Many chiropractors advertise their success in treating migraine headaches. Norwegian researchers conducted a scientific study of chiropractic manipulation for migraine headaches in 104 patients. They divided patients into three groups: one that received real chiropractic manipulation of the spine, one that received a sham treatment that consisted of just putting pressure over the shoulders and lower back, and one that continued their usual medication. The real and sham chiropractic groups received 12 treatment sessions over 12 weeks and all three groups were followed for a year. After 12 weeks patients in all three study groups reported improvement. However, a year later, only the two chiropractic groups still felt better. On average, they had about four migraine days a month, down from six to eight before the treatment started. Patients who just continued their medications lost all of their improvement and their migraine frequency was back where it was at the baseline.

The results published in the European Journal of Neurology suggest that chiropractic is indeed effective in reducing migraine frequency, however, it also suggests that any hands-on treatment is equally effective. This probably explains the popularity of chiropractic, physical therapy, massage, reflexology, Reiki, energy therapies, Feldenkreis, and all other hands-on treatments.

All these treatments are worth trying, but avoid high velocity adjustments when undergoing chiropractic treatment as it carries a small risk of serious side effects (see this previous post). I would also pick inexpensive treatments and pick therapists you feel a rapport with. The treatment should be pleasant and never painful. You should also combine these therapies with a healthy lifestyle, including a healthy diet, regular sleep, exercise, meditation, and supplements.

Vitamin C deficiency appears to be more common in people with back pain, according to a study just published in the journal Pain by Canadian researchers. Vitamin C (ascorbic acid) is important for collagen formation and collagen is one of the main ingredients of ligaments, tendons, and bones. Recent studies have reported that vitamin C deficiency is common in the general population. The authors “hypothesized that lack of vitamin C contributes to poor collagen properties and back pain”. They used nationwide data from the U.S. National Health and Nutrition Examination Survey from 2003–2004. Information was available for 4,742 individuals older than 20. Low serum vitamin C levels were associated with one and a half times higher prevalence of neck pain and 1.3 times higher prevalence of low back pain, as well as low back pain with pain radiating to below the knee in the preceding three months. Deficiency was also associated with the self-described diagnosis of arthritis or rheumatism and related functional limitations. The authors concluded that the association between vitamin C deficiency and spinal pain warrants further investigation to determine the possible importance of vitamin C in the treatment of back pain patients.

Neck pain is very common in patients with migraine and tension-type headaches, so it is possible that vitamin C could also play a role in the treatment of headaches. My search revealed no studies looking at vitamin C levels in migraine sufferers. It may be worth checking vitamin C levels in those headache patients who do not respond to usual treatments and recommending supplementation to those who are deficient. However, even if I see good responses to vitamin C in my patients, these observations are not going provide true scientific evidence, even if hundreds of my patients report feeling better. This is because besides giving vitamin C, I would continue to recommend regular exercise, healthy diet, meditation, and other vitamins and minerals, all of which could be contributing to improvement. We need a large study to measure vitamin C levels in headache patients, and the deficient patients should be enrolled in a double-blind study to find out if vitamin C can improve different types of headaches.

Two leading headache experts, Drs. Richard Lipton and Dawn Buse of the Montefiore Headache clinic gave positive comments on the report published in Pain and described in my recent post. Another headache specialist from Texas, Dr. Deborah Friedman was also quoted about this research report in Neurology Today.

“Acupuncture studies are difficult because the blinding is difficult,” Richard B. Lipton, MD, FAAN, the Edwin S. Lowe professor and vice chair of neurology at the Albert Einstein College of Medicine, said. He noted that even comparisons using sham procedures may not entirely blind the patient to whether he or she is receiving a real treatment in which needles are inserted in the “meridian” — the points where energy is said to flow.“ That said, the authors in their review show that acupuncture is very substantially better than usual care. I think in aggregate these data demonstrate that real acupuncture is very helpful to people with episodic migraine in terms of reducing the number of headache days. My longstanding practice has been to arrange acupuncture for patients who ask for it, but not to recommend it otherwise,” Dr. Lipton said. “This review is going to impact what I do. It’s 22 randomized trials, and the Cochrane review is 150 pages. I think this is an important summary of the best evidence. I think it’s quite positive. I want to make my patients better so the imperfect blinding doesn’t matter.”

