Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care have prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.

Evidence-based nonpharmacologic strategies for comprehensive pain care the consortium pain task force white paper

Importance The long-term prophylactic effects of acupuncture for migraine are uncertain. Objective To investigate the long-term effects of true acupuncture compared with sham acupuncture and being placed in a waiting-list control group for migraine prophylaxis. Design, Setting, and Participants This was a 24-week randomized clinical trial (4 weeks of treatment followed by 20 weeks of follow-up). Participants were randomly assigned to true acupuncture, sham acupuncture, or a waiting-list control group. The trial was conducted from October 2012 to September 2014 in outpatient settings at 3 clinical sites in China. A total of 249 participants 18 to 65 years old with migraine without aura based on the criteria of the International Headache Society, with migraine occurring 2 to 8 times per month. Interventions Participants in the true acupuncture and sham acupuncture groups received treatment 5 days per week for 4 weeks for a total of 20 sessions. Participants in the waiting-list group did not receive acupuncture but were informed that 20 sessions of acupuncture would be provided free of charge at the end of the trial. Main Outcomes and Measures Participants used diaries to record migraine attacks. The primary outcome was the change in the frequency of migraine attacks from baseline to week 16. Secondary outcome measures included the migraine days, average headache severity, and medication intake every 4 weeks within 24 weeks. Results A total of 249 participants 18 to 65 years old were enrolled, and 245 were included in the intention-to-treat analyses. One hundred eighty-nine (77.1%) were women. Baseline characteristics were comparable across the 3 groups. The mean (SD) change in frequency of migraine attacks differed significantly among the 3 groups at 16 weeks after randomization ( P P  = .002) and in the true acupuncture vs waiting-list group (difference of 1.8 attacks; 95% CI, 1.1-2.5; P P  = .07). Conclusions and Relevance Among patients with migraine without aura, true acupuncture may be associated with long-term reduction in migraine recurrence compared with sham acupuncture or assigned to a waiting list. Trial Registration clinicaltrials.gov Identifier:NCT01687660

/pdf/the-long-term-effect-of-acupuncture-for-migraine-prophylaxis-51wtd2nzl6.pdf

The Long-term Effect of Acupuncture for Migraine Prophylaxis: A Randomized Clinical Trial.

Skin blood flux (SkBF) changes caused by drinking cold water are generally associated with vagal tone and osmotic factors in digestive system. According to acupuncture theory, change of SkBF at ST 36 might reflect the functional changes of digestive system. The aim of this study is to analyze the changes of SkBF after drinking 3°C 0.9% saline or 5% glucose injection by monitor blood flux at bilateral ST 36. The results indicated that, after drinking different cold water, the change ratio of SkBF at right side ST 36 has been different. Because all solutions have the same temperature (3°C) and both saline and glucose solution have the same osmolality, suggesting that the SkBF changes resulting from drinking cold water are not regulated just by the vagal tone and osmolality, there must have been other factors. These results have not been consistent with the frequency domain results of heart rate variability (HRV) analysis. Coherence analysis of blood flux signals at bilateral ST 36 indicated that there have been different coherence-frequency curves among different groups in special frequency bands, which suggested that coherence analysis might provide a potential tool to evaluate different status.

/pdf/response-of-blood-perfusion-at-st-36-acupoint-after-drinking-1de9y0mc6d.pdf

Response of Blood Perfusion at ST 36 Acupoint after Drinking Cold Glucose or Saline Injection.

Migraine is a common and disabling brain disorder with a strong inherited component. Because patients with migraine have severe and disabling attacks usually of headache with other symptoms of sensory disturbance (eg, light and sound sensitivity), medical treatment is often required. Patients can be managed by use of acute attack therapies (eg, simple analgesics or non-steroidal anti-inflammatory drugs) or specific agents with vasoconstrictor properties (ie, triptans or ergot derivatives). Future non-vasoconstrictor approaches include calcitonin gene-related peptide receptor antagonists. Preventive therapy is probably indicated in about a third of patients with migraine, and a broad range of pharmaceutical and non-pharmaceutical options exist. Medication overuse is an important concern in migraine therapeutics and needs to be identified and managed. In most patients, migraine can be improved with careful attention to the details of therapy, and in those for whom it cannot, neuromodulation approaches, such as occipital nerve stimulation, are currently being actively studied and offer much promise.

