Headaches and Complimentary & Integrative Medicine (CIM)

In a European survey of headache clinics, 81.7% of patients used CIM. Patients are increasingly turning to CIM to supplement their medical regimens for headache management or as a replacement for the same (Gaul et al., 2009).

Some people are more likely to adopt CIM than others. Specifically, a study found that patients who use CIM are more likely to be female, educated, married, have a higher income, and be in full time employment (Adams et al., 2013). But generally, people interested in CIM are motivated for many reasons:

1. To reduce reliance on medication. Many people prefer “natural” approaches.
2. If medication hasn’t proven to be effective or side effects were intolerable. (See article on headache and neuromodulation: Why the enthusiasm about novel migraine treatments? – soon to be published.)
3. It is empowering. It can be empowering to know that your lifestyle choices can affect your health. As headache is not commonly a condition that can be “eliminated”, patients must learn to accept it, understand it and manage it.
4. It addresses the causes of the problem. As headache is a condition that has its roots not just in a medical paradigm (i.e., crisis followed by intervention) but in a biopsychosocial paradigm (see articles on Headaches and behavior; Headaches and wellness; Headaches and Biofeedback – soon to be published; mindfulness, Podcast Concussion 101 Episode 5: The glass is half full). As stress is the biggest trigger for headaches, and many things will affect one’s stress level, it’s natural to change one’s lifestyle, regulate one’s emotions and strengthen one’s thoughts to empower a change.

The most commonly used CIM treatments world-wide are acupuncture, massage, chiropractic care and homeopathy whereas the most commonly used treatments in the U.S. were meditation, breathing exercises and yoga (Wells et al., 2011)

The conventional medical community is largely rooted in a culture of evidence-based medicine. While there are many motivations and advantages to this, it also makes them less likely to promote CIM. This does not necessarily imply that they advise against it, it is just to say that allopathic doctors are more likely to recommend treatments that have been statistically shown to be effective (vs placebo) in high quality clinical trials.

For example, allopathic doctors have started recommending nutraceuticals like magnesium, riboflavin and co-enzyme Q10 as these supplements are fairly amenable to studying in randomized controlled trials (RCTs). That is, the act of taking a pill is easy to replicate in both groups – the group receiving the supplement and the group taking the sham; this is controlling for the placebo effect. So, if one group shows a clinically measurable effect that is unlikely to occur by chance alone, then the drug can be recommended.

Many CIM modalities aren’t so “neatly” amenable to study in RCTs that control accurately for all confounding factors.

Generally, the quality of evidence for CIM in headache management is generally low and occasionally moderate (Millstine et al., 2017).

CIM modalities are intrinsically challenging to study because of the nature of the treatments of CIM. For example:

• When studying the effect of yoga on headaches, it is hard to control for the broad diversity of practice styles and cultural approaches.
• Manual therapy techniques are considered CIM when delivered by a massage therapist, chiropractor or osteopath but not so when delivered by a physiotherapist (Chaibi et al., 2014)
• It is difficult to standardize practitioner provided services such as manipulation, massage and acupuncture
• It is difficult to find an adequate control condition for CIM modalities like acupuncture as the expectations about the effects of acupuncture may contribute to outcomes (Zheng et al., 2014). That is, “sham” acupuncture can still show an effect, perhaps for physiological reasons. How can we better control for potentially confounding factors without comparing acupuncture to a potentially competing treatment (i.e., “sham” acupuncture)?

Other practical considerations that mitigate the quality of CIM studies are:

• study sizes tend to be small (perhaps due to the lack of funds that back pharmaceutical trials)
• study lengths tend to be small (perhaps due to financial constraints as mentioned above but also because the nature of CIM are generally more time-consuming than taking a pill and it will be technically hard to find patients to make such a large time commitment for a study.)
• patients are less likely to adhere to recommendations when not under direct supervision (for the same reason above).

Furthermore, integrative medicine currently lacks an overseeing organization that publishes clinical guidance through guidelines publications. Without a clear endorsement by a global organization, CIM recommendations are less likely to receive traction by the allopathic community.

The Bottom-line

• Despite the challenges in studying acupuncture in clinical trials, it has been shown to improve headache frequency and severity in numerous clinical trials for both acute headache pain and in headache prevention (Liu et al., 2016; Linde et al., 2016; Wang et al., 2012; Li et al., 2009; Yang et al., 2011; Diener et al., 2006; Ahn et al., 2011; Jonas et al., 2016).

