Author's Accepted Manuscript
Treating the Root Cause: Acupuncture for the Treatment of Migraine, Menopausal Vasomotor Symptoms, and Chronic Insomnia Amber E. Hammes Lac, Dietlind L. Wahner-Roedler MD, Brent A. Bauer MD
www.elsevier.de/endend
PII: DOI: Reference:
S1550-8307(14)00066-4 http://dx.doi.org/10.1016/j.explore.2014.04.001 JSCH1934
To appear in:
Explore
Cite this article as: Amber E. Hammes Lac, Dietlind L. Wahner-Roedler MD, Brent A. Bauer MD, Treating the Root Cause: Acupuncture for the Treatment of Migraine, Menopausal Vasomotor Symptoms, and Chronic Insomnia, Explore, http://dx.doi.org/ 10.1016/j.explore.2014.04.001 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
-1-
[Category: Case Report] Revised Ms. No. EXPLORE-D-13-00084 Treating the Root Cause: Acupuncture for the Treatment of Migraine, Menopausal Vasomotor Symptoms, and Chronic Insomnia Amber E. Hammes, LAc Dietlind L. Wahner-Roedler, MD Brent A. Bauer, MD
Author Affiliations: Complementary Integrative Medicine Program (Ms Hammes and Drs Wahner-Roedler and Bauer) and Division of General Internal Medicine (Drs Wahner-Roedler and Bauer), Mayo Clinic, Rochester, Minnesota. Reprints: Dietlind L. Wahner-Roedler, MD, Division of General Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ([email protected]). Conflict of interest: none. Text word count: 2,372 Abstract word count: 220 No. of tables: 0 No. of figures: 0 Running title: Acupuncture for 3 Medical Conditions Publisher: To expedite proof approval, send proof via e-mail to [email protected]. ©2013 Mayo Foundation for Medical Education and Research
[Category: Case Report]
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Treating the Root Cause: Acupuncture for the Treatment of Migraine, Menopausal Vasomotor Symptoms, and Chronic Insomnia
Abstract Objective: This case report describes the effectiveness of a single intervention, acupuncture, for relieving or abolishing severe migraines, menopausal vasomotor symptoms, and chronic insomnia and, thus, markedly improving quality of life. Clinical Features: A 49-year-old woman was referred for acupuncture treatment of her daily migraines, menopausal vasomotor symptoms, and chronic insomnia. The patient had received polypharmacy treatment for these conditions for several years but had rather limited relief of her symptoms. Intervention and Outcome: The patient received 10 weekly or biweekly acupuncture treatments over 3 months. Her migraines reduced in frequency and intensity after her first acupuncture treatment, and she was able to discontinue use of her migraine medications after her eighth treatment. Subsequently, her menopausal vasomotor symptoms and chronic insomnia resolved. Conclusion: This case illustrates successful treatment of the symptoms of 3 medical conditions with a single complementary, alternative, and integrative medicine procedure, namely, acupuncture, one of the key elements of traditional Chinese medicine. The patient’s medical problems had been treated for years with a multitude of medications, which led to adverse effects and little symptomatic improvement. Providers of complementary, alternative, and integrative medicine and providers practicing allopathic
-3-
medicine should seek treatment options for their patients that promise to be helpful for various symptoms or diseases, that is, treating the root cause, rather than using polypharmacy for various symptoms.
Keywords: alternative medicine; integrative medicine; natural; traditional Chinese medicine Introduction Migraine is a common and often debilitating neurologic disease affecting about 12% of the general population (1). Because of its high prevalence and its debilitating features that result in loss of workplace productivity, migraine has considerable economic and public health implications. A typical migraine attack evolves through 4 phases: the premonitory, the aura, the headache, and the postdrome phases (2). The headache of migraine is usually unilateral and tends to have a throbbing or pulsatile quality. Common triggers include emotional stress, hormones in women, not eating, sleep disturbances, odors, lights, alcohol, smoke, heat, and certain foods (3). The underlying cause of migraine is complex. Current knowledge suggests that a primary neuronal dysfunction, including cortical spreading and sensitization, leads to a multitude of sequential changes that account for the different phases of migraine (2). Although the importance of genetics in familial hemiplegic migraine has long been recognized, the genetic basis of migraine is complex and is actively being investigated. Common medical treatment of migraine for patients whose headache responds poorly to nonsteroidal anti-inflammatory drugs includes the use of migraine-specific agents (triptans, ergotamine), dopamine antagonists, and
-4-
