Ch110-X2954

12/22/06

3:48 PM

Page 1157

c h a p t e r

110

Acupuncture for Headaches

Aaron J. Michelfelder,
MD, FAAFP, FAAMA

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1157
Mechanism of Action. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1157
Safety of Acupuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1157
Training in Acupuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . 1158
Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1158
Technique for Acupressure . . . . . . . . . . . . . . . . . . . . . . . . . . . 1158
Technique for Acupuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . 1158
Evidence for Acupuncture in Headache . . . . . . . . . . . . . 1160

Overview
Acupuncture is the technique of piercing the skin with needles
in specific points on the body to treat or prevent various
conditions. Acupuncture has been used for thousands of
years by practitioners in many different cultures and societies
around the world. As acupuncture becomes more and more
popular, physicians will need to have at least a basic working
knowledge of the technique. The best physicians will be
utilizing all of their knowledge about integrative medicine to
provide the most comprehensive care available for patients.
Acupuncture points are not random. They are palpable,
and a point often corresponds to a depression in a muscle or
bone or to a neural foramen. An acupuncture point usually
has its own neurovascular bundle, which distinguishes it
from surrounding tissue, and is sometimes quite tender to
palpation. In traditional Chinese medicine (TCM), these
points connect to energy (Qi) channels within the body
called meridians. There are fourteen principal meridians (six
bilateral [total of 12] and two central), typically named after
organs of the body: Kidney (KI), Heart (HT), Small Intestine

Selecting Acupuncture/Acupressure Points . . . . . . . . . 1160

General Relaxation/Calming Points . . . . . . . . . . . . . . . . . . . . 1160
Trigger Points in the Cervical Region . . . . . . . . . . . . . . . . . . . 1161
Local Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1162
During an Acupuncture Treatment . . . . . . . . . . . . . . . . . . 1162
Post-Treatment Home Program . . . . . . . . . . . . . . . . . . . . 1162
What to Look for in an Acupuncturist . . . . . . . . . . . . . . . 1162
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1163

(SI), Bladder (BI), Liver (LV), Master of the Heart, also called
Pericardium (MH), Triple Heater (TH), Gall Bladder (GB),
Spleen (SP), Lung (LU), Large Intestine (LI), Stomach (ST),
Conception Vessel (CV), and Governor Vessel (GV).

Mechanism of Action
The mechanism of action of acupuncture is unclear;
however, there is significant evidence that acupuncture
effects changes in the muscles where the needle is inserted,
changes starting at nerves near the needle and passing all the
way up to the higher cortex, as well as changes in circulating
and local hormones, cytokines, neurotransmitters, and
other body chemicals.1

Safety of Acupuncture
Despite the use of sterile needles to pierce unsterilized skin,
serious adverse reactions to acupuncture are very rare.
A systematic review of the world literature on prospective

Ch110-X2954

12/22/06

1158

3:48 PM

PART III, SECTION

Page 1158

4 BIOMECHANICAL

studies of the safety of acupuncture revealed that in nine trials

involving tens of thousands of treatments, pneumothorax was
the only life-threatening complication and occurred twice;
infections did not occur at all.2 A prospective survey of 34,000
treatments by traditional acupuncturists in the United
Kingdom found no serious adverse events.3 In the largest
prospective trial to date, involving 97,733 patients and more
than 760,000 treatments performed by 7050 physicians in
Germany, pneumothorax occurred twice, and there was one
occurrence each of exacerbation of depression, acute
hypertensive crisis, vasovagal reaction, and an asthma attack
with hypertension and angina.4 The reactions most commonly
reported were needling pain in 3.28%, hematoma in 3.19%,
bleeding in 1.38%, and orthostasis in 0.46% of patients.
Overall, nonserious adverse events were reported to occur in
7.1% of patients.4

Training in Acupuncture
Laws concerning the practice of acupuncture are defined by
each state. Practitioners include licensed acupuncturists,
who have completed at least 3 years of training at an Oriental
college of medicine; chiropractors, who receive variable
amounts of training in chiropractic school but may have
additional training after school; and physicians and dentists
who have completed acupuncture training courses outside
their regular professional training. For physicians to practice
acupuncture, some states require no training at all, others
require 200 hours, and some 300 hours, of acupuncture
training. Board certification is available to physicians
through the American Board of Medical Acupuncture.
Details on physician training and licensure can be found on
the website for the American Academy of Medical
Acupuncture (Table 110-1).

