Voice-over: Welcome to Spotlight on Migraine, a podcast series hosted by the Association of Migraine Disorders. Through personal stories and interviews with experts, we expose the true scope of migraine by exploring symptoms, treatments, research topics, and more. This episode is brought to you in part by our generous sponsors, Amgen, Novartis, and Alder BioPharmaceuticals.
In this episode, we hear a brief lecture from Dr. Mariah Stump, a women’s internal medicine doctor and medical acupuncturist. Dr. Stump briefly covers the basics of acupuncture, how it is used, and evidence that validates acupuncture as a suitable adjunct therapy for managing migraine.
Since 2015, Amgen and Novartis have been working together to develop pioneering therapies in Alzheimer’s disease and migraine. Together, Amgen and Novartis share in a mission to fight migraine and the stereotypes and misconceptions surrounding this debilitating disease.
Dr. Mariah Stump: Thanks for being here today. I’m Mariah Stump. I’m a primary care women’s health internal medicine doc at Women’s Medicine Collaborative, which is an outpatient women’s health practice out of the Miriam Hospital. So I do sort of wear two hats in my practice. I do traditional primary care, women’s health, and then I also am one of the two doctors who helps run the Lifestyle Medicine Center at Women’s Medicine Collaborative. So we’re one of the only lifestyle medicine centers in the state, and what that lifestyle medicine means is sort of prevention and looking at medical problems from a preventative standpoint.
So I’m a certified medical acupuncturist, and what that means, I’ll get a little bit into in the talk, but I did a acupuncture course through the Harvard CME sort of course for physicians. And it’s a 300-hour-plus course with also, technically, seeing patients as well as the book learning. And so I’m really excited to be talking here today about non-pharmacologic approaches to migraine care. I have many migraine patients in my own practice, and so I’m always looking for ways to try to help patients navigate this through non-medical approaches or find alternatives with them without using medication.
So I’m here to tell you more about the research behind acupuncture, that it is evidence based in migraines and tension headaches. So I have no financial relationship with anything commercial. I will be mentioning places here today and things, but I have no relationship with those.
So I wanted to go through first the basics of acupuncture, because I don’t know if many of you — how many here has actually had acupuncture before? Oh, wow! So a lot. Great. And so that’s wonderful — more than my average audience, I would say, which is exciting. So you may know something about it already, so I won’t spend too much time with the history and the background, but I think it’s important to go through this at least quickly.
So acupuncture, Latin for — acus, needle, and punctura, penetration. So we’re using small needles to penetrate the skin. What we have to compare needles with are when we get steroid injections or when we get flu shots, and those needles are really large, right? I mean, they hurt, right? So acupuncture needles are 16 times smaller than those. They’re even smaller than a sewing needle, so I mean, they’re really tiny. So it’s one of those things where we think our perception of how they’re going to hurt is actually more than how much they do hurt, because they really don’t hurt, and the intention is not to have them hurt, actually. They feel a little bit like someone’s pulling up on the skin, but not really painful. If they feel painful, it’s probably not being done correctly. That’s not the intention.
So they’re really small, as you can see. So why the needles are placed where they are is very complex, and that’s something that, unfortunately — in this short time that I have today, I do not have time to get into Chinese medicine and the meridians and sort of why they’re placed the way they are. But suffice to say that there’s a long, complex history behind acupuncture that is actually very evidence based in the sense that it’s been going on for thousands of years from China, India, Japan, Korea, and these points are on meridians. And I’ll go through sort of what meridians are in a second.
But why has it been around for thousands of years — actually, I didn’t put this, so it’s 2,000 years — and we’re just sort of catching on in the U.S. now? Well, I don’t really know the answer to that question. I think we’re kind of behind in a lot of ways here, but Europe uses acupuncture all the time in treatments of many conditions including migraines.
So in 1971, when the New York Times journalist [inaudible], James Reston, went over to China — he was reporting on — sort of the Nixon era, if you will. He was reporting on something political — not sure his story — but the point is he went over there and started experiencing right lower quadrant pain. So he was like, “Oh, my God, this is the worst pain in my life,” so he has to go to a hospital in China. So he actually ended up having to have his appendix out, and so his right lower quadrant pain was — he had the surgery. So he’s recovering post-operatively, and what to give him? So he’s in a Chinese hospital, so they give him acupuncture. So he’s waking up from his anesthesia and stuff in this post-op pain, and he’s like, “What are these things on my skin? This is so weird!” But he actually recovered fairly well and felt pretty good, and he was like, “This is amazing.”
