture on chronic post-traumatic headache (CPTH) in individuals with mild traumatic brain injury (mTBI). The trial demonstrated that acupuncture significantly reduced the number of headache days and pain intensity in individuals with CPTH, with no notable differences between the two dose groups. While the authors’ comparison of different dosages is commendable, the treatment frequency, a critical determinant of efficacy, requires further exploration.

In the trial, the authors defined high-dose acupuncture as twice-weekly treatments over 5 weeks (totaling 10 sessions). However, clinical trials and prior research on headache disorders^2–5 have demonstrated that a treatment frequency of ≥3 sessions/week yields superior efficacy. Systematic reviews further indicate that most studies adopted three sessions/week as the standardized acupuncture protocol. ⁶ A key trial ⁷ exploring acupuncture for pain management in other anatomical regions established a comparative framework between high-frequency (three sessions per week) and low-frequency (one session per week) treatment protocols. By the fourth week of intervention, statistically significant differences in pain alleviation outcomes were observed between the two groups. These findings suggest that setting the high-dose regimen at three sessions per week may be more reasonable and evidence-based. The choice of twice-weekly treatments in the current study may have limited the potential to detect differences between low- and high-dose groups. It is possible that a more intensive regimen could have yielded greater therapeutic benefits, particularly for a condition as complex and debilitating as CPTH.

We commend the authors for their rigorous methodology and contribution to the growing body of evidence on acupuncture for CPTH. However, we suggest that future studies consider adopting a more conventional high-dose regimen (three sessions per week) to better evaluate the dose-response relationship of acupuncture in this population. Additionally, incorporating a sham acupuncture or standard care control group would further strengthen the study design and help clarify the specific effects of acupuncture.