Acupressure can also be used to relax trigger points as well

as other areas of spasm within muscles that may or may not
be acupuncture points.
The purpose of the technique is to find the point or area
to be stimulated, as follows:
1. With your index finger or thumb, start superficial and
apply just enough pressure to move the skin.
2. Move the finger or thumb in gentle slow circles.
3. With every few circles, apply more and more pressure
until you feel the muscle fibers beginning to relax
beneath your fingers. If you are stimulating an area
without a muscle, such as over the supraorbital foramen,
just keep applying slow, steady downward, circular
pressure over the foramen.
4. With stimulation of an acupuncture point, the patient
should eventually feel a dull aching sensation. Stimulation
of the point should last at least several minutes past which
the patient feels this aching sensation. You may have to
apply acupressure intermittently, such as for a few
minutes, several times an hour.
This technique is a good one to teach patients to perform
on themselves for problems such as sinus headaches and
pressure.

Technique for Acupuncture

Acupuncture needles come in all sizes, from very small
( 40 gauge) to much larger (up to 20 gauge). An acupuncture
needle comes to a very sharp point and has a handle of
plastic or wrapped metal. Because acupuncture needles are
not hollow like phlebotomy needles, they are believed to
separate tissue more than to cut it (Fig. 110-1).
1. After the desired acupuncture point is found, palpation
of the point is important to prepare the body for the
needle (Fig. 110-2).
2. A very small needle may need an introducer, which is
included with most needles. The introducer is a plastic

Techniques
FIGURE 110-1

Technique for Acupressure

Acupressure is essentially massage, but with the purpose of
stimulating an acupuncture point for a desired effect.

table 110-1.

Resources for Acupuncture

The American Academy of

Medical Acupuncture (AAMA)

www.medicalacupuncture.
com/

The National Certification

Commission for Acupuncture
and Oriental Medicine (NCCAOM)

www.nccaom.org/

National Center for Complementary

and Alternative Medicine (NCCAM),
a Center of the National Institutes
of Health

http://nccam.nih.gov/

Package of acupuncture needles.

Ch110-X2954

12/22/06

3:48 PM

Page 1159

CHAPTER

110

ACUPUNCTURE FOR HEADACHES

1159

FIGURE 110-2

FIGURE 110-4

Palpation.

Needle in introducer.

tube a few millimeters shorter than the needle. Place the

introducer on top of the acupuncture point, and then
drop the needle into the introducer (Figs. 110-3 and
110-4). The handle of the needle will protrude a few
millimeters from the top of the introducer.
3. Holding the introducer between the thumb and third
finger of your dominant hand, tap the needle into the
skin using your index finger (Figs. 110-5 and 110-6).
With practice, the right amount of force needed to pierce
the skin is simple to recognize.
4. After the initial tap of the needle into the skin, carefully
remove the introducer. Then, the needle may be pushed
in deeper and angled to wherever you would like it to go.
Typically, the needle will go into the body of a muscle,
but the depth depends on the acupuncture point. A point

on the back of the neck may be 2 to 3 centimeters deep,

but a point on the forehead may only be a few millimeters
deep.
Inserting the needles without the plastic introducer
requires some training and supervision and is beyond the
scope of this chapter.
Once a needle has been inserted, it can either be
stimulated or left alone. If it is left alone, the coiled handle
and temperature difference between the needle tip in the
body and the needle handle at room temperature causes
electrons to move from inside the body into the needle.
Inserting a needle and then leaving it alone is called needle
in dispersion. The needle becomes a capacitor removing
electrons from the body. In TCM, this action is believed to
be calming, cooling, and depleting.

FIGURE 110-3

FIGURE 110-5

Positioning the introducer.

Tapping needle into place.

Ch110-X2954

12/22/06

1160

3:48 PM

PART III, SECTION

Page 1160

4 BIOMECHANICAL

FIGURE 110-6

Needle in place.

To add electrons to the body, the needle can be stimulated

by a back-and-forth twirling action, which the acupuncturist
achieves by rotating the needle about 180 degrees alternating
clockwise and counterclockwise. The needle can also be
stimulated by warming with something like Chinese moxa,
an herb pressed into an incense-like stick that, when lit,
smolders and emits a steady stream of heat. Electrical
stimulators are very popular and may be connected to the
needles in a circuit to add electron flow from one needle
to another. This is the process for percutaneous electrical
nerve stimulation (PENS), the acupuncture version of
transcutaneous electrical nerve stimulation (TENS). Lasers
can also be used to stimulate acupuncture points with or
without needles.

Both acupuncture and acupressure can be used to

stimulate acupuncture points. Patients can be taught to
perform their own acupressure, thus empowering them to
help themselves.