https://www.thelancet.com/pdfs/journals/laneur/PIIS1474-4422(10)70005-3.pdf

Current practice and future directions in the prevention and acute management of migraine

Background: Acupuncture is commonly used to treat migraine. We assessed the efficacy of acupuncture at migraine-specific acupuncture points compared with other acupuncture points and sham acupuncture. Methods: We performed a multicentre, single-blind randomized controlled trial. In total, 480 patients with migraine were randomly assigned to one of four groups (Shaoyang-specific acupuncture, Shaoyang-nonspecific acupuncture, Yangming-specific acupuncture or sham acupuncture [control]). All groups received 20 treatments, which included electrical stimulation, over a period of four weeks. The primary outcome was the number of days with a migraine experienced during weeks 5–8 after randomization. Our secondary outcomes included the frequency of migraine attack, migraine intensity and migraine-specific quality of life. Results: Compared with patients in the control group, patients in the acupuncture groups reported fewer days with a migraine during weeks 5–8, however the differences between treatments were not significant ( p > 0.05). There was a significant reduction in the number of days with a migraine during weeks 13–16 in all acupuncture groups compared with control (Shaoyang-specific acupuncture v. control: difference –1.06 [95% confidence interval (CI) –1.77 to –0.5], p = 0.003; Shaoyang-nonspecific acupuncture v. control: difference –1.22 [95% CI –1.92 to –0.52], p p = 0.011). We found that there was a significant, but not clinically relevant, benefit for almost all secondary outcomes in the three acupuncture groups compared with the control group. We found no relevant differences between the three acupuncture groups. Interpretation: Acupuncture tested appeared to have a clinically minor effect on migraine prophylaxis compared with sham acupuncture. Trial Registration: Clinicaltrials.gov NCT00599586

/pdf/acupuncture-for-migraine-prophylaxis-a-randomized-controlled-4gci0hnkel.pdf

Acupuncture for migraine prophylaxis: a randomized controlled trial

Objective.— To discuss the results of a multicenter randomized controlled trial of the efficacy of verum acupuncture in treating acute migraine attacks.



Background.— Acupuncture has been used in China for centuries to treat migraine headache. Convincing evidence of its efficacy in alleviating pain, however, has been inadequate to date.



Methods.— A total of 218 patients with migraine were recruited for the study; 180 met the inclusion criteria; 175 completed the callback process and were randomized into 3 groups. One group received verum acupuncture while subjects in the other 2 groups were treated with sham acupuncture. Each patient received 1 session of treatment and was observed over a period of 24 hours. The main outcome measure was the differences in visual analog scale (VAS) scores before treatment and 0.5, 1, 2, and 4 hours after treatment.



Results.— Significant decreases in VAS scores from baseline were observed in the fourth hour after treatment when VAS was measured in the patients who received either verum acupuncture or sham acupunctures (P < .05). The VAS scores in the fourth hour after treatment decreased by a median of 1.0 cm, 0.5 cm, and 0.1 cm in the verum acupuncture group, sham acupuncture group 1, and sham acupuncture group 2, respectively. Similarly, there was a significant difference in the change in VAS scores from baseline in the second hour after treatment among the 3 groups (P = .006). Moreover, at the second hour after treatment, only patients treated with verum acupuncture showed significant decreases in VAS scores from baseline by a median of 0.7 cm (P < .001). Significant differences were observed in pain relief, relapse, or aggravation within 24 hours after treatment as well as in the general evaluations among the 3 groups (P < .05). Most patients in the acupuncture group experienced complete pain relief (40.7%) and did not experience recurrence or intensification of pain (79.6%).



Conclusion.— Verum acupuncture treatment is more effective than sham acupuncture based on either Chinese or Western nonacupoints in reducing the discomfort of acute migraine. Verum acupuncture is also clearly effective in relieving pain and preventing migraine relapse or aggravation. These findings support the contention that there are specific physiological effects that distinguish genuine acupoints from nonacupoints.

Acupuncture for Treating Acute Attacks of Migraine: A Randomized Controlled Trial

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Acupuncture for Treating Acute Attacks of Migraine: A Randomized Controlled Trial