Acupuncture in cluster headache: four cases and review of the literature
- First Online:
- Cite this article as:
- Fofi, L., Allais, G., Quirico, P.E. et al. Neurol Sci (2014) 35: 195. doi:10.1007/s10072-014-1769-6
Although cluster headache (CH) is the most disabling form of primary headache, little evidences regarding alternative and complementary therapies are available. Only few dated studies and some isolated cases are described. We describe four patients with CH treated with acupuncture as a preventive treatment, combined with verapamil or alone. All patients received acupuncture treatment twice/week for 2 weeks, then once/week for 8 weeks, and then once/alternate weeks for 2 weeks. According to Traditional Chinese Medicine the acupoints selected were: Ex HN-5 Taiyang, GB 14 Yangbai (both only on the affected side), GB 20 Fengchi (on both sides), LI 4 Hegu, LR 2 Xingjiang, SP 6 Sanyinjiao, ST 36 Zusanli (all on both sides). At each point, after the insertion of the needle, the feeling of “De Qi” was evoked; after obtaining this sensation the acupoints were not further stimulated for a period of 20 min, until their extraction. In all patients an interruption of cluster attacks was obtained. To our knowledge, this is the first report concerning acupuncture in CH patients which details the protocol approach, acupoints and duration of the treatment. Our results offer the opportunity to discuss the emerging role of acupuncture in the therapy of CH, assuming a possible influence on opioid system.
KeywordsAcupointsAcupunctureCluster headachePreventive treatment
Although recurrent in most cases, CH has considerable impact on social functions, quality of life and use of healthcare so that lifestyle changes are described in 96 % of the patients. The use of specialists and off-hour services was significantly higher among cluster patients in comparison with the general population .
The employment of acute symptomatic therapies (subcutaneous sumatriptan, inhalation of 100 % oxygen, parenteral dihydroergotamine, and oral zolmitriptan) and prophylactic treatments (steroids, verapamil, lithium, valproic acid, topiramate, indomethacin, and others) is well documented. However, a proportion of patients does not respond to these conventional therapies or only partially responds, whereas others complain of significant side effects . Some untreatable cases require invasive treatments  such as neurosurgical approaches or prescription of hallucinogenic substances .
To our knowledge, this is the first report which document the efficacy of acupuncture in CH and proposes an acupuncture treatment protocol.
Materials and methods
We describe four patients with CH treated with acupuncture as a preventive treatment, combined with verapamil or alone. All patients were treated with the same acupuncture protocol. During the protocol all patients collected daily headache diaries.
Acupuncture points and treatment protocol
The Traditional Chinese Medicine (TCM) describes a syndromic picture very similar to the CH called “Liver Fire”, characterized by severe headache with “burning, throbbing, distending or penetrating” pain located in the oculo-temporal region, conjunctival injection, nausea, vomiting, runny nose, tearing, agitation, sensation of heat and sweating of the face.
For the acupunctural treatment we selected the acupoints according to TCM, as follows:
Local points: Ex HN-5 Taiyang, GB 14 Yangbai (both only on the affected side).
Regional points: GB 20 Fengchi (on both sides).
Distal points: LI 4 Hegu, LR 2 Xingjiang, SP 6 Sanyinjiao, ST 36 Zusanli (all on both sides).
All points were punctured by experienced acupuncturists with 0.3 mm diameter sterile disposable steel needles (lenght: 52 mm), that were inserted to a depth of 10–30 mm and manipulated until the patient reported the characteristic irradiating sensation, said to indicate effective needling, that is commonly called De Qi; after obtaining this sensation the acupoints were not further stimulated for a period of 20 min, until their extraction.
All patients received acupuncture treatment twice/week for 2 weeks, then once/week for 8 weeks, and then once/alternate weeks for 2 weeks.
Case report no. 1
A 39-year-old male, reporting a 20 years history of episodic CH happening in July–August or November–December. Until 2008 he had one cluster period every 2 years (2–3 attacks/week), then the frequency increased and became annual. The pain was stabbing, strictly unilateral, localized on right orbital-supraorbital region, lasting 15–20 min and usually occurred during the night. Associated symptoms were photophobia, phonofobia, agitation, restlessness, and marked autonomic signs (ipsilateral tearing, rhinorrhea, conjunctival injection, miosis, forehead and facial sweating and flushing). During the last 3 years, verapamil (360 mg/day) was effective in suppressing the cluster period, until the last time when the attack frequency remained four per week, despite this treatment. For this reason he started acupuncture according to our protocol while continuing verapamil. After the third acupuncture treatment a reduction of the number of attacks was observed, after the sixth treatment the verapamil dose was reduced to 240 mg/day, after the ninth treatment to 120 mg/day and stopped completely after the tenth treatment. Remission was maintained with one acupuncture/week for another 4 weeks.
A new cluster started after 45 days from the last treatment, so that acupuncture alone with the same protocol was promptly initiated with immediate benefit.
Case report no. 2
A 23-year-old male was diagnosed with chronic CH ab initio 5 years prior. The cluster frequency was 1–4 attacks/day and the attack duration was 120 min; the pain, localized on left orbital and fronto-temporal areas, was associated with ipsilateral tearing, conjunctival injection, palpebral oedema, agitation and irritability. Sumatriptan s.c. was rapidly effective for attacks, while oxigen mask therapy was not. For prevention, prednisone, lithium and verapamil (360 mg/day) were not effective; only verapamil (600 mg/day) was able to reduce the attacks, but not to induce remission (one attack on alternate days). The combination of acupuncture and verapamil (360 mg/day) led to a frequency of 1–4 attacks/month. The remission was maintained for 2 months after the end of the acupuncture treatment. Cluster headache attacks then returned with a frequency of one attack daily. Reintroducing acupunture, the frequency fell to one attack/week.
