J Rheumatol. 2006 May;33(5):957-67.Click here to read Links
Medicinal and injection therapies for mechanical neck disorders: a Cochrane systematic review.
* Peloso PM,
* Gross AR,
* Haines TA,
* Trinh K,
* Goldsmith CH,
* Aker P.
Amgen Inc., Thousand Oaks, California, USA. email@example.com
OBJECTIVE: To systematically review randomized trials on medicines and injections used to improve pain, function/disability,
and patient satisfaction in adults with mechanical neck disorders (MND) with or without associated headache or radicular findings.
METHODS: We searched CENTRAL (Issue 4, 2002), and MEDLINE, EMBASE, MANTIS, CINHAL from their start to March 2003. Two authors
independently selected articles, abstracted data, and assessed methodological quality using the Jadad criteria. When clinical
heterogeneity was absent, we combined studies using random-effects metaanalysis models. RESULTS: Thirty-two selected trials
had an overall methodological quality of mean 3.2/5. For acute whiplash, administering intravenous methylprednisolone within
8 hours reduced pain at one week [SMD -0.90 (95% CI -1.57 to -0.24)], and sick leave but not pain at 6 months compared to
placebo. For chronic MND at short-term followup, intramuscular injection of lidocaine was superior to placebo [SMD 1.36 (95%
CI -1.93 to -0.80)]. In chronic MND with radicular findings, epidural methylprednisolone and lidocaine reduced neck pain [SMD
-1.46 (95% CI -2.16 to -0.76)] and improved function at one-year followup compared to the intramuscular route. In subacute/chronic
MND, we found conflicting evidence for oral psychotropic agents. In chronic MND with or without radicular findings or headache,
there was moderate evidence from 5 high quality trials showing that botulinum toxin (Botox A) intramuscular injections were
not better than saline in improving pain [SMD pooled -0.39 (95% CI -1.25 to 0.47)], disability, or global perceived effect.
CONCLUSION: Intramuscular injection of lidocaine for chronic MND and intravenous injection of methylprednisolone for acute
whiplash were effective treatments. There was limited evidence of effectiveness of epidural injection of methylprednisolone
and lidocaine for chronic MND with radicular findings. Muscle relaxants and nonsteroidal antiinflammatory drugs have unclear
benefits. There was moderate evidence that Botox-A intramuscular injections for chronic MND were not better than saline.
PMID: 16652427 [PubMed - indexed for MEDLINE]
J Athl Train. 2006 Jan-Mar;41(1):117-9.Click here to read Links
Does McKenzie therapy improve outcomes for back pain?
* Busanich BM,
* Verscheure SD.
University of Oregon, Department of Human Physiology, Eugene, OR 97403, USA. firstname.lastname@example.org
CLINICAL QUESTION: What is the clinical evidence base for McKenzie therapy in management of back pain? DATA SOURCES:
Studies were identified using a computer-based literature search of 7 databases: MEDLINE, EMBASE, DARE, CINAHL, PEDro, the
Cochrane Register of Clinical Trials (CENTRAL), and the Cochrane Database of Systematic Reviews. Search terms included McKenzie
therapy, McKenzie treatment, and McKenzie method. Studies published before September 2003 were eligible. STUDY SELECTION:
To be included in the review, each study had to fulfill the following criteria: (1) the study was a randomized or quasi-randomized
controlled trial, (2) the subjects' primary complaint was nonspecific low back pain or neck pain with or without radiation
to the extremities, (3) the authors investigated the efficacy of the McKenzie method/McKenzie treatment in comparison with
no treatment, sham treatment, or another treatment, (4) individualized patient treatment and treatment were specified according
to McKenzie principles, and (5) the authors reported at least one of the outcome measures of pain, disability, quality of
life, work status, global perceived effect, medication use, medical visits, or recurrence. Studies were included with no language
restriction and with subjects of all age groups, of either sex, and with any duration of symptoms. Studies were excluded if
subjects had any of the following spinal conditions: cauda equina syndrome, cord compression, infection, fracture, neoplasm,
