Ideally, acupuncture treatment should be given based on diagnosis principles of Chinese medicine (14). It may be difficult for a physician without an academic background in Chinese medicine to do that, so in such instances, the authors recommend a simple and useful principle: remember the concept of the yin and yang balance and treat the patient holistically. In migraine patients with temporal throbbing quality, excessive yang exists with a deficiency of yin. In order to rebalance the yin and yang, the practitioner would supplement the yin by tonifying the acupoints in the foot such as spleen meridian 6 and liver meridian 3, and eliminate the excessive yang by draining points in the head and hand such as extraordinary head and neck point 5, stomach meridian 8, and large intestine meridian 4. Stimulation of the yin points will soothe the patient and improve sleep. Suppression of the yang points will relieve the acute headache. Needling of the Ashi points in the head can also suppress the pain.
In Chinese medicine, acupuncture aims to restore the balance of Yin and Yang, cleanse the blockade of meridians, and resume the Qi flow. Ultimately, the goal of acupuncture is to reduce the headache frequency and severity through proposed inhibition of the brainstem headache center including trigeminal nucleus caudalis.
Acupuncture treatment is typically given over the course of 4 to 6 weeks, 2 to 3 times per week. Each treatment involves 6 to 10 needlings lasting 20 to 30 minutes. The treatment goal is 50% or more pain, symptom, or functional improvement.
After extensive review of literature produced from January 1970 to October 1997 searched through MEDLINE, Allied and Alternative Medicine, EMBASE, MANTIS, and nine journals not indexed by the National Library of Medicine, the National Institutes of Health Consensus Development Panel has concluded that acupuncture was a useful adjunctive therapy for headache management (41). Multiple randomized controlled studies have been done to investigate its efficacy in the treatment of different kinds of headache including migraine, tension, and headaches with combined characteristics. Current literature seems to support the use of acupuncture in migraine treatment, whereas there is not enough scientific evidence to evaluate its role in the management of other types of headache (39; 32; 33).
In general, acupuncture is a safe and noninvasive procedure. There are a few contraindications to the use of acupuncture (09; 37). Acupuncture applied with an electrical stimulator (electroacupuncture) should not be performed on those with cardiac pacemakers. Acupuncture should not be given to those with skin and soft tissue infections, bleeding disorders, or on anticoagulants. It is not recommended in infants.
Pregnancy is not a contraindication for acupuncture treatment, although certain acupoints should be avoided.
Migraine. More studies of acupuncture have been done in migraine than any other type of headache. Acupuncture has demonstrated some benefits in the acute abortion of migraine. In a randomized controlled trial to study the efficacy of acupuncture treatment for acute migraine, 175 patients were randomized into three groups (28). One group received verum acupuncture, and subjects in the other two groups were treated with sham acupuncture. Each patient received 1 session of treatment and was observed over a period of 24 hours. Significant decreases in visual analogue scale (VAS) scores from baseline were observed in the fourth hour after treatment when visual analogue scale was measured in the patients who received either verum acupuncture or sham acupunctures (P < .05). The VAS scores in the fourth hour after treatment decreased by a median of 1.0 cm, 0.5 cm, and 0.1 cm in the verum acupuncture group, sham acupuncture group 1, and sham acupuncture group 2, respectively. The decrease was significant between the verum group and the sham acupuncture group 2 (P=0.007). Significant differences were also observed in pain relief, relapse, or aggravation within 24 hours after treatment. Wang and colleagues conducted a study on 150 patients to investigate the efficacy of acupuncture for acute migraine attacks compared with sham acupuncture (66). Every patient received a verum or sham acupuncture treatment when having the migraine attack, and medications were allowed if the pain failed to be relieved 2 hours after the acupuncture treatment. The mean VAS scores 24 hours after treatment was significantly decreased from 5.7 to 3.3 by 2.4 in the verum group versus 5.4 to 4.7 by 0.7 in the sham group (P = 0.001). The acute medication intake at 24 and 48 hours after the treatment was also significantly reduced in the real acupuncture group (P < 0.05).