narcotics. Preventive approaches include the use of antiepileptics (topiramate, valproic acid), calcium channel blockers (candesartan, propranolol, timolol, and verapamil), antidepressants (amitriptyline), and other medications such as botulinum toxin A. No single pharmaceutical medication or combination of such agents has been shown to be 100% effective. All of the medications have the potential to cause adverse effects ranging from nausea to seizures (4). Menopausal vasomotor symptoms, or hot flashes, are described as an intense heat sensation over the trunk and face, and they may be accompanied by flushing of the skin and sweating. These are due to a decrease in ovarian hormones, namely, estrogen, and occur in more than 80% of perimenopausal and menopausal women (4). Vasomotor symptoms can begin before cessation of menses and last for 2 to 3 years. For women with moderate to severe vasomotor symptoms, estrogen or estrogenprogesterone regimens are the most common and effective approach to symptom relief. Because data from the Women’s Health Initiative suggest that women should not use estrogen-progesterone therapy for more than 3 to 4 years (4), these therapies are not recommended for long-term management of symptoms. Insomnia is classified as difficulty with falling or staying asleep, intermittent wakefulness during the night, early morning awakening, or any combination of these problems. Transient episodes of insomnia are common. Frequency and duration of insomnia determine the need for treatment. Psychiatric disorders such as depression or mania are often associated with persistent insomnia. There are 2 broad management strategies for insomnia, and they may be used in combination. Psychological interventions such as
-5-
sleep hygiene are used to instruct the patient in how to obtain restful sleep. Medical intervention includes orally administered benzodiazepines, nonbenzodiazepine hypnotics, and antidepressants (4). From a traditional Chinese medicine perspective, all symptoms experienced by an individual are considered to stem from 1 root cause. Identifying an underlying imbalance in the body and targeting treatment at that diagnosis should begin to improve all symptoms. Migraine is categorized into pattern discriminations determined by the characteristics and cause of the headache. Most frequently, the pattern involves counterflow of qi upward to the head. In a healthy state, qi flows along specific pathways, or meridians, in the body. There is a balance of flow both to and from the head. Disturbance of qi flow along a meridian flowing from the head causes counterflow against the meridian and stagnation of qi, causing head pain. Most notably, the liver meridian tends to be the culprit of qi counterflow. This function of this meridian is to process emotional stress; when the meridian becomes overwhelmed, the qi flow becomes disrupted and counterflow occurs. This results in qi traveling upward to the head and eyes and causing head pain and vision disturbances or horizontally to the spleen and stomach meridians and causing nausea and vomiting (5). Migraines can also be triggered by an external invasion such as wind-heat, wind-cold, wind-damp, or summer-heat. This triggering occurs typically when a person is ill. The body tries to push out the pathogen and, in the process, harmonious qi flow is disturbed. This disturbance leads to a rebellion of upwards qi flow, triggering a migraine (5). Hot flashes and insomnia can both be categorized as a deficiency of yin. In the basic principles of traditional Chinese medicine, for balance to
-6-
be established and maintained in the body, there must be an interdynamic balance of yin (cooling) and yang (warming) energy. According to this view, estrogen is considered to be a yin, or cooling, hormone (6). When this hormone becomes depleted around menopause, there is not enough yin to cool and anchor the yang energy, and deficient heat occurs. Too much heat can lead to spontaneous sweating, sweating at night, a sensation of heat in the upper aspect of the body, and restless sleep. Applying the traditional Chinese medicine principle of treating patients according to their unique pattern differential allows multiple patient complaints to be simultaneously treated by the practitioner and many potential adverse effects of medication to be avoided. Chinese medicine applies individualized acupuncture treatments and Chinese herbal formulas to reestablish qi flow, establish harmony between yin and yang, and treat any underlying imbalances that the practitioner determines from pulse and tongue assessment. This case report describes the successful use of acupuncture for treatment of migraines, hot flashes, and insomnia. Case Report History A 49-year-old woman was referred for acupuncture treatment of migraine by her neurologist. She recalled first having what she came to recognize as migraines in her late 20s. They were described as being hemicranial, more common on the right than on the left, pulsatile, and worse with routine physical activity such as climbing steps. She had associated photophobia and mild phonophobia. There was no aura. The headaches typically lasted hours. On several occasions, she had prolonged and severe
-7-
headaches that required treatment in the emergency department, typically with a combination of ketorolac tromethamine and prochlorperazine. For several years, the use of rizatriptan benzoate 10 mg as an abortive agent at onset of migraine proved to be effective for management of the headaches. In the fall of 2010, the patient had an episode of rather severe herpes zoster with difficult-to-control pain. Various agents were used for treatment, including pregabalin and oxycodone hydrochloride. By early 2011, the headaches had essentially started to occur daily. She reported awakening with a headache that she rated 8 on a pain scale of 1 to 10. Rizatriptan 10 mg ameliorated the headache a bit, but she usually required a second and a third dose. After the third dose later in the day, she would typically be headachefree and remain headache-free through the night, awakening with a headache the following morning. She had taken rizatriptan on a daily basis for at least 6 months. She also had received