inflammatory disease, pregnancy, any form of headache, whiplash-associated disorders, vertigo/dizziness, or vertebrobasilar
insufficiency. DATA EXTRACTION: Data were independently extracted from each study by 2 investigators using a standardized
data extraction form. The standardized data extraction form and experience level of the investigators were not included in
the review. In studies with more than 2 treatment groups, the treatment contrast of more relevance to current Australian physiotherapy
was selected. Data were also extracted for short-, intermediate-, and long-term follow-up based on the criteria suggested
by the Cochrane Back Review Group. Short-term follow-up was defined as less than 3 months from onset of treatment. Intermediate-term
follow-up was defined as at least 3 months and less than 12 months from onset of treatment. Long-term follow-up was defined
as equal to or greater than 12 months. All eligible studies were rated for methodologic quality using the PEDro scale. The
PEDro scale is a checklist that examines the "believability and the interpretability of trial quality."(1) The 11-item
checklist yields a maximum score of 10 if all criteria are satisfied. The first item on the scale (Eligibility Criteria) is
not scored. The PEDro scores were extracted from the PEDro database. If a study had not been entered into the database and
scored, it was reviewed and scored by an experienced PEDro rater. MAIN RESULTS: Normalized data for pain and disability were
given possible total scores of 100. The article's scores on the PEDro scale were average, ranging from 4 to 8 of 10. The most
common flaw in the methods, which occurred in all 6 studies, was the failure to blind both the patient and therapist. Four
of the 6 did not blind the researcher interpreting the data. For both pain and disability at short-term (<3 months) follow-up,
individual study results for low back pain favored McKenzie therapy compared with the following: nonsteroidal anti-inflammatory
drugs, educational booklet, back massage with back care advice, strength training with therapist supervision, spinal mobilization,
or general mobility exercises. Trends favored McKenzie therapy at intermediate-term (3-12 months) follow-up for pain and disability,
as well as work absences. The McKenzie treatment group in the cervical spine study had less pain and disability at both short-
and intermediate-term follow-up than did the exercise group, although the effect sizes were small. The same McKenzie treatment
group tended to have fewer health care contacts in the ensuing 12 months than the comparison exercise group. The results suggest
that McKenzie therapy provides a reduction in short-term pain (mean reduction of 8.6 on a 100-point scale) compared with the
therapies mentioned above. A second (sensitivity) analysis was conducted to include data from 3 studies that were initially
excluded because of lack of individualized treatment. The sensitivity analysis was used to determine if the exclusion of these
studies would significantly alter the conclusion of the review. Instead, the sensitivity analysis strengthened the evidence
supporting the notion that McKenzie therapy is more effective in short-term pain relief than other therapies (reduction of
11.4 on a 100-point scale). CONCLUSIONS: This review provides evidence that McKenzie therapy results in a decrease in short-term
(<3 months) pain and disability for low back pain patients compared with other standard treatments, such as nonsteroidal
anti-inflammatory drugs, educational booklet, back massage with back care advice, strength training with therapist supervision,
and spinal mobilization. No statistical differences were found between McKenzie therapy and other therapies at intermediate-term
(3-12 months) follow-up. Data are insufficient on long-term (>12 months) outcomes or outcomes other than pain and disability
(eg, quality of life). To date, no authors have compared McKenzie therapy with placebo or no treatment. Also, few data are
available on the McKenzie method and its effect on neck pain. Future researchers should focus on these issues.
PMID: 16619104 [PubMed]
Spine J. 2004 May-Jun;4(3):335-56.Click here to read Links
Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence
* Bronfort G,
* Haas M,
* Evans RL,
* Bouter LM.