Acupuncture has also demonstrated some favorable effects on migraine prophylaxis. In the Cochrane Database of Systematic Reviews, 22 trials with 4419 participants were evaluated (32). Six compared acupuncture to no prophylactic treatment or routine care only. After 3 to 4 months, patients receiving acupuncture had significantly higher response rate and fewer headaches. Fourteen trials compared a 'true' acupuncture intervention with a variety of sham interventions. Pooled analyses did not show a statistically significant superiority for true acupuncture in any of the time windows for pooled responder rate ratio, however, there was a trend of significance of group differences (0.05 < p < 0.1) in four analyses (responder rate ratio, headache frequency, migraine days, and migraine attacks up to 2 months after randomization). Four trials demonstrated that acupuncture was slightly better than proven prophylactic drug treatment and associated with fewer adverse events. The authors concluded that (1) there was consistent evidence that acupuncture provided additional benefit to treatment of acute migraine attacks only or to routine care; (2) there was no convincing evidence for an effect of 'true' acupuncture over sham interventions; (3) acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment, and has fewer adverse events. Acupuncture should be considered a treatment option for patients willing to undergo this treatment. A systematic review and meta-analysis evaluated the therapeutic effect of acupuncture on migraine. Twenty-eight randomized controlled trials were included, involving 2874 patients. The results showed that true acupuncture was more effective than sham acupuncture or medication. The true acupuncture treatment achieved significantly greater improvement in reduction of the visual analog scale (VAS) score than sham acupuncture and fewer side effects than medications (44). The metaanalysis of 3380 participants from 20 studies also demonstrated the similar true acupuncture treatment outcome (12). A systematic review of 20 randomized controlled trials involving 2725 patients compared the true and sham acupuncture in migraine management (27). The patients received the treatment with duration of 1 session or 30 minutes to 20 weeks, and were followed up from 0 week or 24 hours to 54 weeks. In comparison to sham acupuncture, the true acupuncture had achieved greater improvements in migraine frequency, visual analog scale score, and responder rate, but there was no significant difference in the number of migraine days.
Vincent studied 30 patients with chronic migraine and found acupuncture treatment to be significantly better than sham treatment in the reduction of pain severity (48% vs. 14%) and the use of rescue medications (38% vs. 28%) (65).
Linde and colleagues completed a randomized controlled trial on 302 patients for the effect of migraine prophylaxis (34). Each patient received 12 sessions of treatment over 8 weeks. Compared to baseline, the mean number of days with headache of moderate or severe intensity decreased by 2.2 days in both the true acupuncture and sham acupuncture groups and by 0.8 days in the waiting list group. True acupuncture was no more effective than sham acupuncture in this study (34). A study by Alecrim-Andrade and colleagues evaluated percentage of patients with a 50% or greater reduction in migraine attack frequency and number of days with migraine (01). At the second month of treatment, patients with real acupuncture treatment significantly improved more than those with sham acupuncture (P=0.021 and P=0.007). However, the differences between these 2 groups disappeared in the third month of treatment as a consequence of the high improvement of the sham acupuncture group. The verum acupuncture was rated by patients as superior to sham acupuncture in general effectiveness. Li and colleagues conducted a randomized controlled trial in 480 patients who received either verum or sham acupuncture (29). All patients received 20 treatments over a period of 4 weeks. There was no significant reduction in the number of days with migraine during weeks 5 to 8 (P < 0.05), but weeks 13 to 16 (P = 0.003, < 0.001, =0.011, respectively) in all 3 acupuncture groups compared with the control group. In a 24-week study of clinical trial on 249 patients, patients randomly received 4 weeks of treatment with true acupuncture, sham acupuncture, or no acupuncture waiting-list control, followed by 20 weeks of follow-up (81). The mean change of frequency of migraine differed significantly among the 3 groups at 16 weeks after randomization, a greater reduction was observed in the true acupuncture than in the shame acupuncture (P = 0.002) or waiting-list (P < 0.001), and the significant reduction lasted throughout the remaining period of the study. A multicenter, randomized clinical trial studied 150 patients for the acupuncture effect as prophylaxis of episodic migraine without aura (70). Patients received 20 sessions of either true acupuncture or sham acupuncture treatment over 8 weeks and 12 weeks of follow-up. True acupuncture resulted in a more significant reduction in migraine days of 3.5 versus 2.4 for sham acupuncture (P=0.005) at weeks 13 to 16, and 3.9 versus 2.2 (P < 0.001) at weeks 17 to 20. The migraine attacks at weeks 17 to 20 were also significantly more reduced in the true acupuncture group than the sham group, 2.3 versus 1.6 (P < 0.001).
