Acupuncture alleviates migraine headaches. Many clinical trials compare MRI scans, biological markers, and subjective clinical outcomes in human trials. This investigation varies by using only biological markers to confirm the results in a laboratory investigation. Overall, this multi-arm investigation demonstrates that a limited acupuncture point prescription of local points is enhanced by the addition of distal acupoints. 

Researchers from Shandong University of Traditional Chinese Medicine found both a limited conventional acupuncture protocol and Shu Gan Tiao Shen acupuncture produce significant positive clinical outcomes for patients with migraines. Shu Gan Tiao Shen (translated as liver-soothing and spirit-calming) acupuncture is a method of acupuncture used by China’s renowned Traditional Chinese Medicine (TCM) doctor, Professor Shan Qiuhua. The primary acupoints in Shu Gan Jie Yu are: Baihui (GV20), Fengchi (GB20), Neiguan (PC6), and Taichong (LV3). [1] The researchers also explained the biological mechanisms stimulated by acupuncture. The study was funded by the National Natural Science Foundation of China.

 Biological Markers
Prior to getting into the results, let’s go over the biomarkers used in the study. Calcitonin gene-related peptide (CGRP) is an important marker of migraines. [2] It is released from the trigeminal neuro-microvascular system and triggers migraines by promoting sensitization of peripheral and central trigeminal neurons and glial cells, brain blood vessel vasodilation, and by enhancing release of substance P (SP) and 5-hydroxytryptamine (5-HT). [3] Receptor activity-modifying protein 1 (RAMP1) is essential for producing the receptor for CGRP.

A previous study demonstrates that elevation of RAMP1 can cause migraines by increasing neuronal CGRP receptor activity. [4] In addition, 5-hydroxytryptamin 1D Receptor (5-HT1DR) is a 5-hydroxytryptamine (5-HT) receptor. When interacting with 5-HT, 5-HT1DR mRNA relieves migraines by decreasing CGRP levels in the trigeminal ganglion and nucleus. Acupuncture was successful at increasing these levels, thereby facilitating migraine relief.

 Design
The randomized study involved 40 laboratory rats. Subjects were divided into four arms, with 10 subjects in each arm. The first arm is a blank control group, which didn’t receive any intervention. The other three arms were injected with nitroglycerin to induce a migraine model. After injection, the third arm received conventional acupuncture (CA), while the fourth arm received Shu Gan Tiao Shen acupuncture (SGTSA). The second arm was a migraine model group which received no treatment for the study duration.

 Results
Compared with the control group, the levels of RAMP1 protein and mRNA in the spinal trigeminal nucleus (STN) and mesencephalon were significantly increased (P<0.05), while those of 5-HT1DR protein and mRNA considerably decreased (P<0.05) in the model group. After acupuncture treatment, both increased levels of RAMP1 protein and mRNA and decreased levels of 5-HT1DR mRNA and protein were significantly reversed in the two acupuncture groups (P<0.05). In addition, Shu Gan Tiao Shen acupuncture provided significantly superior outcomes over conventional acupuncture in down-regulating RAMP1 mRNA and protein levels in the STN and mesencephalon (P<0.05) and in up-regulating 5-HT1DR mRNA and protein levels (P<0.05). The researchers conclude that, “Our data indicates that acupuncture provides positive outcomes for migraine treatment.” They add that Shu Gan Tiao Shen acupuncture produced a superior benefit over conventional acupuncture by down-regulating RAMP1 mRNA and protein levels and up-regulating 5-HT1DR mRNA and protein levels to a greater degree.

 Acupuncture Points
The following primary acupoints were selected for the CA group:

• Baihui (GV20)
• Fengchi (GB20, bilateral)

The following primary acupoints were selected for the SGTSA group:

• Baihui (GV20)
• Fengchi (GB20, bilateral)
• Neiguan (PC6, bilateral)
• Taichong (LV3, bilateral)

For the Baihui and Fengchi acupoints, the acupuncture needle was inserted obliquely, to a depth of 1–2 mm. For the Neiguan and Taichong acupoints, the acupuncture needle was inserted perpendicularly, to a depth of 1–2 mm. The needle retention time was 30 minutes. Acupoints were located according to Acupuncture Points of Experimental Animals issued by the China Association for Acupuncture and Moxibustion.

 TCM Theories
The modern laboratory findings of the study are consistent with ancient TCM acupuncture principles. Shu Gan Tiao Shen acupuncture employs the use of acupoints Baihui (GV20), Fengchi (GB20), Neiguan (PC6), and Taichong (LV3). Baihui is located on the very top of the head. Needling this local acupoint clears the mind, opens the orifices, and calms the spirit. This acupoint is indicated for headaches and migraines. Fengchi is a local point commonly used for migraines. Neiguan is the Luo-connecting point. Needling this acupoint frees the blood vessels, regulates heart-qi, and lifts the spirit. Taichong is the Yuan-source point of the liver meridian. This acupoint is indicated for migraines because needling it soothes the liver and promotes the free flow of qi and blood through the head. Clinically, Neiguan and Taichong are often used in combination to sooth the liver, relieve depression, regulate the heart, and calm the spirit.

The research confirms that acupuncture relieves migraines. The laboratory findings demonstrate that acupuncture regulates the balance of several biomarkers related to migraines; namely, CGRP, RAMP1, and 5-HT1DR. Shu Gan Tiao Shen acupuncture produces superior outcomes over the more limited conventional acupuncture protocol for migraine treatment.