Department of Research, Wolfe-Harris Center for Clinical Studies, Northwestern Health Sciences University, 2501 W,
84th Street Bloomington, MN 55431, USA. email@example.com
BACKGROUND CONTEXT: Despite the many published randomized clinical trials (RCTs), a substantial number of reviews
and several national clinical guidelines, much controversy still remains regarding the evidence for or against efficacy of
spinal manipulation for low back pain and neck pain. PURPOSE: To reassess the efficacy of spinal manipulative therapy (SMT)
and mobilization (MOB) for the management of low back pain (LBP) and neck pain (NP), with special attention to applying more
stringent criteria for study admissibility into evidence and for isolating the effect of SMT and/or MOB. STUDY DESIGN: RCTs
including 10 or more subjects per group receiving SMT or MOB and using patient-oriented primary outcome measures (eg, patient-rated
pain, disability, global improvement and recovery time). METHODS: Articles in English, Danish, Swedish, Norwegian and Dutch
reporting on randomized trials were identified by a comprehensive search of computerized and bibliographic literature databases
up to the end of 2002. Two reviewers independently abstracted data and assessed study quality according to eight explicit
criteria. A best evidence synthesis incorporating explicit, detailed information about outcome measures and interventions
was used to evaluate treatment efficacy. The strength of evidence was assessed by a classification system that incorporated
study validity and statistical significance of study results. Sixty-nine RCTs met the study selection criteria and were reviewed
and assigned validity scores varying from 6 to 81 on a scale of 0 to 100. Forty-three RCTs met the admissibility criteria
for evidence. RESULTS: Acute LBP: There is moderate evidence that SMT provides more short-term pain relief than MOB and detuned
diathermy, and limited evidence of faster recovery than a commonly used physical therapy treatment strategy. Chronic LBP:
There is moderate evidence that SMT has an effect similar to an efficacious prescription nonsteroidal anti-inflammatory drug,
SMT/MOB is effective in the short term when compared with placebo and general practitioner care, and in the long term compared
to physical therapy. There is limited to moderate evidence that SMT is better than physical therapy and home back exercise
in both the short and long term. There is limited evidence that SMT is superior to sham SMT in the short term and superior
to chemonucleolysis for disc herniation in the short term. However, there is also limited evidence that MOB is inferior to
back exercise after disc herniation surgery. Mix of acute and chronic LBP: SMT/MOB provides either similar or better pain
outcomes in the short and long term when compared with placebo and with other treatments, such as McKenzie therapy, medical
care, management by physical therapists, soft tissue treatment and back school. Acute NP: There are few studies, and the evidence
is currently inconclusive. Chronic NP: There is moderate evidence that SMT/MOB is superior to general practitioner management
for short-term pain reduction but that SMT offers at most similar pain relief to high-technology rehabilitative exercise in
the short and long term. Mix of acute and chronic NP: The overall evidence is not clear. There is moderate evidence that MOB
is superior to physical therapy and family physician care, and similar to SMT in both the short and long term. There is limited
evidence that SMT, in both the short and long term, is inferior to physical therapy. CONCLUSIONS: Our data synthesis suggests
that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment
of both low back pain and NP. There have been few high-quality trials distinguishing between acute and chronic patients, and
most are limited to shorter-term follow-up. Future trials should examine well-defined subgroups of patients, further address
the value of SMT and MOB for acute patients, establish optimal number of treatment visits and consider the cost-effectiveness
PMID: 15125860 [PubMed - indexed for MEDLINE]
J R Soc Med. 2006 Apr;99(4):192-6.Click here to read Click here to read Links
J R Soc Med. 2006 Jun;99(6):277-8, author reply 279-80.
J R Soc Med. 2006 Jun;99(6):277; author reply 279-80.
J R Soc Med. 2006 Jun;99(6):278-9; author reply 279-80.
J R Soc Med. 2006 Jun;99(6):278; author reply 279-80.
A systematic review of systematic reviews of spinal manipulation.
* Ernst E,
* Canter PH.
