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Episodic or chronic tension-type headache (TTH) is a common type of headache characterised by a bilaterally pressing or tightening quality of pain, not aggravated by activity and usually without autonomic symptoms.1 Acupuncture originated in China about 2500 years ago involving the insertion of thin needles into the skin at specific points.2 Several randomised controlled trials (RCTs) have shown that different kinds of acupuncture may have various effects on patients with TTH, although its effectiveness is still controversial. This systematic review is an update of Cochrane review originally published in 2009,3 investigating whether acupuncture is more effective than no prophylactic treatment/routine care only, more effective than ‘sham’ (placebo) acupuncture or as effective as other interventions in reducing headache frequency in patients with TTH.
This systematic review was a review of randomised trials with a postrandomisation observation period of at least 8 weeks, which compared the clinical effects of an acupuncture intervention with those of a control (treatment of acute headaches only or routine care), a sham acupuncture intervention or other prophylactic interventions in adults with episodic or chronic TTH. Duration of disease had to be at least 6 months in the great majority of participants. The primary outcome was response (at least 50% reduction of headache frequency) after the completion of treatment. The secondary outcomes included response at other time points, number of headache days, headache intensity, frequency of analgesic use and headache scores. It used the number of participants dropping out due to adverse effects and the number of participants reporting adverse effects to assess safety and acceptability. The review clearly stated the criteria of considered studies, the search methods and data collection and analysis, and the GRADE approach was used to assess the quality of evidence.
Twelve trials with 2349 participants met the inclusion criteria. Acupuncture was compared with routine care or treatment of acute headache only in two trials, and proportional participants' response was higher in the acupuncture group than in control groups (trial 1: RR 2.5; 95% CI 2.1 to 3.0; trial 2: RR 11; 95% CI 3.7 to 35). Pooled analyses of 7 trials compared acupuncture with various sham interventions found a small but significant reduction in headache frequency over 6 months (RR 1.3; 95% CI 1.09 to 1.5). Comparing acupuncture with physiotherapy, massage or relaxation in four trials provided no useful information.
This updated systematic review demonstrated the effectiveness of acupuncture as a prophylactic treatment of TTH. Only one new, small, sham-controlled trial was added in this review, so the findings remain largely unchanged. In the guideline published before, acupuncture was recommended as class C for patients with migraine.4 Authors assessed the effectiveness of acupuncture in patients with TTH through three aspects. First, on comparing acupuncture with no prophylactic treatment or routine care only, results showed participants in the acupuncture group had reduction in headache frequency; however, long-term effects were not investigated. Second, the comparison of acupuncture with various sham interventions illustrated that the correct selection of acupoints may play a less important role than many acupuncturists had thought. This could perhaps be due to acupuncture depending more on whether the needles penetrate into the skin. In contrast, other studies applying acupressure or laser acupuncture on patients with TTH have indicated that particular acupuncture points were a crucial issue regardless of the method of stimulation.2 These different kinds of acupuncture trials were not selected in this review, and the importance of acupoints is still controversial. Finally, the comparison of acupuncture with other interventions such as physiotherapy, massage and relaxation did not yield significant results. Overall, acupuncture may be considered for treating frequent episodic or chronic TTH, but the importance of acupoints and the effect of acupuncture compared with other prophylactic drug treatments need to be discussed.
Implications for practice
This systematic research provided evidence that acupuncture could be considered to be a non-pharmacological tool in patients with TTH.3 It also highlighted the directions for further studies. Large, high-quality RCTs with long-term follow-up periods are needed to determine the sustained effectiveness of this kind of therapy.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.