botulinum toxin injections for her migraines. Oral ketorolac was tried but caused gastric upset. A combination agent of acetaminophen, butalbital, and caffeine (Fioricet); amitriptyline in the evening; and duloxetine hydrochloride 20 mg as a prophylactic agent were not particularly effective. The patient further reported having insomnia since the birth of her daughter 21 years ago. She would awaken several times during the night, get up, and move to a different room, chair, or couch. Nightly use of zolpidem tartrate resulted in minimal improvement of her insomnia. The patient’s other major concern was hot flashes. She had been given hormone replacement therapy in the past and her symptoms had resolved. However, because she had undergone a breast biopsy and had a strong family history of breast cancer, her breast clinic physician had
-8-
advised her to discontinue use of the hormone replacement therapy. Since then, she had been having hot flashes and profuse sweating day and night. Physical Examination by Acupuncturist The patient’s pulses were taken bilaterally at the radial arteries, and the tongue was visually inspected according to the diagnostic technique of traditional Chinese medicine. The cun and chi positions in the left wrist were deep, and the overall pulse was wiry. The pulses were slightly rapid at 78 beats per minute. The tongue was small and red. The tip was peeled and red, the tongue body had scanty coating, and the sublingual vessels were thin and distended to the tip of the tongue. Traditional Chinese Medicine Diagnosis Assessment of the patient’s tongue and pulses and interpretation of her symptoms of deficient heat (hot flashes, insomnia) and counterflow of qi (migraine headache) led to the diagnosis of kidney and heart yin deficiency and liver qi stagnation causing deficient heat rising. Biomedical Diagnosis Migraine headache without aura, presumed menopausal symptoms, and intractable insomnia were the biomedical diagnoses. Traditional Chinese Medicine Treatment Principle Recommendations were nourish yin, clear deficient heat, move qi, and sooth the liver and heart. Acupuncture Treatment The patient lay supine and acupuncture points were selected. Needles were inserted until a dull, achy (de qi) sensation was obtained. Needles were retained for 20 minutes with a tonifying technique. Acupuncture procedures were performed with DBC Spring Ten sterile and
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disposable needles 0.20 × 30 mm. Details regarding the various acupuncture sessions are outlined in the Table. Outcome The patient was treated weekly for treatments 1 through 4. She reported the following: 0 to 2 mild headaches per week that were easily treated with one dose of rizatriptan, improved sleep, and a reduction in the frequency of hot flashes and night sweats. After treatment 4, the patient discontinued use of duloxetine hydrochloride and had rebound headaches, dizziness, and digestive upset. She returned to use of a daily dose of 20 mg and symptoms resolved. The patient began having acupuncture every 2 weeks after treatment 4. The migraines continued to become less frequent, and her sleep improved to waking once a night. On treatment 7, her point selection was altered to determine whether more improvement could be made. After treatment 8, the patient discontinued use of duloxetine hydrochloride and did not have withdrawal symptoms. She also discontinued use of zolpidem tartrate. She has reported no migraine headaches, sleeps through the night, and has not experienced hot flashes or night sweats. She continues to have an acupuncture treatment once every 4 to 6 weeks. Discussion This case report illustrates the successful treatment of migraine, hot flashes, and insomnia with acupuncture. The experience was rewarding for both the practitioner of complementary, alternative, and integrative medicine and the patient. A review of the literature indicates that many acupuncture trials for migraine headaches have been performed and that they have had
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different results (8). Several large, well-designed trials have reported no or only a small difference between the results of real and sham acupuncture (811), whereas other, smaller studies were more likely to show superiority of acupuncture over sham acupuncture or drug treatment (8,12). At least 3 large, adequately powered trials found no difference between real acupuncture and sham acupuncture (9-11). Recently, Li et al (10) reported a large, multicenter study on the effectiveness of acupuncture for prevention of migraine. A total of 480 patients were randomly assigned to one of 4 groups: Shaoyang-specific acupuncture, Shaoyang-nonspecific acupuncture, Yangming-specific acupuncture, or sham acupuncture (control). The authors found that the outcomes after acupuncture were substantially better than with sham acupuncture during weeks 13 through 16, but the effect was clinically minor. There was no difference between the 3 acupuncture groups. A meta-analysis published in 2012 using the data from 29 eligible randomized controlled trials with a total of 17,922 patients concluded that acupuncture is an effective treatment of chronic pain, including migraine, and is therefore a reasonable referral option (13). The authors further reported substantial differences between acupuncture and sham treatment, an indication that acupuncture is more than a placebo. Thus, many acupuncture studies have concluded that acupuncture has clinical effects on migraine headaches. Acupuncture is also a popular form of complementary and alternative medicine used by women for menopausal symptoms (14,15). Its effectiveness as a treatment option for menopausal hot flashes was assessed in a systematic review in 2009 by Lee et al (16). The authors searched the literature using 17 databases and included randomized controlled trials of