 

More about Acupuncture

• Comes from Traditional Chinese Medicine (TCM) 2500 years ago
• Insertion of hair-thin needles into specific points call acupoints (also known as energy meridians).
• Most commonly manipulated acupoints for headache treatment are: GV-20, GB 14, Yin Tang, LR 3, SP 6, ST 36.
• The strategic insertion of the needles are meant to keep Qi (pronounced Chee and refers to balance life energy) flowing in an ideal fashion.
• The physiological mode of action is not fully understood.
• Factors that can be modified in the provision of acupuncture include: frequency of sessions, length of session, whether ear acupuncture is done adjunctively, whether electrical vs heat vs manual stimulation is used.
• The ear is said to hold a microsystem of the body and clinically meaningful effects can occur if certain spots on the ear are stimulated.

The Bottom-line

• Massage improved migraine frequency by about 28% in a systematic review involving 706 patients (Chaibi et al., 2011).
• Manual therapy showed immediate benefit after a 4-6 weeks regimen when compared to pharmacotherapy (Mesa-Jiminez et al., 2015)

 

More about Manual Therapy

• Generally performed by massage therapists, chiropractors, physiotherapists and osteopaths.
• Physical measures to improve pain and stiffness.
• There are many different manual therapy techniques and styles to performing those techniques.

The Bottom-line

• Despite the intrinsic challenges, mentioned above, in studying Yoga & Tai Chi in clinical trials, it has been found to reduce headache frequency and pain (Hall et al., 2016; John et al., 2007; Kumar et al., 2020).
• It has also been shown to decreased the amount of medication use (Kumar et al., 2020)
• Medical management + Yoga has superior results in reducing migraine intensity (by ~12-17%), migraine frequency (by ~ 32%) and “rescue” medication use (by ~28%) vs. Medication alone (Kumar et al., 2020) after 3 months of 1 hour per day, 5 days per week yoga.

 

More about Yoga & Tai Chi

• Yoga involves a sequence of movements, postures, breathing & relaxation techniques.
• Tai Chi has similar components to Yoga but motions are more flowing involving balance shifts.
• These have been used by chronic pain patients for years.

The Bottom-line

• Evidence for supplements in headache treatment will be reviewed in one of our next articles (Migraine Prevention and Supplements – soon to be published).
• Evidence regarding dietary omega 3 & 6 and ketogenic diets are mixed and/or the studies’ designs were not strong. (Millstine et al., 2017)

The Bottom-line

• Mindfulness Meditation has not yet been shown to significantly improve headache frequency or pain (Day et al., 2014; Wells et al., 2014; Cathcart et al., 2014).
• Guided Imagery was shown to reduce headache frequency and severity (Abdoli et al., 2012)
• Evidence for biofeedback in headache treatment has been addressed in previous articles we published (Biofeedback, Headache and biofeedback – soon to be published).

 

More about Mind-body Treatments

• These therapies involve highlighting the connection between the mind and body; that each one influences the other and that knowledge of this can be exploited for health benefits.
• Behavioural training/techniques has been addressed in other articles we published (CBT-i, Headaches and Behaviour).
• Relaxation strategies have been addressed in other articles we published (Relaxation Strategies).
• Mindfulness Meditation has been used successfully in the treatment of chronic pain (Kabat-Zinn, 1986). Mindfulness has been discussed in other articles we published (Mindfulness Defined, Mindfulness Implemented).

There are many different forms of behavioural training: CBT, CBT-insomnia, stress management, energy management, coping skills, etc. A review of the utility of behavioural training in headache management has been reviewed in another article we published (Headache and Behaviour).

Abdoli S, Rahzani K, Safaie M, Sattari A. A randomized control trial: the effect of guided imagery with tape and perceived happy memory on chronic tension type headache. Scand J Caring Sci 2012;26:254-61doi:10.1111/j.1471-6712.2011.00926.x.

Adams J, Barbery G, Lui CW. Complementary and alternative medicine use for headache and migraine: a critical review of the literature. Headache 2013;53:459-73doi:10.1111/j.1526-4610.2012.02271.x.

Ahn CB, Lee SJ, Lee JC, Fossion JP, Sant’Ana A. A clinical pilot study comparing traditional acupuncture to combined acupuncture for treating headache, trigeminal neuralgia and retro-auricular pain in facial palsy. J Acupunct Meridian Stud 2011;4:29-43doi:10.1016/S2005- 2901(11)60005-8.

Chaibi A, Tuchin PJ, Russell MB. Manual therapies for migraine: a systematic review. J Headache Pain 2011;12:127-33doi:10.1007/s10194-011-0296-6.