Evidence for Acupuncture

in Headache
The allopathic tradition of the randomized placebo-controlled
clinical trial is very difficult to apply to acupuncture. It is hard
to define placebo acupuncture, because many people argue
that any needle piercing the skin is acupuncture. Many studies
use no acupuncture as the control intervention, or sham
acupuncture, which usually means inserting needles into
places that are not acupuncture points. Some studies have tried
to use acupressure as the control. In any case, many studies
have been unsuccessful in blinding patients or their physicians
as to whether or not they had acupuncture, and the

acupuncturist is certainly not blinded as to whether traditional

or sham acupuncture is being used on the patient. Many
studies also use protocols whereby every patient receives the
same treatment. Many acupuncturists believe that to be
effective, acupuncture treatments must be individualized.
To put acupuncture studies into context, the U.S. Food
and Drug Administration (FDA) requires only two studies of
a drug showing that it is better than placebo before it can be
approved. A drug could show neutral results in many studies,
but as long as two studies have positive results, the drug can
be approved for use. Possibly because of the difficulties in
experimental design, there are many studies of acupuncture
with positive results, and many with neutral results.
In 1999, Melchart and colleagues5 performed a review of
22 randomized controlled trials of acupuncture for
headache involving 1042 patients from European countries.
These reviewers concluded that the trials tended to be small
and had methodologic problems; however, the evidence was
suggestive of a role for acupuncture in headache treatment.5
In a newer, well-designed trial reported in 2004, Vickers and
associates6 studied acupuncture for 401 patients with
chronic headaches in the United Kingdom. Subjects either
underwent acupuncture treatments once a week for 3 months
or no acupuncture. Over one year, the treatment group had
a 34% decrease in headache score, versus 16% in the control
group. Also, the treatment group was found to have 20 fewer
days of headache per year, 15% less medication use, 25%
fewer visits to the general practitioner, and 15% fewer days
off work. Wonderling and coworkers,7 examining the costeffectiveness of acupuncture for headaches in the United
Kingdom, found that acupuncture improves health-related
quality of life at a small additional cost and is relatively
cost-effective.
The latest evidence shows that acupuncture is helpful in
treating headaches.

Selecting Acupuncture/
Acupressure Points
Selection of acupuncture/acupressure points for treatment
of headaches should proceed as follows:
1. Start with general relaxation /calming points.
2. Release trigger points in the posterior cervical region.
3. Depending on the type of headache, use local points.

General Relaxation/
Calming Points
Governor Vessel 20
The Governor Vessel 20 (GV-20) point is at the top of the
head, over the sagittal suture, which is created by the closure
of the posterior fontanelle. Often, there is a bony ridge at this
point. Visually, GV-20 can be found by tracing an imaginary

Ch110-X2954

12/22/06

3:48 PM

Page 1161

CHAPTER

line from the ear lobes up through the middle of the top of
the ears (the helix) and up to the midline. Where that line
crosses the sagittal suture (midline) is the GV-20 point. The
patient can apply acupressure to this point or a needle can be
inserted here and left in dispersion (Fig. 110-7).

110

ACUPUNCTURE FOR HEADACHES

1161

FIGURE 110-8

The Large Intestine 4 (LI-4) acupuncture point.

Large Intestine 4 (LI-4)

The Large Intestine 4 (LI-4) point is located in the body of
the first interosseus muscle in the hand, between the first
and second metacarpal bones. This point is usually tender,
and patients can easily perform acupressure to this point
bilaterally on themselves (Fig. 110-8).

Trigger Points in the

Cervical Region
People with headaches tend to have stiff posterior cervical
muscles. Massage, heat, chiropractic and osteopathic
manipulation, acupressure, trigger point injections, and
acupuncture can all help release the muscle spasm.

Gall Bladder 20
The Gall Bladder 20 (GB-20) point is located at the base of
the skull, posteriorly, between the insertions of the

LI-4

sternocleidomastoid and the trapezius muscles. Start by

placing the thumb and index fingers of one hand on the
mastoid processes and sliding them posteriorly. Your
fingertips will fall into two depressions at the base of the
skull. Superiorly, you will feel the skull. On either side of
your fingers, you will feel the sternocleidomastoid or
trapezius muscles (Fig. 110-9).
Palpate all the muscles of the posterior neck from the base
of the skull down to the shoulders. Any tender points or
areas of spasm should be addressed with massage,
acupuncture, or acupressure.

FIGURE 110-7

The Governor Vessel 20 (GV-20) acupuncture point.

FIGURE 110-9

The Gall Bladder 20 (GB-20) acupuncture point.

GV-20

GB-20

Ch110-X2954

12/22/06

1162

3:48 PM

PART III, SECTION

Page 1162

4 BIOMECHANICAL

Local Points
Frontal Headaches
For frontal headaches, including sinus, tension, and
migraine, the Governor Vessel 24.5 (GV-24.5) may be used.
GV-24.5 is located on the glabella, between the eyebrows
(Fig. 110-10).