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acupuncture versus sham acupuncture. A total of 6 trials could be included. Only one of these 6 trials suggested positive results. However, this study was thought to be too small to generate reliable findings. The sham-controlled trials failed to show specific effects of acupuncture for control of menopausal hot flashes. Again, the authors stressed that one of several different explanations for these findings could be that sham acupuncture is also effective and thus no intergroup difference could be demonstrated (12). A Cochrane review concerning the effectiveness of acupuncture for insomnia published in 2012 concluded that, because of poor methodologic quality and a high level of heterogeneity, current evidence is not sufficiently rigorous to support or refute acupuncture for treating insomnia and that larger high-quality clinical trials are needed (17). In summary, although multiple trials have documented contrasting results regarding acupuncture’s efficacy for treating migraines, hot flashes, and insomnia, the case described illustrates that its use should still be considered, especially in patients with a multitude of symptoms for which polypharmacy has had minimal success. Despite some contrasting information, we agree with the opinion of Diener (11) that it is ethical to use acupuncture even if the effectiveness may be partially due to a placebo effect, taking into consideration that a placebo effect is real and certainly superior to no treatment or medical treatments without any effectiveness. Conclusion This case demonstrates the effectiveness of acupuncture for improving quality of life for a patient with severe migraine headaches, hot flashes, and insomnia and for making the use of multiple, possibly harmful,
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medications unnecessary. Randomized controlled trials summarized in Cochrane reviews have not shown a clear-cut efficacy of acupuncture for these clinical conditions. Many randomized controlled trials are efficacy trials, particularly conducted for regulatory drug approval. Alternatively, effectiveness trials are intended for a specific population and may be more relevant to the health care decisions of providers and patients. Because the mechanism of how acupuncture works is not yet understood, it is difficult to find a truly benign sham comparison. Further trials evaluating the effectiveness of acupuncture over standard care are needed.
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References 1.
Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M. Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache. 2001 JulAug;41(7):646-57.
2.
Charles A. The evolution of a migraine attack: a review of recent evidence. Headache. 2013 Feb;53(2):413-9. Epub 2012 Dec 20.
3.
Kelman L. The triggers or precipitants of the acute migraine attack. Cephalalgia. 2007 May;27(5):394-402. Epub 2007 Mar 30.
4.
Papadakis M, McPhee SJ, Rabow MW, editors. Current medical diagnosis and treatment 2013. 52nd ed. New York: McGraw-Hill Medical; c2012. 1,840 p.
5.
Flaws B, Sionneau P. The treatment of modern western medical diseases with Chinese medicine: a textbook and clinical manual. 2nd ed. Boulder (CO): Blue Poppy Press; c2002. 596 p.
6.
Maciocia G. Obstetrics and gynecology in Chinese medicine. 2nd ed. New York: Churchill Livingstone; c2011. 1,067 p.
7.
Kuoch DJ. Acupuncture desk reference. 2nd ed. Vol. 1. San Francisco (CA): Acumedwest, LLC; c2011. 474 p.
8.
Diener HC, Kronfeld K, Boewing G, Lungenhausen M, Maier C, Molsberger A, et al; GERAC Migraine Study Group. Efficacy of acupuncture for the prophylaxis of migraine: a multicentre randomised controlled clinical trial. Lancet Neurol. 2006 Apr;5(4):310-6. Erratum in: Lancet Neurol. 2008 Jun;7(6):475.
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9.
Linde K, Streng A, Jurgens S, Hoppe A, Brinkhaus B, Witt C, et al. Acupuncture for patients with migraine: a randomized controlled trial. JAMA. 2005 May 4;293(17):2118-25.
10.
Li Y, Zheng H, Witt CM, Roll S, Yu SG, Yan J, et al. Acupuncture for migraine prophylaxis: a randomized controlled trial. CMAJ. 2012 Mar 6;184(4):401-10. Epub 2012 Jan 9.
11.
Diener HC. Acupuncture prophylaxis of migraine no better than sham acupuncture for decreasing frequency of headaches. Evid Based Med. 2013 Feb;18(1):33-4.
12.
Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for migraine prophylaxis. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD001218.
13.
Vickers AJ, Cronin AM, Maschino AC, Lewith G, MacPherson H, Foster NE, et al; Acupuncture Trialists’ Collaboration. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012 Oct 22;172(19):1444-53.
14.
Nelson HD, Vesco KK, Haney E, Fu R, Nedrow A, Miller J, et al. Nonhormonal therapies for menopausal hot flashes: systematic review and meta-analysis. JAMA. 2006 May 3;295(17):2057-71.
15.
Bair YA, Gold EB, Zhang G, Rasor N, Utts J, Upchurch DM, et al. Use of complementary and alternative medicine during the menopause transition: longitudinal results from the Study of Women’s Health Across the Nation. Menopause. 2008 JanFeb;15(1):32-43.