Studies comparing acupuncture with conventional drugs including caffeine or ergotamine and flunarizine showed significantly better outcomes in the acupuncture group regarding reduction in headache severity and frequency (14; 02). In a study on 114 patients with migraine comparing acupuncture and metoprolol, the proportion of responders (reduction of migraine attacks by at least 50%) was 61% in the acupuncture group and 49% in the metoprolol group (P=0.261) after 9 to 12 weeks of treatment. Both physicians and patients reported fewer adverse effects in the acupuncture group (52). Yang’s group investigated the efficacy of acupuncture compared with topiramate treatment in chronic migraine prophylaxis in 66 patients (71). In the acupuncture group, 33 patients received acupuncture treatment for 24 sessions over 12 weeks; topiramate was administered to 33 patients, with a 4-week titration initiated at 25 mg/day and increased by 25 mg/day weekly to a maximum of 100 mg/day, followed by an 8-week maintenance period. A significantly larger decrease in the mean monthly number of moderate or severe headache days from 20.2±1.5 days to 9.8±2.8 days was achieved in the acupuncture group compared with 19.8±1.7 days to 12.0±4.1 days in the topiramate group (p< 0.01). The 50% responder rate was 75.8% in the acupuncture group versus 30.3% in topiramate group (P< 0.01). Only 6% of the acupuncture group had adverse events, compared to 66% of topiramate group. A systematic review was conducted to compare the acupuncture effect versus standard pharmacological therapy for migraine prevention (79). Seven randomized controlled trials were included, with a total of 1430 participants. The studies showed acupuncture to be more effective than the standard treatment for migraine prevention. The preventive medications included in the studies were flunarizine, topiramate, beta-blocker including metoprolol, valproic acid, and botulinum toxin. Acupuncture was significantly more effective at reducing the frequency of migraine attack, headache days, and headache intensity. It also showed significantly better improvement of the proportion of responders with at least 50% reduction in migraine days and better MIDAS scores. The authors concluded that the acupuncture is just as effective and has fewer side effects than many of the current standard pharmaceutical agents.
Facco and colleagues conducted a study on 160 patients who suffered from migraine without aura to compare the treatment effect of true acupuncture, ritualized mock acupuncture, standard mock acupuncture, and rizatriptan (11). A total of 127 patients completed the study. Only the true acupuncture group provided a significant improvement in MIDAS Index, at both 3-month and 6-month follow-up, compared to the only use of rizatriptan (P< 0.0001).
Acupuncture may be used as an adjunct to prophylactic drugs. Foroughipour’s group studied the benefit of adding acupuncture to 100 patients with migraine for whom prophylactic drugs had not produced a fall of at least 50% in the number of headache days (13). Patients received a total of 12 sessions of either true or sham acupuncture treatment 3 times per week for 4 weeks. Compared to the baseline, there was a reduction in the number of attacks in both groups. However, adding true acupuncture to conventional prophylactic drugs did significantly better than the addition of sham acupuncture for the successive 4 months of follow-up (P< 0.001 at the end of each of the first 3 months and P = 0.001 the fourth month). Acupuncture may provide a positive outcome to patients in terms of functionality and quality of life.
Vickers and colleagues studied 401 patients in a primary care setting, with predominantly migraine, who received acupuncture versus control intervention (usual care with no acupuncture) over 3 months (63). Headache score, Short-Form 36 (SF-36) health status, and use of medication were assessed at 3 months, 6 months, 9 months, and 12 months. Compared to the control group at 12 months, patients in the acupuncture group experienced less headache score (34% reduction from the baseline vs. 16% in control, P = 0.0002), 22 fewer days of headache per year (p = 0.003), improvement in physical role functioning (P = 0.036) and energy (P = 0.02) and change in health (P = 0.0004), and 15% less medication (P = 0.02).
Vijayalakshmi’s group studied 60 migraineurs over 30 days to compare acupuncture treatment to oral flunarizine along with paracetamol (64). The quality of life was assessed with the WHOQOL BREF (WHO Quality of Life Biomedical Research and Education Foundation) questionnaire and the disability was assessed with the MIDAS (Migraine Disability Assessment) questionnaire. Both acupuncture and the drug study groups improved migraineurs’ life quality and disability; however, acupuncture did significantly better than the drug (P < 0.005).
In the metaanalysis of 15 randomized controlled trials involving 2545 participants to study the prevention of chronic migraine, acupuncture was found to effectively reduce the monthly headache days, which was better but not significantly superior over the prophylactic effect of botulinum neurotoxin A (BoNT-A) (84).