So he comes home, and he does a story on it, and that’s where the hype — I guess, you will — started on acupuncture in the U.S. It’s kind of strange that a non-medical person sort of led the way to — but as our last speaker was saying, sometimes, anecdotal evidence and people experiencing this kind of leads the way for some scientific research.
So what a meridian is is very complex, but the very, very, very simplified version of what a meridian is is it’s like a vessel. Think of it as a vessel or a highway flowing through your body. They run head to toe, and we have 12 meridians, and they correspond with anatomic organs, at least in the Western model. So you may hear people say spleen, large intestine, gallbladder, kidney, and you’re thinking, “Well, I don’t have a kidney problem. Why are you putting a point in my kidney meridian?” Right? So it’s not exactly analogous in that sense.
What they do is they harbor or they — when I say energy, I often lose people. You’re like, “Ugh, you’re starting to talk about energy. I’m checking out. This isn’t scientific.” So to prove that we are conductors of energy, if I ran my feet across this carpet, and I touch something — maybe not, because I’m wearing the right shoes. But if you’re wearing socks, what would happen if I touched something? It would make an electric shock, right. What do we carry in our body? Protons, electrons, right? And what is our body mostly made up of? Water, right. So is water a good conductor of electricity? You’d better darn believe it. I don’t want to kick my hairdryer near my sink, right? We all know that.
So our bodies carry energy, and we conduct energy quite well. So the tip of the acupuncture needle is made of…metal, right. So what we’re literally tapping into is our bodies’ own innate energy system. It’s not just energy that we’re using for acupuncture, but when we stick the needle in the skin, we stimulate two things. We stimulate opioid receptors in the brain — we’ll get to — and we also stimulate fascia, what’s underneath. And by the needle actually penetrating the skin, we’re producing an anti-inflammatory respo — or, actually, a local inflammatory response, which sends signals to our brain.
So it’s complicated, but the meridians hold energy, and we tap into these energy systems. All right? So when you have a migraine, when you have migraines — and that’s why you’re here today — is something wrong with your brain? So that’s not really what I’m saying, but for acupuncture in the brain, we often use ear points. We often use points on certain channels. And again, it’s not sticking them right into the scalp, because that’s what people would imagine. “Okay, I have a head issue. They’re all going to be in my scalp.” No, they may be at distal points. That’s because the vessel runs from hand up to head and from head to toe.
So how does it work? What’s the science behind it? So we insert very thin needles, which causes the release of endogenous — so that means within our body already — opioids. So we all know what happens when we run, right? We release that runner’s high. Well, I have to say, you have to run for a pretty long time to release that runner’s high. Same kind of thing. You have to have the acupuncture needles in for about 10 or 20 minutes to release some of these endogenous opioids, but they do. Acupuncture is used for analgesia for surgery. People in other parts of the world can use this during surgery. It actually works pretty well. I don’t know that I would ever do that [laughter], right? But hey, people do it.
So it releases endorphins and enkephalins into the CSF, the cerebrospinal fluid. And release of that plays a role in the anti-pain effect in our body. How do we know this happens? So one of the first sort of seminal studies was — does everyone know what Narcan is? Anyone know what Narcan — you’ve all heard of that because of the opioid crisis. So it’s the antagonist to opioids. So the opioid receptor antagonist in naloxone can block the analgesia produced by acupuncture. That means you’re getting acupuncture, and someone gives you Narcan — it’s going to abolish that analgesic response. So we did this first in animal models, and then they said, “Well, let’s replicate it in human models.” And it actually was replicated.
So other pain pathway theories — this is also getting, again, to say that acupuncture works on the opioid receptors. So we think of endorphins mainly, but it’s also enkephalins and dynorphins. Those are the other two that it works on. So it depends on which level of electroacupuncture you’re giving someone — or just regular acupuncture you’re giving someone — which ones get stimulated, but all of them at different times and one of them at a few times, depending on, again, what level of hertz or electroacupuncture you’re doing.
This woman in my model here was getting electric acupuncture. It looks like someone’s charging a car, right? You put the black, and then you put the red, and then you hook that up to the electric charger or the frequency. So the dynorphins act at the spinal level, the endorphins act within the brain, and then enkephalins act within both the brain and the spinal level.