16.
Lee MS, Shin BC, Ernst E. Acupuncture for treating menopausal hot flushes: a systematic review. Climacteric. 2009 Feb;12(1):16-25.
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17.
Cheuk DK, Yeung WF, Chung KF, Wong V. Acupuncture for insomnia. Cochrane Database Syst Rev. 2012 Sep 12;9:CD005472.
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Table. Acupuncture Treatment Sessions and Acupuncture Point Selection Treatment Session
Acupuncture Points Selected
1-6
He gu LI-4, Taichong LR-3, Qihai CV6, Shanzhong CV-17, Yin Xi HT-6, Zhaohai KI-6, Ran Gu KI-2, Yin Tang, Baihui GV-20, Auricular: Shen Men, Kidney
7-22
He Gu LI-4, Taichong LR-3, Guanyuan CV-4, Qihai CV-6, Shanzhong CV17, Yin Xi HT-6, Zhaohai KI-6, Zulingqi GB-41, Baihui GV-20, Auricular: Shen Men, Kidney
Treating the Root Cause: Acupuncture for the Treatment of Migraine, Menopausal Vasomotor Symptoms, and Chronic Insomnia Amber E. Hammes Lac, Dietlind L. Wahner-Roedler MD, Brent A. Bauer MD
www.elsevier.de/endend
PII: DOI: Reference:
S1550-8307(14)00066-4 http://dx.doi.org/10.1016/j.explore.2014.04.001 JSCH1934
To appear in:
Explore
Cite this article as: Amber E. Hammes Lac, Dietlind L. Wahner-Roedler MD, Brent A. Bauer MD, Treating the Root Cause: Acupuncture for the Treatment of Migraine, Menopausal Vasomotor Symptoms, and Chronic Insomnia, Explore, http://dx.doi.org/ 10.1016/j.explore.2014.04.001 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
-1-
[Category: Case Report] Revised Ms. No. EXPLORE-D-13-00084 Treating the Root Cause: Acupuncture for the Treatment of Migraine, Menopausal Vasomotor Symptoms, and Chronic Insomnia Amber E. Hammes, LAc Dietlind L. Wahner-Roedler, MD Brent A. Bauer, MD
Author Affiliations: Complementary Integrative Medicine Program (Ms Hammes and Drs Wahner-Roedler and Bauer) and Division of General Internal Medicine (Drs Wahner-Roedler and Bauer), Mayo Clinic, Rochester, Minnesota. Reprints: Dietlind L. Wahner-Roedler, MD, Division of General Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ([email protected]). Conflict of interest: none. Text word count: 2,372 Abstract word count: 220 No. of tables: 0 No. of figures: 0 Running title: Acupuncture for 3 Medical Conditions Publisher: To expedite proof approval, send proof via e-mail to [email protected]. ©2013 Mayo Foundation for Medical Education and Research
[Category: Case Report]
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Treating the Root Cause: Acupuncture for the Treatment of Migraine, Menopausal Vasomotor Symptoms, and Chronic Insomnia
Abstract Objective: This case report describes the effectiveness of a single intervention, acupuncture, for relieving or abolishing severe migraines, menopausal vasomotor symptoms, and chronic insomnia and, thus, markedly improving quality of life. Clinical Features: A 49-year-old woman was referred for acupuncture treatment of her daily migraines, menopausal vasomotor symptoms, and chronic insomnia. The patient had received polypharmacy treatment for these conditions for several years but had rather limited relief of her symptoms. Intervention and Outcome: The patient received 10 weekly or biweekly acupuncture treatments over 3 months. Her migraines reduced in frequency and intensity after her first acupuncture treatment, and she was able to discontinue use of her migraine medications after her eighth treatment. Subsequently, her menopausal vasomotor symptoms and chronic insomnia resolved. Conclusion: This case illustrates successful treatment of the symptoms of 3 medical conditions with a single complementary, alternative, and integrative medicine procedure, namely, acupuncture, one of the key elements of traditional Chinese medicine. The patient’s medical problems had been treated for years with a multitude of medications, which led to adverse effects and little symptomatic improvement. Providers of complementary, alternative, and integrative medicine and providers practicing allopathic
-3-
medicine should seek treatment options for their patients that promise to be helpful for various symptoms or diseases, that is, treating the root cause, rather than using polypharmacy for various symptoms.
