Acupuncture for Traumatic Brain Injury-Related Headache and Pain

Traumatic brain injury (TBI) is highly prevalent in the military, with up to 20% of service members affected.¹ The trauma spectrum response (TSR) designates the wide array of symptoms associated with TBI and post-traumatic stress disorder. These include chronic pain, and headache in particular, anxiety, depression and sleep disturbance.²

Current treatments focus on individual symptoms, and although providing relief, fail to address the complex nature of TSR. By contrast, acupuncture was shown to address multiple symptoms, rendering it more effective than conventional treatments in addressing TSR.^{3, 4}

Animal studies showed that acupuncture-induced analgesia was mediated by substances released in the cerebrospinal fluid.⁴ In humans, PET studies revealed a decrease in thalamic asymmetry in patients with chronic pain following acupuncture treatment.⁴ In addition, acupuncture was found to relieve multiple types of headaches, including chronic daily headaches, tension headaches, and migraine, as well as pain and other TSR symptoms.^5-9

In a study recently published in Medical Acupuncture, researchers sought to compare 2 types of acupuncture, traditional Chinese acupuncture (TCA) and auricular acupuncture (AA) to usual care (UC).¹⁰

Despite being based on common principles, TCA and AA employ distinct approaches to diagnostic, as well as needle sites and treatment duration. While AA is symptom-oriented and uses the somatotopic map of the outer ear to target anatomical regions, TCA aims to restore dynamic regulation and to promote healing through needle insertion at specific sites. TCA treatment involves comprehensive patient evaluation, with the goal of lasting pain relief, and relapse prevention; it therefore lasts longer than AA where the patient’s immediate response guides treatment.^{11, 12}

Study subjects (n=31; ages 18-69) had mild-to-moderate, non-acute TBI and frequent headaches, and were randomized to receive TCA (n=11), AA (n=12) or UC (n=8).¹⁰ Patients in the acupuncture groups underwent a 6 week-long treatment consisting of 10 sessions; those in the UC group received standard medical care for the same duration. All study participants had a follow-up assessment 6 weeks after the end of the treatment.

The Headache Impact Test (HIT), consisting of a 6-item questionnaire aimed to assess headache burden in the month preceding the test constituted the primary study outcome. Chronic pain experienced during the 7 days preceding follow-up was measured using the numerical rating scale (NRS). Other TSR symptoms (sleep quality, post-traumatic stress disorder, physical and psychological functioning) were also assessed.

Both acupuncture groups saw reductions in mean HIT scores compared to UC (TCA, -4.6%, P =.234; AA, -10.2%, P =.009), whereas patients in the UC group had increased HIT scores (+0.8%). In addition, current global pain was significantly decreased in TCA and AA participants compared to UC subjects (TCA, P =.0036; AA, P =.0155). Usual pain was also reduced in the TCA group, compared to UC (TCA, P =.0166). Combined TCA and AA showed significant reductions in 3 of the global pain measures, when compared to the UC group (NRS Pain Now, P =.0021; NRS Pain Usual, P =.0153; NRS Pain Best, P =.0004).

Study Limitations and Conclusions

Although this study did not investigate long-term effects of acupuncture treatments on TBI-related headaches and pain, authors conclude that AA, rather than TCA could be included into military training facilities, as it does not require extensive training, is more quickly delivered, and more flexible than TCA. This study provides additional evidence indicating effectiveness of acupuncture in treating TSR and supports the notion that an integrated care should produce better outcomes for the treatment of TBI and PTSD.

References

1. Terrio H, Brenner LA, Ivins BJ, et al. Traumatic brain injury screening: preliminary findings in a US Army Brigade Combat Team. J Head Trauma Rehabil. 2009;24(1):14-23.

2. Gironda RJ, Clark ME, Ruff RL, et al. Traumatic brain injury, polytrauma, and pain: challenges and treatment strategies for the polytrauma rehabilitation. Rehabil Psychol. 2009;54(3):247-258.

3. Jonas WB, Walter JAG, Fritts M, Niemtzow RC. Acupuncture for the trauma spectrum response: Scientific foundations, challenges to implementation. Med Acupunct. 2011;23(4):249–262.

4. Shen J. Research on the neurophysiological mechanisms of acupuncture: review of selected studies and methodological issues. J Altern Complement Med. 2001;7 Suppl 1:S121-127.

5. Coeytaux RR, Kaufman JS, Kaptchuk TJ, et al. A randomized, controlled trial of acupuncture for chronic daily headache. Headache. 2005;45(9):1113-1123.

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

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

8. Lee JH, Choi TY, Lee MS, Lee H, Shin BC, Lee H. Acupuncture for acute low back pain: a systematic review. Clin J Pain. 2013;29(2):172-185.

9. Engel CC, Cordova EH, Benedek DM, et al. Randomized effectiveness trial of a brief course of acupuncture for posttraumatic stress disorder. Med Care. 2014;52(12 Suppl 5):S57-64.

10. Jonas WB, Bellanti DM, Paat CF, Boyd CC, Duncan A, Price A, Zhang W, French LM, and Chae H. Medical Acupuncture. June 2016, 28(3): 113-130. 

11. Domingo C. Introduction to Chinese traditional medicine and acupuncture. Energy-balancing therapeutic method. Rev Enferm. 2001;24(10):50-52.

12. Barker R, Kober A, Hoerauf K, et al. Out-of-hospital auricular acupressure in elder patients with hip fracture: a randomized double-blinded trial. Acad Emerg Med. 2006;13(1):19-23.