Chaibi A, Russell MB. Manual therapies for primary chronic headaches: a systematic review of randomized controlled trials. J Headache Pain 2014;15:67doi:10.1186/1129-2377-15-67.

Day MA, Thorn BE, Ward LC, et al. Mindfulness-based cognitive therapy for the treatment of headache pain: a pilot study. Clin J Pain 2014;30:152-61.

Cathcart S, Galatis N, Immink M, Proeve M, Petkov J. Brief mindfulnessbased therapy for chronic tension-type headache: a randomized controlled pilot study. Behav Cogn Psychother 2014;42:1- 15doi:10.1017/S1352465813000234.

Diener HC, Kronfeld K, Boewing G, et al. Efficacy of acupuncture for the prophylaxis of migraine: a multicentre randomised controlled clinical trial. Lancet Neurol 2006;5:310-6doi:10.1016/S1474-4422(06)70382-9.

Gaul C, Eismann R, Schmidt T, et al. Use of complementary and alternative medicine in patients suffering from primary headache disorders. Cephalalgia 2009;29:1069-78doi:10.1111/j.1468-2982.2009.01841.x.

Hall A, Copsey B, Richmond H, et al. Effectiveness of Tai Chi for chronic musculoskeletal pain conditions: updated systematic review and metaanalysis. Phys Ther 2016. doi:10.2522/ptj.20160246

John PJ, Sharma N, Sharma CM, Kankane A. Effectiveness of yoga therapy in the treatment of migraine without aura: a randomized controlled trial. Headache 2007;47:654-61doi:10.1111/j.1526-4610.2007.00789.x.

Jonas WB, Bellanti DM, Paat CF, et al. A randomized exploratory study to evaluate two acupuncture methods for the treatment of headaches associated with traumatic brain injury. Med Acupunct 2016;28:113-30doi:10.1089/acu.2016.1183.

Kabat-Zinn JLL, Burney R. Four year follow-up of a meditation-based program for the self regulation of chronic pain: treatment outcomes and compliance. Clin J Pain 1986;2:159-73doi:10.1097/00002508-198602030-00004.

Kumar A, Bhatia R, Sharma G, et al. Effect of yoga as add-on therapy in migraine (CONTAIN). Neurology. 2020:10.1212/WNL.0000000000009473. doi:10.1212/wnl.0000000000009473.

Li Y, Liang F, Yang X, et al. Acupuncture for treating acute attacks of migraine: a randomized controlled trial. Headache 2009;49:805-16doi:10.1111/j.1526-4610.2009.01424.x.

Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of episodic migraine. Cochrane Database Syst Rev 2016;6:CD001218.

Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of tension-type headache. Cochrane Database Syst Rev 2016;4:CD007587.

Liu Y, Yu S. Recent approaches and development of acupuncture on chronic daily headache. Curr Pain Headache Rep 2016;20:4doi:10.1007/s11916-015-0535-7.

Mesa-Jimenez JA, Lozano-Lopez C, Angulo-Diaz-Parreno S, Rodriguez-Fernandez AL, De-la-Hoz-Aizpurua JL, Fernandez-de-Las-Penas C. Multimodal manual therapy vs pharmacological care for management of tension type headache: a meta-analysis of randomized trials. Cephalalgia 2015;35:13232 doi:10.1177/0333102415576226.

Millstine, Denise & Y Chen, Christina & Bauer, Brent. (2017). Complementary and integrative medicine in the management of headache. BMJ. 357. j1805. 10.1136/bmj.j1805.

Wang LP, Zhang XZ, Guo J, et al. Efficacy of acupuncture for acute migraine attack: a multicenter single blinded, randomized controlled trial. Pain Med 2012;13:623-30doi:10.1111/j.1526-4637.2012.01376.x.

Wells RE, Bertisch SM, Buettner C, Phillips RS, McCarthy EP. Complementary and alternative medicine use among adults with migraines/severe headaches. Headache 2011;51:1087-97doi:10.1111/j.1526-4610.2011.01917.x.

Wells RE, Burch R, Paulsen RH, Wayne PM, Houle TT, Loder E. Meditation for migraines: a pilot randomized controlled trial. Headache 2014;54:1484-95doi:10.1111/head.12420.

Yang CP, Chang MH, Liu PE, et al. Acupuncture versus topiramate in chronic migraine prophylaxis: a randomized clinical trial. Cephalalgia 2011;31:1510-21doi:10.1177/0333102411420585.

Zheng H, Huang W, Li J, et al. Association of pre- and post-treatment expectations with improvements after acupuncture in patients with migraine. Acupunct Med 2015;33:121-8doi:10.1136/acupmed-2014-010679.