Keywords: alternative medicine; integrative medicine; natural; traditional Chinese medicine Introduction Migraine is a common and often debilitating neurologic disease affecting about 12% of the general population (1). Because of its high prevalence and its debilitating features that result in loss of workplace productivity, migraine has considerable economic and public health implications. A typical migraine attack evolves through 4 phases: the premonitory, the aura, the headache, and the postdrome phases (2). The headache of migraine is usually unilateral and tends to have a throbbing or pulsatile quality. Common triggers include emotional stress, hormones in women, not eating, sleep disturbances, odors, lights, alcohol, smoke, heat, and certain foods (3). The underlying cause of migraine is complex. Current knowledge suggests that a primary neuronal dysfunction, including cortical spreading and sensitization, leads to a multitude of sequential changes that account for the different phases of migraine (2). Although the importance of genetics in familial hemiplegic migraine has long been recognized, the genetic basis of migraine is complex and is actively being investigated. Common medical treatment of migraine for patients whose headache responds poorly to nonsteroidal anti-inflammatory drugs includes the use of migraine-specific agents (triptans, ergotamine), dopamine antagonists, and
-4-
narcotics. Preventive approaches include the use of antiepileptics (topiramate, valproic acid), calcium channel blockers (candesartan, propranolol, timolol, and verapamil), antidepressants (amitriptyline), and other medications such as botulinum toxin A. No single pharmaceutical medication or combination of such agents has been shown to be 100% effective. All of the medications have the potential to cause adverse effects ranging from nausea to seizures (4). Menopausal vasomotor symptoms, or hot flashes, are described as an intense heat sensation over the trunk and face, and they may be accompanied by flushing of the skin and sweating. These are due to a decrease in ovarian hormones, namely, estrogen, and occur in more than 80% of perimenopausal and menopausal women (4). Vasomotor symptoms can begin before cessation of menses and last for 2 to 3 years. For women with moderate to severe vasomotor symptoms, estrogen or estrogenprogesterone regimens are the most common and effective approach to symptom relief. Because data from the Women’s Health Initiative suggest that women should not use estrogen-progesterone therapy for more than 3 to 4 years (4), these therapies are not recommended for long-term management of symptoms. Insomnia is classified as difficulty with falling or staying asleep, intermittent wakefulness during the night, early morning awakening, or any combination of these problems. Transient episodes of insomnia are common. Frequency and duration of insomnia determine the need for treatment. Psychiatric disorders such as depression or mania are often associated with persistent insomnia. There are 2 broad management strategies for insomnia, and they may be used in combination. Psychological interventions such as
-5-
sleep hygiene are used to instruct the patient in how to obtain restful sleep. Medical intervention includes orally administered benzodiazepines, nonbenzodiazepine hypnotics, and antidepressants (4). From a traditional Chinese medicine perspective, all symptoms experienced by an individual are considered to stem from 1 root cause. Identifying an underlying imbalance in the body and targeting treatment at that diagnosis should begin to improve all symptoms. Migraine is categorized into pattern discriminations determined by the characteristics and cause of the headache. Most frequently, the pattern involves counterflow of qi upward to the head. In a healthy state, qi flows along specific pathways, or meridians, in the body. There is a balance of flow both to and from the head. Disturbance of qi flow along a meridian flowing from the head causes counterflow against the meridian and stagnation of qi, causing head pain. Most notably, the liver meridian tends to be the culprit of qi counterflow. This function of this meridian is to process emotional stress; when the meridian becomes overwhelmed, the qi flow becomes disrupted and counterflow occurs. This results in qi traveling upward to the head and eyes and causing head pain and vision disturbances or horizontally to the spleen and stomach meridians and causing nausea and vomiting (5). Migraines can also be triggered by an external invasion such as wind-heat, wind-cold, wind-damp, or summer-heat. This triggering occurs typically when a person is ill. The body tries to push out the pathogen and, in the process, harmonious qi flow is disturbed. This disturbance leads to a rebellion of upwards qi flow, triggering a migraine (5). Hot flashes and insomnia can both be categorized as a deficiency of yin. In the basic principles of traditional Chinese medicine, for balance to
-6-
be established and maintained in the body, there must be an interdynamic balance of yin (cooling) and yang (warming) energy. According to this view, estrogen is considered to be a yin, or cooling, hormone (6). When this hormone becomes depleted around menopause, there is not enough yin to cool and anchor the yang energy, and deficient heat occurs. Too much heat can lead to spontaneous sweating, sweating at night, a sensation of heat in the upper aspect of the body, and restless sleep. Applying the traditional Chinese medicine principle of treating patients according to their unique pattern differential allows multiple patient complaints to be simultaneously treated by the practitioner and many potential adverse effects of medication to be avoided. Chinese medicine applies individualized acupuncture treatments and Chinese herbal formulas to reestablish qi flow, establish harmony between yin and yang, and treat any underlying imbalances that the practitioner determines from pulse and tongue assessment. This case report describes the successful use of acupuncture for treatment of migraines, hot flashes, and insomnia. Case Report History A 49-year-old woman was referred for acupuncture treatment of migraine by her neurologist. She recalled first having what she came to recognize as migraines in her late 20s. They were described as being hemicranial, more common on the right than on the left, pulsatile, and worse with routine physical activity such as climbing steps. She had associated photophobia and mild phonophobia. There was no aura. The headaches typically lasted hours. On several occasions, she had prolonged and severe