Dawn C. Buse, PhD, associate professor of neurology at Albert Einstein College of Medicine of Yeshiva University, also found the review persuasive, while noting that the mechanism by which acupuncture works is unknown and may be influenced by factors other than the procedure itself. “This review demonstrates that acupuncture may be helpful in reducing the frequency of migraine attacks and is likely to be well tolerated when compared to pharmacologic treatment,” she said. “We do not know from this review how patients who incorporate both acupuncture and optimized pharmacologic approaches fare. However, we know from meta-analyses of combined behavioral and pharmacologic approaches to migraine management that the combination is superior to either approach alone both in initial and sustained response.” She added: “Evidence suggests that many additional factors unrelated to acupuncture needling including expectations, beliefs, openness to experience, and the quality of the patient-provider relationship may play important roles in the beneficial effects of acupuncture for a particular patient. In addition, it is likely that patients who participate in and as a result report benefit from acupuncture are people who are interested and open to nonpharmacologic approaches. It is likely a patient who is open to nonpharmacologic approaches may also be a patient who will take a more active role in migraine management.” Dr. Buse noted that this type of patient is likely to have better treatment outcomes, no matter what type of treatment, due to higher levels of self-efficacy and willingness to actively engage in all aspects of treatment such as following treatment recommendations for healthy lifestyle habits, exercising, managing stress and healthy sleep hygiene. “Based upon these findings, it is reasonable to suggest that a patient who is interested and motivated to try acupuncture to manage migraine may benefit,” she told Neurology Today. “There are likely to be few if any side effects or risks to acupuncture, other than time and financial expense since acupuncture may not be covered by insurance. In addition, it may be difficult to advise a patient how to find a provider with proper training, skill, and knowledge to provide successful treatment and to know exactly what successful treatment would entail. The body of literature suggests that combined pharmacologic plus behavioral approaches are superior to either one alone, Dr. Buse noted. It may be therefore wise to recommend that patients who are interested in acupuncture combine it with optimized pharmacologic and behavioral treatments for the best chance of treatment outcome with lasting benefits, she said.

Dr. Lipton echoed that comment. “Acupuncture is one of many nonpharmacologic treatments for migraine,” he said. “The nonpharmacologic interventions include education, helping people identify triggers, some vitamins and herbs that are evidence-based, cognitive-behavior therapy and biofeedback. So my broad comment is that we should not restrict what is in our toolbox and consider a range of non-pharmacologic as well as pharmacologic treatments.”

But another reviewer, Deborah I. Friedman, MD, MPH, FAAN, chief of the division of headache medicine and professor of neurology & neurotherapeutics and ophthalmology at University of Texas-Southwestern in Dallas, expressed some reservations about the quality of the data. “Acupuncture is helpful in some patients with episodic migraine, particularly as an ‘add on’ treatment, but the quality of the data from clinical trials is moderate overall. There is a lot of variability in acupuncture technique amongst practitioners,” she said. “Patients who are interested in acupuncture should be referred to reputable practitioners who have had proper training.” She added: “In general, I don’t discourage it, but I rarely suggest it as an option unless the patient asks about it, or if I get the sense that they are interested in natural remedies. I tell my patients that the clinical evidence to support acupuncture treatment for migraine is not strong, with mixed results. However, it is safe and many patients find it useful, particularly those who are attracted to ‘natural’ or non-pharmacological treatments, and those who have not tolerated conventional therapies.” Dr. Friedman said that in the program at University of Texas Southwestern Medical Center, physical therapists are trained to do dry needling. “It seems to benefit many of our patients with refractory head and neck pain,” she said. “I make it clear to my patients that this is not the same as traditional acupuncture, and encourage them to try it once to see if it helps.”