Four-hundred eighty migraineurs were recruited in China for the study of cost-effectiveness ratio (expressed as cost per 1 day reduction of headache days from baseline to week 16) in terms of the choices of meridians and specific acupoints (05). Patients were assigned to the Shaoyang-specific acupoint group, Shaoyang-nonspecific acupoint group, Yangming-specific acupoint group, and sham nonacupoint group. The treatment of specific acupoints in Shaoyang meridians is more cost-effective than the other 3 groups (P < 0.05).
Supasiri and colleagues conducted a study to examine whether 5 sessions of acupuncture is noninferior to 10 sessions for migraine treatment (55). In comparison to the baseline, both groups prevented the migraine attacks, reduced the severity of headache, and improved the quality of life; however, there was no significant difference in the therapeutic benefits up to 1 month after the treatment.
The role for the use of acupuncture in menstrual migraine treatment is still unclear; a metaanalyses of 13 studies with 826 subjects failed to show the true acupuncture was superior to the sham acupuncture in reducing monthly migraine frequency and duration, average headache intensity, and analgesic use at the completion of treatment or follow-up (73). Further research is needed for more supportive evidences before the acupuncture can be recommended in the treatment of menstrual migraine.
Tension-type headache. The role of acupuncture in tension-type headache is unclear. A study in Cochrane Database of Systematic Reviews evaluated 12 trials with 2349 participants (33). Seven trials compared acupuncture with sham acupuncture, a small but significant reduction of headache frequency over sham over a period of 6 months. The benefits of acupuncture over sham acupuncture were also found for response, with 52% of responders in the acupuncture group versus 43% in the sham group, but no statistically significant difference was mentioned. A randomized, placebo-controlled, crossover design study evaluated 18 patients and found that the acupuncture group had significantly more pain relief than the sham-needling group (18). White and colleagues completed a multicenter, randomized, controlled trial on 50 patients (68). The study found that patients in both the true and sham groups experienced a significant headache reduction during the course of treatment, but no significant difference existed between these 2 groups. A randomized, placebo-controlled study by Karst and colleagues found a significant but weak improvement in quality of life parameters (clinical global impressions, Nottingham Health Profile) after the true treatment group, but no significant difference between true and sham acupuncture in reduction of headache severity and frequency, despite a 5-month follow-up (25). In a multicenter, sham-controlled, patient- and observer-blinded, randomized study on 407 patients, ten 30-minute sessions were given over a 6-week period (08). At the 6-month follow-up, 33% of patients who received true acupuncture achieved 50% or greater headache frequency reduction, compared to 27% in the sham group. The difference was insignificant (P=0.18); however, the reduction of headache days was significantly better in the real acupuncture group (P=0.004). A randomized, sham-controlled, crossover trial was conducted on 34 patients with chronic tension-type headache (03). The study found that electroacupuncture is superior to sham intervention by reducing 60% of head pain from the baseline versus 38% in the sham group (P=0.005) after 10 sessions of treatment within 5 weeks. Electroacupuncture analgesia is associated with increased serum brain-derived neurotrophic factor, implying the involvement of central nervous system neuroplasticity.
Chronic headache. Sun and Gan conducted a systematic review of clinical trials from years 1966 to 2007 to evaluate acupuncture for the management of chronic headache (54). Thirty-one studies were reviewed, including migraine (n=17), tension-type headache (n=10), or mixed headache (n=4). The majority of included trials comparing true acupuncture and sham acupuncture showed a trend in favor of acupuncture. In 14 trials, the combined data demonstrated a statistically significant higher responder rate in the acupuncture group compared to the sham group (53% vs. 45%) during the period of 8 weeks to 3 months after the randomization. Pooled data from 7 trials showed a 62% responder rate in acupuncture group compared to 45% in medication (propranolol, ergot, metoprolol, flunarizine, etc.) group during the same follow-up period; the difference was statically significant.
Cluster headache. Extremely little information is available on the effect of acupuncture in cluster headache. Gwan reported a single case relieved by acupuncture (17). In a small study, acupuncture significantly raised CSF metenkephalin levels, but only improved symptoms in 2 out 7 patients (19).
Other types of headache. In a controlled cross-over study of 41 patients with both migraine and tension headache, Loh and colleagues found more patients benefited from acupuncture than medication treatment (59% vs. 25%) (36). Acupuncture for frontal and orbital headache was also reported as being helpful in noncontrolled studies (69; 31).
In a survey of 78 acupuncturists involving 31,822 consultations, a total of 2178 adverse events or side effects for an incidence of 684 per 10,000 were reported (67). The most common side effects, including bleeding, needling pain, aggravation of symptoms, and aggravation followed by resolution of symptoms, were reported in 70% of the cases.