So what’s the basic of research? If you were to pick up one of the many journals that now have acupuncture research in them that are all peer-reviewed — which means that they’re all reviewed by other members of the medical community. It’s not just like you’re reading something in a blog or you’re reading something on the Internet or you’re reading something even in the New York Times. This is something that is a peer-reviewed journal, so the quality of the medical research is high to get published in these journals. When you read these, the way that acupuncture will be described is that it’s — they’re sham. So what does sham mean? I want to describe this quickly, because I think it’s important when you pick up something and you’re reading it and a lay audience, you may not know how the study’s done. Sham acupuncture is done if you put acupuncture points at non-meridian points, like I was saying, or you don’t put them deep enough. So many of the randomized control trials show a sham acupuncture.
Other ways it works, quickly — and then I’ll get to migraines, I promise — is that fMRI studies show that when people have pain like migraine, the brain remembers that pain. So certain aspects of the fMRI, function MRI imaging, we see light up in the limbic area of the brain. The limbic area is one of the emotional centers, meaning when people have pain, they remember the pain, and we remodel our brain associated with that. And acupuncture helps alleviate that, and we’ve seen it on MRI studies.
So people ask, “What’s the difference between acupuncture and dry needling?” Has anyone had dry needling before for anything? A couple people. Okay, so dry needling is the same tool, the same needles, just for a different goal. So often when people are getting physical therapy, they’ll get dry needling instead of acupuncture. The training is very different, but it is a very helpful modality for certain musculoskeletal disorders. But for migraine, specifically, I would recommend acupuncture instead.
So many migraine patients are going to seek non-pharmacological approaches because of many reasons, like you’ve heard all day today. They may be pregnant. They may have tried many medications. I don’t have to go through this. That’s sort of why you’re here.
Acupuncture for migraine — so there’s 14 randomized control trials that show that acupuncture — and I have the study here. I don’t have really time to go through it in detail, but suffice it to say that acupuncture for treatment of chronic tension headaches and migraine was effective. In a 24-week randomized control trial included 245 patients — 49 patients with migraine, found that true acupuncture significantly reduced the frequency of migraine attacks compared with sham. So it was better than the sham I described to you and better than people who were on a waiting list, and they did some other exercises, like they did PT and they used their regular medications. And this was a JAMA article.
So acupuncture is safe. I get a lot of question about, “Well, how safe is acupuncture? Oh, my God, they’re putting it near my neck. They’re putting it near my head, putting it in my ears. Is it safe?” It is very safe. You may get a tiny bit of bruising — not bruising, but just a little redness at the site, but it’s very safe. Compared to the medications often used with migraines — for migraines, it’s actually a lot safer.
And I want to stress that acupuncture should be used as an adjunct. I’m a medical doctor. I’m not here to say, “Let’s completely reject your” — if you’re on Topamax or you’re on Imitrex, you don’t need to go off of them. You could also stay on them and also do acupuncture, because it’s a very good adjunct. A lot of my patients who I see in my clinic, I’m able to get them down on their dosing of both of those types of meds rather than zero. Not going to say it’s zero, but they’re able to come down.
Botox — people ask me about this. What’s the difference between — is acupuncture better than Botox? There is a recent study showing that acupuncture showed more effectiveness and fewer complications and side effects than Botox, and that was a recent study. Again, I don’t have time to go through the nitty-gritty of each study, but if you want the references for this, I can certainly give them to you. Acupuncture versus Botex and — Botex — Botox and valproic acid — sorry, I’m trying to talk fast — acupuncture, as you can see in this solid line, reduced the need for other medication per month than the other two modalities.
Ear acupuncture — I won’t take time. This is very effective for anxiety, PTSD, and also some migraine patients.
And then last point, some people have asked me this, because it may be a question — “I’ve gotten my ear piercing, and I’ve gotten this. Is this the same thing as acupuncture?” This diath ear piercing in the auricular cartilage is anecdotal. It’s not the same thing as acupuncture. It may produce some sort of we think maybe placebo or maybe a little bit of analgesia soon after it’s done, but it’s not exactly sort of the same as acupuncture.
So barrier of cost — in my clinic, I am through the Lifespan system, so I’m on West River, and I do take Tufts insurance and some Blue Cross. We’re working on United and other forms of healthcare. So if that’s a barrier, the community — the acupuncturists do cost between 80 and $100, which is a lot money, so I would recommend going to a community acupuncture center, and they look sort of like this, a nice open room, nice pleasant space, well-trained people doing acupuncture for you.
So conclusions — acupuncture’s safe. It’s effective. It’s scientific. Use it. It’s really great [laughter]. Okay, thank you.
Voice-over: Thank you for tuning in to Spotlight on Migraine. For more information on migraine disease, please visit MigraineDisorders.org.
This podcast is sponsored in part by Amgen/Novartis and Alder BioPharmaceuticals.
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