Complementary Medicine, Peninsula Medical School, Universities of Exeter & Plymouth, 25 Victoria Park Road, Exeter
EX2 4NT, UK. Edzard.Ernst@pms.ac.uk
OBJECTIVES: To systematically collate and evaluate the evidence from recent systematic reviews of clinical trials
of spinal manipulation. DESIGN: Literature searches were carried out in four electronic databases for all systematic reviews
of the effectiveness of spinal manipulation in any indication, published between 2000 and May 2005. Reviews were defined as
systematic if they included an explicit and repeatable inclusion and exclusion criteria for studies. RESULTS: Sixteen papers
were included relating to the following conditions: back pain (n=3), neck pain (n=2), lower back pain and neck pain (n=1),
headache (n=3), non-spinal pain (n=1), primary and secondary dysmenorrhoea (n=1), infantile colic (n=1), asthma (n=1), allergy
(n=1), cervicogenic dizziness (n=1), and any medical problem (n=1). The conclusions of these reviews were largely negative,
except for back pain where spinal manipulation was considered superior to sham manipulation but not better than conventional
treatments. CONCLUSIONS: Collectively these data do not demonstrate that spinal manipulation is an effective intervention
for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable
PMID: 16574972 [PubMed - indexed for MEDLINE]
J Orthop Sports Phys Ther. 2006 Mar;36(3):160-9. Links
Methodological quality of randomized controlled trials of spinal manipulation and mobilization in tension-type headache,
migraine, and cervicogenic headache.
* Fernandez-de-las-Penas C,
* Alonso-Blanco C,
* San-Roman J,
* Miangolarra-Page JC.
Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos,
Alcorcon, Madrid, Spain. firstname.lastname@example.org
STUDY DESIGN: Literature review of quality of clinical trials. OBJECTIVE: To determine the methodological quality
of published randomized controlled trials that used spinal manipulation and/or mobilization to treat patients with tension-type
headache (TTH), cervicogenic headache (CeH), and migraine (M) in the last decade. BACKGROUND: TTH, CeH, and M are the most
prevalent types of headaches seen in adults. Individuals who have headaches frequently use physical therapy, manual therapy,
or chiropractic care. Randomized controlled trials are considered an optimal method with which to assess the efficacy of any
intervention. METHODS: Computerized literature searches were performed in MEDLINE, EMBASE, COCHRANE, AMED, MANTIS, CINHAL,
and PEDro databases. Randomized controlled trials in which spinal manipulation and/or mobilization had been used for TTH,
CeH, and M published in a peer-reviewed journal as full text, and with at least 1 clinically relevant outcome measure (ie,
headache intensity, duration, or frequency) were reviewed. The methodological quality of the studies was assessed independently
by 2 reviewers using a set of predefined criteria. RESULTS: Only 8 studies met all the inclusion criteria. One clinical trial
evaluated spinal manipulation and mobilization together, and the remaining 7 assessed spinal manipulative therapy. No controlled
trials analyzing exclusively the effects of spinal mobilization were found. Methodological scores ranged from 35 to 56 points
out of a theoretical maximum of 100 points, indicating an overall poor methodology of the studies. Only 2 studies obtained
a high-quality score (greater than 50 points). No significant differences in quality scores were found based on the type of
headache investigated. Methodological quality was not associated with the year of publication (before 2000, or later) nor
with the results (positive, neutral, negative) reported in the studies. The most common flaws were a small sample size, the
absence of a placebo control group, lack of blinded patients, and no description of the manipulative procedure. CONCLUSIONS:
There are few published randomized controlled trials analyzing the effectiveness of spinal manipulation and/or mobilization
for TTH, CeH, and M in the last decade. In addition, the methodological quality of these papers is typically low. Clearly,
there is a need for high-quality randomized controlled trials assessing the effectiveness of these interventions in these
PMID: 16596892 [PubMed - indexed for MEDLINE]
Spine. 2005 Nov 1;30(21):E641-8.Click here to read Links
A Cochrane review of electrotherapy for mechanical neck disorders.
* Kroeling P,
* Gross AR,
* Goldsmith CH;
* Cervical Overview Group.