-7-
headaches that required treatment in the emergency department, typically with a combination of ketorolac tromethamine and prochlorperazine. For several years, the use of rizatriptan benzoate 10 mg as an abortive agent at onset of migraine proved to be effective for management of the headaches. In the fall of 2010, the patient had an episode of rather severe herpes zoster with difficult-to-control pain. Various agents were used for treatment, including pregabalin and oxycodone hydrochloride. By early 2011, the headaches had essentially started to occur daily. She reported awakening with a headache that she rated 8 on a pain scale of 1 to 10. Rizatriptan 10 mg ameliorated the headache a bit, but she usually required a second and a third dose. After the third dose later in the day, she would typically be headachefree and remain headache-free through the night, awakening with a headache the following morning. She had taken rizatriptan on a daily basis for at least 6 months. She also had received botulinum toxin injections for her migraines. Oral ketorolac was tried but caused gastric upset. A combination agent of acetaminophen, butalbital, and caffeine (Fioricet); amitriptyline in the evening; and duloxetine hydrochloride 20 mg as a prophylactic agent were not particularly effective. The patient further reported having insomnia since the birth of her daughter 21 years ago. She would awaken several times during the night, get up, and move to a different room, chair, or couch. Nightly use of zolpidem tartrate resulted in minimal improvement of her insomnia. The patient’s other major concern was hot flashes. She had been given hormone replacement therapy in the past and her symptoms had resolved. However, because she had undergone a breast biopsy and had a strong family history of breast cancer, her breast clinic physician had
-8-
advised her to discontinue use of the hormone replacement therapy. Since then, she had been having hot flashes and profuse sweating day and night. Physical Examination by Acupuncturist The patient’s pulses were taken bilaterally at the radial arteries, and the tongue was visually inspected according to the diagnostic technique of traditional Chinese medicine. The cun and chi positions in the left wrist were deep, and the overall pulse was wiry. The pulses were slightly rapid at 78 beats per minute. The tongue was small and red. The tip was peeled and red, the tongue body had scanty coating, and the sublingual vessels were thin and distended to the tip of the tongue. Traditional Chinese Medicine Diagnosis Assessment of the patient’s tongue and pulses and interpretation of her symptoms of deficient heat (hot flashes, insomnia) and counterflow of qi (migraine headache) led to the diagnosis of kidney and heart yin deficiency and liver qi stagnation causing deficient heat rising. Biomedical Diagnosis Migraine headache without aura, presumed menopausal symptoms, and intractable insomnia were the biomedical diagnoses. Traditional Chinese Medicine Treatment Principle Recommendations were nourish yin, clear deficient heat, move qi, and sooth the liver and heart. Acupuncture Treatment The patient lay supine and acupuncture points were selected. Needles were inserted until a dull, achy (de qi) sensation was obtained. Needles were retained for 20 minutes with a tonifying technique. Acupuncture procedures were performed with DBC Spring Ten sterile and
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disposable needles 0.20 × 30 mm. Details regarding the various acupuncture sessions are outlined in the Table. Outcome The patient was treated weekly for treatments 1 through 4. She reported the following: 0 to 2 mild headaches per week that were easily treated with one dose of rizatriptan, improved sleep, and a reduction in the frequency of hot flashes and night sweats. After treatment 4, the patient discontinued use of duloxetine hydrochloride and had rebound headaches, dizziness, and digestive upset. She returned to use of a daily dose of 20 mg and symptoms resolved. The patient began having acupuncture every 2 weeks after treatment 4. The migraines continued to become less frequent, and her sleep improved to waking once a night. On treatment 7, her point selection was altered to determine whether more improvement could be made. After treatment 8, the patient discontinued use of duloxetine hydrochloride and did not have withdrawal symptoms. She also discontinued use of zolpidem tartrate. She has reported no migraine headaches, sleeps through the night, and has not experienced hot flashes or night sweats. She continues to have an acupuncture treatment once every 4 to 6 weeks. Discussion This case report illustrates the successful treatment of migraine, hot flashes, and insomnia with acupuncture. The experience was rewarding for both the practitioner of complementary, alternative, and integrative medicine and the patient. A review of the literature indicates that many acupuncture trials for migraine headaches have been performed and that they have had