 Migraine Relief
In related findings, researchers (Zhao et al.) conclude that acupuncture reduces migraine attack frequency, duration, and intensity. The researchers note, “True acupuncture [TA] exhibited persistent, superior, and clinically relevant benefits for migraine prophylaxis, reducing the migraine frequency, number of days with migraine, and pain intensity to a greater degree than SA [sham acupuncture] or WL [wait list].” Also, patients receiving true acupuncture demonstrated significant improvements in the “emotional domain of quality of life.” The research team concludes, “Acupuncture should be considered as one option for migraine prophylaxis in light of our findings.” [5]

The research team followed 249 subjects over a 24 week period and employed the use of manual acupuncture to elicit deqi and also used electroacupuncture. The researchers note that true acupuncture “was more efficacious for migraine prophylaxis than SA or no acupuncture, and the improvement induced by acupuncture persists for at least 24 weeks.” True acupuncture reduces the pain levels of migraine attacks while simultaneously reducing the duration of migraines. The researchers conclude, “Compared with SA [sham acupuncture] and WL [wait list] control groups, TA manifested persisting superiority and clinically relevant benefits for at least 24 weeks in migraine prophylaxis, including reducing the number of migraine frequency and days with migraine, as well as decreasing pain intensity.”

True acupuncture patients and sham acupuncture patients received 20 sessions of electroacupuncture treatments at a rate of once per day, for a total of 5 consecutive days. A two-day break followed each session prior to applying the next round of treatments. Each acupuncture treatment was 30 minutes long and the total span of acupuncture treatments lasted 4 weeks. Four acupoints were permitted during each acupuncture treatment. Two acupoints were applied to all patients in the real acupuncture group:

• Fengchi (GB20)
• Shuaigu (GB8)

Two additional acupuncture points were used based on diagnostics:

• Hegu (LI4)
• Neiting (ST44)
• Taichong (LV3)
• Qiuxu (GB40)
• Waiguan (TB5)
• Yanglingquan (GB34)
• Kunlun (BL60)
• Houxi (SI3)

Needles were 25–40 mm in length and were 32 gauge (0.25 mm). Left and right side acupuncture points were chosen by alternating sides, a practice common to prevent overstimulation in deficient patients. Deqi was stimulated with manual acupuncture at each point. Electroacupuncture was applied with an alternating frequency of 2/100 Hz. The frequency changed every 3 seconds. The intensity was set to tolerance levels and was limited to 0.1–1.0 mA. The researchers determined that acupuncture is an effective treatment modality, producing lasting and significant clinical outcomes.

 Population
Researchers from the Department of Neurology at the Albert Einstein College of Medicine (Bronx, New York) surveyed the USA and quantified the migraine prevalence. They conclude, “The number of migraineurs has increased from 23.6 million in 1989 to 27.9 million in 1999 commensurate with the growth of the population. Migraine is an important target for public health interventions because it is highly prevalent and disabling.” [6] Based on the aforementioned evidence and the widespread prevalence of migraine sufferers, acupuncture is a reasonable treatment option and access to care is essential to prevent widespread suffering. Patients seeking advice regarding acupuncture are advised to consult with local licensed acupuncturists.

 References:
[1] Wang MM, Yu XH, Di W, Cui HF, Wang CC, Han J, Yang DH. Manual Acupuncture Stimulation Regulates Expression of Receptor Activity-modifying Protein 1 and 5-HT 1D Receptor Proteins and Genes in Migraine Rats [J]. Acupuncture Research, 2018,43(07):440-444.
[2] Huang L, Cui YL, Chen YQ. Effect of Jiawei Sanchang Decoction on Behavioral Symptoms, Plasma NO, NOS, CGRP and Contents of NOS_1 and CGRP in Trigeminal Nerve Bone Nuclei in Rats with Nitroglycerin-induced Migraine [J]. Lishizhen Medicine and Materia Medica Research, 2016, 27 (12): 2890-2892.
[3] Levy D, Burstein R, Strassman A M. Calcitonin Gene-related Peptide Does Not Excite or Sensitize Meningeal Nociceptors: Implications for the Pathophysiology of Migraine [J]. Ann Neurol, 2005, 58(5): 698-705. 
[4] Zhongming Zhang, Christina S. Winborn, Blanca Marquez de Prado and Andrew F. Russo. Sensitization of Calcitonin Gene-Related Peptide Receptors by Receptor Activity-Modifying Protein-1 in the Trigeminal Ganglion [J]. Journal of Neuroscience 7 March 2007, 27 (10) 2693-2703.
[5] Zhao, Ling, Jiao Chen, Ying Li, Xin Sun, Xiaorong Chang, Hui Zheng, Biao Gong et al. “The long-term effect of acupuncture for migraine prophylaxis: a randomized clinical trial.” JAMA Internal Medicine (2017).
[6] Lipton, Richard B., Walter F. Stewart, Seymour Diamond, Merle L. Diamond, and Michael Reed. “Prevalence and burden of migraine in the United States: data from the American Migraine Study II.” Headache: The Journal of Head and Face Pain 41, no. 7 (2001): 646-657. Department of Neurology, Albert Einstein College of Medicine (Bronx, New York).