Dr. Linde, one of the authors of the original report, noted in his comments that the problem of blinding affects the study of many treatments that are not pharmacologic in nature. “While the overall quality of a number of trials is actually quite good, one has to keep in mind that apart from sham-controlled trials acupuncture studies are usually not blind. However, this applies to almost all non-pharmacological treatments.”

Acupuncture for the treatment of migraines has been studied in dozens of clinical trials. A 2012 study mentioned in a previous blog post described a rigorous trial done in 480 patients with highly positive results. The largest, albeit uncontrolled study was done in Germany and involved over 15,000 patients. A well controlled and randomized study of 960 patients comparing acupuncture with sham acupuncture and drug therapy concluded that “…acupuncture is as effective as drug therapy, but …sham acupuncture is as effective as ‘real’ acupuncture.” and “…acupuncture should be offered to patients who do not respond to prophylactic treatment with drugs, terminate drug treatment because of adverse events or have contraindications to drug treatment.”

Most headache specialists recommend acupuncture to their patients even if they believe it works only through the placebo effect. I’ve been a licensed acupuncturist for the past 30 years, but treat a relatively small number of patients with acupuncture. The main reasons are the fact that insurance companies do not pay for it and that it is too time consuming. In the first study mentioned above, which was performed in China, patients were treated five days a week. The minimum frequency of treatments should be once a week. I often recommend that patients find a non-MD acupuncturist (whose rates are usually lower) who is closer to the patient’s home or work place. Another concern with acupuncture is that while it might help during the treatment, the effect might subside once the treatment is stopped.

A study The persistence of the effects of acupuncture after a course of treatment: A meta-analysis of patients with chronic pain, just published in the journal Pain addresses this question.

A group of researchers from the US and Europe examined a large set of information on individual patients from high quality randomized trials of acupuncture for chronic pain. The chronic pain conditions included musculoskeletal pain (low back, neck and shoulder), osteoarthritis of the knee and headache / migraine. Data on longer-term follow-up were available for 20 trials, which included 6,376 patients. In trials comparing acupuncture to no acupuncture control (wait-list, usual care, etc), the treatment effect diminished by a very small amount after treatment ended. They estimated that 90% of the benefit of acupuncture relative to controls would be sustained at 12 months. For trials comparing acupuncture to sham acupuncture, they observed a higher reduction in effect, suggesting about a 50% diminution at 12 months. They concluded that “The effects of a course of acupuncture treatment for patients with chronic pain do not appear to decrease importantly over 12 months. Patients can generally be reassured that treatment effects persist.” They also suggested that studies of the cost-effectiveness of acupuncture should take these findings into account when considering the time horizon of acupuncture effects and that further research should measure longer term outcomes of acupuncture.

We are big proponents of non-drug treatments, including a variety of vitamins, minerals, and herbal supplements. However, potential liver damage by butterbur is why we do not recommend this supplement, even though I was one of the participants in the clinical trial that showed it to be effective in preventing migraines. I also cautioned about risks of some Ayurvedic medications.

A recent report in Hepatology, a journal devoted to liver diseases, suggests that 20% of all cases of liver damage are due to herbal and dietary supplements. The main culprits were anabolic steroids (these are banned in professional sports, but are widely used for muscle building), green tea extract, and supplements with multiple ingredients. Anabolic steroids cause prolonged, but not serious liver injury, which resolves when the supplement is stopped. Green tea extract and many other products cause acute liver damage, similar to that seen in hepatitis. The majority of cases of liver injury are due to products that contain multiple ingredients, which makes it difficult to figure out which of the supplements is responsible. Unfortunately, non-prescription supplements are not regulated by the government. This is mostly because it is a $37 billion dollars a year industry with a powerful lobby in Washington. The authors conclude their report by saying that “the ultimate goal should be to prohibit or more closely regulate potentially injurious ingredients and thus promote public safety.”

Until these products come under FDA’s supervision, you should buy only products made by reputable American and German companies. Germany tightly regulates their supplement industry, so if a product is sold in Germany (and none of the butterbur products are approved there or in Great Britain), it is probably safe to take. Do not buy products made in China where corruption has led to many scandals related to the quality of supplements, drugs, food, and environmental pollution.