Melchart’s group conducted a prospective investigation of adverse effects of acupuncture in 97,733 patients from July 2001 through April 2002, involving 9429 German physicians (38). The number of acupuncture treatment sessions exceeded 760,000. A total of 6936 mild adverse events (7.10%) were reported. The reported mild adverse events in the order of frequency were needling pain, hematoma, bleeding, orthostatic problems, forgotten needles, and others (local skin irritation, deterioration of symptoms, headache, and fatigue). Five serious adverse effects were noted in 6 patients. Two patients developed pneumothorax. The other 4 adverse effects reported were an exacerbation of depression, an acute hypertensive crisis, a vasovagal reaction, and an acute asthma attack with angina and hypertension. In another study on 1968 patients who received acupuncture treatment in clinical trials, 74 patients (3.76%) suffered at least 1 adverse event (83). The most common adverse events were subcutaneous hematoma and hemorrhage in the needling points. The older patients and male gender had a higher risk of the occurrence of adverse events.
Mild adverse effects, in general, will resolve within 1 to 2 days, with no specific care needed. Local compression to the acupoint immediately after the needle removal can reduce the risk of bleeding or hematoma. Pneumothorax is the most frequent serious complication in the category of organ trauma (09). The acupuncture practitioner should be very familiar with the chest wall and mid back anatomy to avoid inserting the needle too deeply to puncture the lung. AIDS and hepatitis can also be transmitted (09), however, the current use of 1-time disposal needles in acupuncture treatment has significantly reduced the risk of cross-infection.
The long-term prognosis of acupuncture on headache is still under investigation. In Vincent’s study of patients with chronic migraine, significant reduction of pain intensity and medication number was found immediately posttreatment compared to the sham group (65). The effect remained at follow-up of 4 months and 1 year. It is unclear whether the improvement remains significantly better than the sham group at time of follow-up. Another randomized, placebo-controlled study of 30 patients with tension-type headache showed that acupuncture reduced the frequency of headaches, analgesic consumption, and the headache pain index at follow-up of 1 and 12 months, compared to baseline, but not compared with the sham group (59). Vickers’ study demonstrated continuing headache relief and functional and health status improvement at 12-month follow-up (63).
Pregnancy. Acupuncture can be used to treat nausea and vomiting in early pregnancy (26; 50) and is considered safe (51). There are few data regarding the safety of using acupuncture for headache in pregnant women. Acupuncture practitioners should know that certain acupoints, such as large intestine meridian 4 and spleen meridian 6, are contraindicated for pregnant women (20); large intestine meridian 4 and spleen meridian 6 are otherwise commonly used acupoints for headache management (36; 68; 02). These 2 points may be used to assist induction of labor at term and preparation of first trimester abortion probably due to the effect of supporting cervical ripening at term (45) and increasing cervical dilation in the first trimester (75). If an acupuncturist does not feel comfortable using acupuncture for pregnant patients, he or she may use the other nonpharmacological treatment alternatives, such as relaxation techniques, biofeedback, and physical therapy. These modalities are considered safe and effective to treat headache in pregnant women (22; 48).
Anesthesia. Acupuncture analgesia has been proposed to mediate by the presynaptic inhibition of afferent pain transmission in the dorsal horn through the gate-control mechanism, release of beta-endorphin binding to the mu opioid receptor, and release of serum magnesium blocking the NMDA-receptor (43; 80). Two acupoints, large intestine meridian point 4 (Li 4) and lung point 7 (Lu 7), are often used in the acupoint selection for the treatment of headache. Li 4 has long been documented in traditional Chinese acupuncture literature to relieve the orofacial pain, and Lu 7 for head and neck pain.
Pediatric patients. The literature of acupuncture treatment in the pediatric population is limited, particularly high quality randomized controlled trials. Gottschling and colleagues conducted a double-blind, randomized, bicenter, placebo-controlled trial to investigate the headache day change after receiving active laser acupuncture versus placebo laser acupuncture treatment (15). At 4 months after the randomization, the mean headache days per month decreased significantly by 6.4 days in the treated group (P < 0.001) and by 1.0 days in the placebo group (P = 0.22) compared to the baseline.
Geriatric patients. The age of patients selected for the studies of acupuncture treatment for headache are typically in wide range, from young adult to elderly. Thus, there is insufficient evidence available for discussion.
Genetically vulnerable patients. After a careful MEDLINE search, there is no literature about acupuncture treatment of headache in genetically vulnerable patients available for discussion.