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different results (8). Several large, well-designed trials have reported no or only a small difference between the results of real and sham acupuncture (811), whereas other, smaller studies were more likely to show superiority of acupuncture over sham acupuncture or drug treatment (8,12). At least 3 large, adequately powered trials found no difference between real acupuncture and sham acupuncture (9-11). Recently, Li et al (10) reported a large, multicenter study on the effectiveness of acupuncture for prevention of migraine. A total of 480 patients were randomly assigned to one of 4 groups: Shaoyang-specific acupuncture, Shaoyang-nonspecific acupuncture, Yangming-specific acupuncture, or sham acupuncture (control). The authors found that the outcomes after acupuncture were substantially better than with sham acupuncture during weeks 13 through 16, but the effect was clinically minor. There was no difference between the 3 acupuncture groups. A meta-analysis published in 2012 using the data from 29 eligible randomized controlled trials with a total of 17,922 patients concluded that acupuncture is an effective treatment of chronic pain, including migraine, and is therefore a reasonable referral option (13). The authors further reported substantial differences between acupuncture and sham treatment, an indication that acupuncture is more than a placebo. Thus, many acupuncture studies have concluded that acupuncture has clinical effects on migraine headaches. Acupuncture is also a popular form of complementary and alternative medicine used by women for menopausal symptoms (14,15). Its effectiveness as a treatment option for menopausal hot flashes was assessed in a systematic review in 2009 by Lee et al (16). The authors searched the literature using 17 databases and included randomized controlled trials of
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acupuncture versus sham acupuncture. A total of 6 trials could be included. Only one of these 6 trials suggested positive results. However, this study was thought to be too small to generate reliable findings. The sham-controlled trials failed to show specific effects of acupuncture for control of menopausal hot flashes. Again, the authors stressed that one of several different explanations for these findings could be that sham acupuncture is also effective and thus no intergroup difference could be demonstrated (12). A Cochrane review concerning the effectiveness of acupuncture for insomnia published in 2012 concluded that, because of poor methodologic quality and a high level of heterogeneity, current evidence is not sufficiently rigorous to support or refute acupuncture for treating insomnia and that larger high-quality clinical trials are needed (17). In summary, although multiple trials have documented contrasting results regarding acupuncture’s efficacy for treating migraines, hot flashes, and insomnia, the case described illustrates that its use should still be considered, especially in patients with a multitude of symptoms for which polypharmacy has had minimal success. Despite some contrasting information, we agree with the opinion of Diener (11) that it is ethical to use acupuncture even if the effectiveness may be partially due to a placebo effect, taking into consideration that a placebo effect is real and certainly superior to no treatment or medical treatments without any effectiveness. Conclusion This case demonstrates the effectiveness of acupuncture for improving quality of life for a patient with severe migraine headaches, hot flashes, and insomnia and for making the use of multiple, possibly harmful,
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medications unnecessary. Randomized controlled trials summarized in Cochrane reviews have not shown a clear-cut efficacy of acupuncture for these clinical conditions. Many randomized controlled trials are efficacy trials, particularly conducted for regulatory drug approval. Alternatively, effectiveness trials are intended for a specific population and may be more relevant to the health care decisions of providers and patients. Because the mechanism of how acupuncture works is not yet understood, it is difficult to find a truly benign sham comparison. Further trials evaluating the effectiveness of acupuncture over standard care are needed.
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Diener HC, Kronfeld K, Boewing G, Lungenhausen M, Maier C, Molsberger A, et al; GERAC Migraine Study Group. Efficacy of acupuncture for the prophylaxis of migraine: a multicentre randomised controlled clinical trial. Lancet Neurol. 2006 Apr;5(4):310-6. Erratum in: Lancet Neurol. 2008 Jun;7(6):475.
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Linde K, Streng A, Jurgens S, Hoppe A, Brinkhaus B, Witt C, et al. Acupuncture for patients with migraine: a randomized controlled trial. JAMA. 2005 May 4;293(17):2118-25.
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Li Y, Zheng H, Witt CM, Roll S, Yu SG, Yan J, et al. Acupuncture for migraine prophylaxis: a randomized controlled trial. CMAJ. 2012 Mar 6;184(4):401-10. Epub 2012 Jan 9.
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Lee MS, Shin BC, Ernst E. Acupuncture for treating menopausal hot flushes: a systematic review. Climacteric. 2009 Feb;12(1):16-25.
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Cheuk DK, Yeung WF, Chung KF, Wong V. Acupuncture for insomnia. Cochrane Database Syst Rev. 2012 Sep 12;9:CD005472.
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Table. Acupuncture Treatment Sessions and Acupuncture Point Selection Treatment Session
Acupuncture Points Selected
1-6
He gu LI-4, Taichong LR-3, Qihai CV6, Shanzhong CV-17, Yin Xi HT-6, Zhaohai KI-6, Ran Gu KI-2, Yin Tang, Baihui GV-20, Auricular: Shen Men, Kidney
7-22
He Gu LI-4, Taichong LR-3, Guanyuan CV-4, Qihai CV-6, Shanzhong CV17, Yin Xi HT-6, Zhaohai KI-6, Zulingqi GB-41, Baihui GV-20, Auricular: Shen Men, Kidney