Migraines and Cluster Headaches

Migraines and cluster headaches are complicated to treat with
acupuncture. Follow the same principles of general relaxation
points, then cervical points, then GV-24.5. After those
procedures, search for any tender points on the scalp.
If needling tender points on the scalp does not provide
satisfactory relief, a more systemic approach with acupuncture
may be more successful. Such an in-depth approach is beyond
the scope of this chapter.

Sinus Headaches
Bladder 2
The Bladder 2 (BL-2) point is located at the frontal notch,
just medial to the supraorbital foramen (see Fig. 110-10).
Insert the needle from above.
Stomach 2
The Stomach 2 (ST-2) point is located lateral to the nose
in a depression where the infraorbital foramen is
found. Needle this one starting laterally, aim toward the
medial canthus of the eye, and insert subcutaneously
(see Fig. 110-10).

Tension Headaches
Temporal Muscle Tender Points
Palpate the muscles of the scalp carefully, and perform
acupressure or acupuncture at any tender areas or regions of
spasm found, especially in the temporal region.

FIGURE 110-10

Acupuncture points Governor Vessel 24.5 (GV-24.5), Bladder 2

(BL-2), and Stomach 2 (ST-2).

During an Acupuncture
Treatment
Needles stay in for about 30 minutes. Patients should be
relaxing in a comfortable room with the lights low and
perhaps some relaxing music in the background.
Distractions should be minimized.
Remove acupuncture needles as follows:
1. Place one finger on the skin next to the needle.
2. While holding finger in place, use the other hand to
gently pull out the needle.
3. Sometimes a drop of blood may be released. There is no
need to apply pressure; simply dab the blood away with
sterile gauze.

Post-Treatment Home
Program
Patients are instructed to moderate their activity for 24 hours
after a treatment. They should avoid eating very hot or very
cold foods, consumption of alcohol, sexual activity, and
other physically demanding activities. They should also
drink plenty of water and get lots of sleep.
Patients can continue to perform acupressure on
themselves starting 24 hours after the treatment. A good
approach is to stimulate GV-20, LI-4, and local neck and
head points two times a day and as needed.
Ideally, acupuncture is integrated into a regimen of
headache trigger avoidance, healthful diet, exercise and stress
reduction as well as possible medication therapy. Acupressure
is a great way to empower patients to take control of their own
symptoms.

What to Look for in an

Acupuncturist
A physician acupuncturist should have completed training
in one of the programs approved by the American Board of

Ch110-X2954

12/22/06

3:48 PM

Page 1163

CHAPTER

Medical Acupuncture. Board certification in medical

acupuncture identifies individuals who have completed at
least 200 hours of training, passed a board examination,
practiced at least 2 years, and performed at least 500
acupuncture treatments.
A non-physician acupuncturist should be licensed. The
letters L.Ac. should follow a licensed acupuncturists name.
Also, the National Certification Commission for Acupuncture
and Oriental Medicine has a database of certified
acupuncturists (see Table 110-1).

1.

3.

Summary
4.

Training for physicians to learn acupuncture is available

through several continuing medical education
programs.
Acupuncture is useful for treating headaches, and
patients can be taught acupressure to empower them to
take control of their own health.
In treating headaches: (1) start with general relaxation
points (GV-20, LI-4), (2) release trigger points in the
posterior cervical region (GB-20 and any tender

ACUPUNCTURE FOR HEADACHES

1163

points), and (3) depending on the type of headache, use

local points.
For referral, look for a physician acupuncturist,
licensed acupuncturist, or chiropractor with
documented training and, ideally, certification in
acupuncture.

r e f e r e n c e s

2.

110

5.
6.
7.

Helms JP: The basic, clinical, and speculative science of acupuncture.

In Acupuncture Energetics: A Clinical Approach for Physicians.
Berkeley, Calif, Medical Acupuncture Publishers, 1995, pp 19-69.
Edzard E, White AR: Prospective studies of the safety of
acupuncture: A systematic review. Am J Med 110:481-485, 2001.
MacPherson H, Thomas K, Walters S, Fitter M: The York
Acupuncture Safety Study: Prospective survey of 34,000 treatments
by traditional acupuncturists. BMJ 323:486-487, 2001.
Melchart D, Weidenhammer W, Streng A, et al: Prospective
investigation of adverse effects of acupuncture in 97,733 patients.
Arch Intern Med 164:104-105, 2004.
Melchart D, Linde K, Fischer P, et al: Acupuncture for recurrent
headaches: A systematic review of randomized controlled trials.
Cephalalgia 19:779-786, 1999.
Vickers AJ, Rees RW, Zollman CE, et al: Acupuncture for chronic
headache in primary care: Large, pragmatic, randomised trial. BMJ
328:744-749, 2004.
Wonderling D, Vickers AJ, Grieve R, et al: Cost effectiveness analysis
of a randomised trial of acupuncture for chronic headache in
primary care. BMJ 328:747-749, 2004.