Patients with impaired renal function. After a careful MEDLINE search, there is no literature about acupuncture treatment of headache in patients with impaired renal function available for discussion.
Patient 1. A 47-year-old Caucasian man with a 10-year history of episodic migraine complained of recurrent bilateral throbbing headache in the temporal region. He used to suffer from 3 to 5 headache attacks per month. Each attack lasted 4 to 8 hours. The headache score was 6 to 8 at the 10-point VAS scale, with nausea, light, and noise hypersensitivity. No visual aura was reported prior to the headache onset. The headache was triggered by lack of sleep and stress, and relieved by staying in the dark and quiet room. The International Headache Society diagnosis was episodic migraine without aura. The patient requested a trial of acupuncture for headache abortion. Inspection of the tongue revealed deep red body with thin yellow coating. In Chinese medicine, his headache history, symptoms, and signs are consistent with the diagnosis of a flare-up of liver-fire and hyperactivity of liver (53). The treatment principle is to restore the balance of yin and yang by draining the excessive Yang and supplementing the deficiency of yin. Using a draining technique, bilateral yang points extraordinary head and neck point 5 (EX-HN 5, Taiyang) at temporal regions were suppressed. Yin points to spleen meridian point 6 (SP 6) and liver meridian point 3 (Liv 3) were strengthened using the tonifying technique. An empirical point for headache and orofacial pain, large intestine meridian point 4 (Li 4), and several local tender points in the head were also drained. All the needles were manually twisted for 20 seconds, 5 minutes apart, and they remained in the body for 25 minutes. The patient reported significant headache relief after 5 minutes of needling and fell asleep afterward. He was headache-free at the end of the treatment session.
Patient 2. A 45-year-old Caucasian man presented to the headache center for 20-year history of chronic tension-type headache. The pain was described as mild to moderate (visual analogue scale score 3 to 7) in severity, band-like and pressing. The pain used to build up late in the day and was aggravated by stress. No nausea, vomiting, phonophobia, photophobia, and analgesics overuse were reported. Physical exam only revealed tenderness at bilateral temporal regions. The headache symptoms and tongue inspection (red and dry body with little coating) was consistent with a diagnosis of deficiency of “kidney essence” (Kidney yin deficiency) in Chinese medicine (53). The treatment principle was to rebalance the yin and yang. The yang points of EX-HN 3, bilateral EX-HN5, and LI4 were drained for the relatively excessive yang. Yin points of bilateral SP6 and KI 3 were tonified to supplement the yin and essence. During a retention time of 20 minutes, all the needles were either drained or tonified for 10 seconds, 5 minutes apart. The visual analogue scale score went down from 4 to 1 after the treatment. After a total of 8 sessions of acupuncture (2 times per week), he was discharged from the clinic with a daily pain score of 0.
Patient 3. A 62-year-old Caucasian man with a 40-year history of episodic cluster headache presented to a headache center for recurrence. During the cycle, his headache used to start 1 hour after sleep with each episode lasting 15 to 45 minutes. There were 3 to 5 episodes per day. Each cycle lasted 3 to 4 months. There were 1 to 2 cycles per year. During a recent cycle, he was treated with acupuncture 2 times per week for 10 sessions. He had no cluster attack following the second treatment session, despite the fact that he purposefully attempted to provoke an attack by drinking alcohol. He presented to the headache center again with recurrence of the headache 1 month after the last session of acupuncture treatment. His headache was building at the time of examination. His visual analogue scale score went up from 3 to 7 within 5 minutes, with a left-side red and watery eye and ptosis. Physical exam found painful spots at the left-side infraorbital region, lateral canthus, splenius capitis muscle, and semispinalis capitis muscle. The pain location and quality, and red tongue with yellowish coating were consistent with a diagnosis of hyperactivity of stomach-fire (excessive yang of stomach) (53). The treatment principle was to rebalance the yin and yang. Draining technique was applied to the yang points of stomach meridian 2, bladder meridian 10, and gallbladder meridian 20, as well as the Ashi points at the orbital-frontal regions. The yin point spleen meridian 6 and kidney meridian 3 were tonified. Each point was manipulated for 10 to 20 seconds alternatively and the pain score went down to 0 within 5 minutes of needling. The autonomic symptoms resolved at the same time. After 2 treatment sessions, the attack frequency remained the same but with a 50% reduction in attack intensity and duration. He requested resuming western medical therapy, despite the trend of improvement, due to financial concerns.