Manual acupuncture versus sham acupuncture and usual care for prophylaxis of episodic migraine without aura: multicentre, randomised clinical trial

Dear Editor
Xu and colleagues show that manual acupuncture is more effective than sham acupuncture and usual care for the prophylaxis of episodic migraine without aura. The findings provide a recommendable non-pharmaceutical therapy to the migraine sufferers. The strengths of this trial are the success of blinding the participants, the use of non-penetrating sham acupuncture at non-acupoints as control to minimise the physiological effect and the low dropout rate. Although the trial is well-designed, we still have several issues.

The authors formulated standardised step-by-step instructions and operations to use the same rituals in the manual acupuncture and sham acupuncture groups, which contributed to the successful blinding. However, the numbers of stimulation points between groups were different in this trial. Ten obligatory acupoints and 1-2 additional acupoints were punctured in the manual acupuncture group, while only 8 non-acupoints were stimulated in the sham acupuncture group. It introduces the possibility that more acupoints in the manual acupuncture group contributed to the positive result. In addition, several secondary outcomes were reported to be measured per four weeks during weeks 1-20 in both protocol and registration system, while only the data from weeks 17 to 20 were presented in the article. The trend through study period may be more visualized and can help the readers get a fuller picture of the results.

A dose-response relationship was found when acupuncture was used for pain conditions. In this trial, participants received 20 sessions during 8 weeks and manual manipulation for each acupoint was repeated four times. Hence, the dose of manual acupuncture was adequate. However, the manual acupuncture requires a substantial commitment of time from the patients. The time necessary for frequent transportation is quite a barrier, especially for the employed patients. Furthermore, a number of patients hesitate to receive acupuncture treatment due to a phobia of penetrating the skin. The noninvasive acupoint stimulator, which can be manipulated by the patients themselves at home after the training by acupuncturists, may be an alternative option for chronic diseases.