Ludwig-Maximilians-University, Munich, Germany. email@example.com
STUDY DESIGN: Systematic review. OBJECTIVE: To assess whether electrotherapy relieves pain or improves function/disability
in adults with mechanical neck disorders (MND). SUMMARY OF BACKGROUND DATA: The effectiveness of electrotherapy as a physiotherapy
option has remained unclear. METHODS: Databases were searched from root to March 2003. Independent reviewers conducted selection,
data abstraction, and quality assessment. Relative risk and standard mean differences were calculated. RESULTS: Fourteen comparisons
were included. For the pain outcome, we found limited evidence of benefit, ie, pulsed electromagnetic field (PEMF) therapy
resulted in only immediate post-treatment pain relief for chronic MND and acute whiplash (WAD). Other findings included unclear
or conflicting evidence (Galvanic current for acute or chronic occipital headache; iontophoresis for acute, subacute WAD;
TENS for acute WAD, chronic MND; PEMF for medium- or long-term effects in acute WAD, chronic MND); and limited evidence of
no benefit (diadynamic current for reduction of trigger point tenderness in chronic MND, cervicogenic headache; permanent
magnets for chronic MND; electrical muscle stimulation (EMS) for chronic MND). CONCLUSIONS: In pain as well as other outcomes,
the evidence for treatment of acute or chronic MND by different forms of electrotherapy is either lacking, limited, or conflicting.
PMID: 16261102 [PubMed - indexed for MEDLINE]
J Neurol. 2005 Oct;252(10):1147-54. Epub 2005 Aug 4.Click here to read Links
Conservative treatments of children with episodic tension-type headache. A systematic review.
* Verhagen AP,
* Damen L,
* Berger MY,
* Passchier J,
* Merlijn V,
* Koes BW.
Department of General Practice, Erasmus Medical Center, 1738, 3000 DR, Rotterdam, The Netherlands. firstname.lastname@example.org
OBJECTIVE: We aimed to assess the effectiveness of conservative treatments in children with tension-type headaches
(TTH). METHOD: We searched Medline, Embase and the Cochrane Library and performed reference checking. Two independent authors
assessed trial quality and extracted data. Analysis was carried out according to type of intervention. RESULTS: In total we
included 11 trials (427 TTH patients, age between 7-18 years) in this review. None of the studies were considered to be of
high quality. Eight studies evaluated the effectiveness of relaxation training. Four studies included a waiting list or no
treatment control group and in one study a placebo was used. CONCLUSION: We found conflicting evidence about the effectiveness
of relaxation therapy when compared with no treatment or other treatments, with Relative Risks varying from 1.4 (0.6-3.2)
to 10.6 (1.6-71.3). With regard to all other interventions evaluated (such as biofeedback, cognitive therapy or flupirtin)
no evidence is found for or against their effectiveness.
PMID: 16047110 [PubMed - indexed for MEDLINE]
Cochrane Database Syst Rev. 2005 Jul 20;(3):CD005454.Click here to read Links
Antidepressants for neuropathic pain.
* Saarto T,
* Wiffen PJ.
Cancer Center, Helsinki University Central Hospital, Haartmaninkatu 4, P O Box 180, Helsinki, Finland, FIN-00029.
BACKGROUND: For many years antidepressant drugs have been used to manage neuropathic pain, and are often the first
choice treatment. It is not clear, however, which antidepressant is more effective, what role the newer antidepressants can
play in treating neuropathic pain, and what adverse effects are experienced by patients. OBJECTIVES: To determine the analgesic
effectiveness and safety of antidepressant drugs in neuropathic pain. Migraine and headache studies were not considered. SEARCH
STRATEGY: Randomised trials of antidepressants in neuropathic pain were identified in MEDLINE (1966 to Dec 2003); EMBASE (1980
to Dec 2003); the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library 2004, Issue 1; and the
Cochrane Pain, Palliative and Supportive Care Trials Register (May 2002). Additional reports were identified from the reference
list of the retrieved papers, and by contacting investigators. SELECTION CRITERIA: Randomised trials reporting the analgesic
effects of antidepressant drugs in adult patients, with subjective assessment of pain of neuropathic origin. Studies that