Case report no. 3
A 38-year-old male, presented the onset of episodic CH when he was 19 years old; cluster period: March–June; frequency from 2–3 attacks/day to 6–7/day with a duration of 20 min. The pain site was left temporo-parietal, frontal, orbital, rarely on upper dental arch. Pain was severe, throbbing and associated with rhinorrea, tearing, conjunctival hyperemia and palpebra oedema. Sumatritpan s.c. was effective as acute treatment. Generally at the beginning of the attacks he took verapamil (360 mg/day) which was able to progressively reduce the frequency to 1/day in 2 weeks and to stop the cluster. During a second cluster period, verapamil combined with acupuncture was prescribed and a complete remission was obtained. The following year, at the beginning of the cluster, he immediately started acupuncture alone, without verapamil, with the same scheduled protocol and after 2 weeks CH went into remission.
Case report no. 4
A 43-year-old female, with CH onset when she was 25 years-old. The attacks happened annually, in the period from January to March with a frequency of 1–2 attacks/day, mainly during the night and with a duration of 60–120 min. The pain site was localized on right ocular region, with irradiation to the root of the nose and to ipsilateral side of the head. The pain was penetrating, burning and associated with photophobia, body sweating, rhinorrea and omolateral tearing, nasal congestion and irritability. She obtained a complete resolution of pain with sumatriptan s.c., but did not respond to oxygen-therapy. For prophilactic therapy methysergide was prescribed, but it was immediately stopped for adverse effects. A 20 day verapamil treatment (360 mg/day) was effective in interrupting the cluster but the patient did not tolerate the drug.
So, at the onset of a new cluster period, a combined treatment of acupuncture and a low dose of verapamil (240 mg/day) was started. After 2 weeks verapamil was reduced to 120 mg/day because attacks decreased to 1 every 3 days. CH remission was obtained after 20 days of acupuncture and verapamil was discontinued.
She needed acupunture plus verapamil (120 mg/day) for six CH periods, after that, acupuncture alone was administered when necessary for the following 3 years.
Acupuncture is nowadays one of the most widespread forms of complementary medicine [10, 11] used for the treatment of chronic pain, including headaches [12, 13]. In the 1990s it was demonstrated that acupuncture was more effective than placebo for the treatment of headache and migraine . In the last decade, acupuncture plus routine care in patients with headache, has been associated with marked clinical improvements compared with routine care alone . The recent Cochrane Database Systematic review  suggests that acupuncture should be considered an effective treatment and a valuable option for patients suffering from migraine or tension-type headache, with fewer adverse effects.
Thereafter, during these years an increased use of complementary and alternative medicine in the treatment of primary headache disorders has been observed, but less is known about acupuncture in CH patients. Only few and dated cases [7–9] about acupuncture in CH patients are described. Melchart et al. , in an observational study on acupuncture in 2,022 patients with headache included 33 patients with CH, demonstrating an overall effect with relevant improvement after 8.6 ± 3.0 acupuncture treatments, but no specific results are available for the subgroup of patients with CH.
Our study proposed a protocol of acupuncture alone or combined with verapamil in four patients affected by CH, three with episodic CH and one with chronic CH. All patients followed the same protocol (14 treatments) with a standardized set of acupuncture points and had a good response.
Acupuncture was identified as a possible alternative therapy in these patients, who responded to subcutaneous sumatriptan as acute treatment, but who did not respond well to common pharmacological preventive therapy. In our three patients with episodic CH, acupuncture was started because either the verapamil dose was not effective (2 pts) or, the verapamil caused side effects (1 pt). In these patients, acupuncture, initially started with verapamil and then continued alone, was effective in stopping cluster attacks.
In chronic CH (1 pt) acupuncture was started in association with low dose of verapamil because it could not completely stop the attacks.
The action mechanism of acupuncture therapy is complex. Studies demonstrated that electrical acupunture can increase endogenous opioid peptides (enkephalin, beta-endorphin) in supraspinal CNS regions and in the spinal cord [17, 18] while manual acupuncture can lead to the activations of the diffuse noxious inhibitory controls (DNIC) with an immediate suppression of pain transmission in neurons of the trigeminal caudalis and/or the spinal dorsal horn [19, 20].
Some biochemical studies evidenced significantly lower met-enkephalin levels in CSF  and lower peripheral blood beta-endorphin  in 65 patients with CH as compared to control, during the pain-free period as well. The authors speculated that these findings reflect reduced CNS levels of beta-endorphin due to an opioid system hypofunction . On the other hand, CSF opioid levels may rise following manual acupuncture or electroacupuncture, as confirmed by Hardebo et al.  who evidenced that CSF met-enkephalin levels rose after acupuncture treatment.
Until now, the role of how acupuncture can act in CH patients is not known. Although the series is limited, this study provides good evidence of the integration of western medicine and traditional chinese medicine in the preventive treatment of CH.
Conflict of interest
All the authors certify that there is no actual or potential conflict of interest in relation to this article.