included patients with chronic headache and migraine were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers agreed the
included studies, extracted data, and assessed methodological quality independently. Fifty trials of 19 antidepressants were
considered eligible (2515 patients) for inclusion. Relative Risk (RR) estimates and Number-Needed-to-Treat (NNTs) were calculated
from dichotomous data for effectiveness and adverse effects. MAIN RESULTS: Tricyclic antidepressants (TCAs) are effective
treatments for the treatment of neuropathic pain.Amitriptyline has an NNT of 2 (95%CI 1.7 to 2.5) RR 4.1(95%CI 2.9-5.9) for
the achievement of at least moderate pain relief. There is limited evidence for the effectiveness of the newer selective serotonin
reuptake inhibitor antidepressant drugs (SSRIs). There were insufficient data for an assessment of evidence of effectiveness
for other antidepressants such as St Johns Wort, venlafaxine and L-tryptophan. For diabetic neuropathy the NNT for effectiveness
was 1.3 (95%CI 1.2 to 1.5) RR 12.4(95%CI 5.2-29.2) (five studies); for postherpetic neuralgia 2.2 (95%CI 1.7 to 3.1), RR 4.8(95%CI
2.5-9.5)(three studies). There was evidence that TCAs are not effective in HIV-related neuropathies. The number needed to
harm(NNH) for major adverse effects defined as an event leading to withdrawal from a study was 16 (95%CI: 10-45). The NNH
for minor adverse effects was 4.6 (95%CI 3.3-6.7) AUTHORS' CONCLUSIONS: Antidepressants are effective for a variety of neuropathic
pains. The best evidence available is for amitriptyline. There are only limited data for the effectiveness of SSRIs. It is
not possible to identify the most effective antidepressant until more studies of SSRIs are conducted.
PMID: 16034979 [PubMed - indexed for MEDLINE]
Cochrane Database Syst Rev. 2005 Jul 20;(3):CD002919.Click here to read Links
Selective serotonin re-uptake inhibitors (SSRIs) for preventing migraine and tension-type headaches.
* Moja PL,
* Cusi C,
* Sterzi RR,
* Canepari C.
Centro Cochrane Italiano, Istituto Mario Negri, Via Eritrea, 62, Milano, Italy, 20157. email@example.com
BACKGROUND: Headache is a common medical problem. In view of recent discoveries about the role of serotonin in pain
mechanisms, selective serotonin re-uptake inhibitors (SSRIs) have been evaluated for the prevention of migraine and tension-type
headaches (TTH). OBJECTIVES: To evaluate the efficacy and tolerability of SSRIs for preventing migraine and TTH. SEARCH STRATEGY:
We searched MEDLINE (1966-2004), EMBASE (1994-2003), the Cochrane Central Register of Controlled Trials (Issue 4, 2003), and
reference lists of retrieved articles. Headache Quarterly was hand searched from 1990 to 2003. SELECTION CRITERIA: We included
randomised controlled trials comparing SSRIs with any type of control intervention in patients of either sex, over 18 years
of age, with migraine or TTH. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data (headache frequency,
index, severity, and duration; use of symptomatic/analgesic medication; days off work; quality of life; mood improvement;
cost-effectiveness; and adverse events) and assessed the methodological quality of trials. MAIN RESULTS: Thirteen studies
utilizing five SSRIs met the inclusion criteria (636 participants). Most of the included studies had methodological and/or
reporting shortcomings; follow up rarely extended beyond 3 months.After 2 months SSRIs did not significantly lower headache
index scores in patients with migraine when compared to placebo (SMD -0.14; 95% CI -0.57 to 0.30). Patients with chronic TTH
treated with an SSRI had a significantly higher analgesic intake of 5 more doses per month when compared to patients treated
with a tricyclic antidepressant (WMD 4.98; 95% CI 1.12 to 8.84). Tricyclics also significantly reduced headache duration by
1.26 hours per day (WMD 1.26; 95% CI 0.06 to 2.45) and marginally reduced headache indexes (SMD 0.42; 95% CI 0.00 to 0.85)
when compared to SSRIs in patients with chronic TTH. When the data on adverse events were considered without regard to headache
diagnostic subgroups, there were no significant differences between SSRIs and placebo for withdrawals due to adverse events
(Peto OR 1.02; 95% CI 0.31 to 3.34). For minor adverse events, SSRIs were generally more tolerable than tricyclics (OR 0.34;
95% CI 0.13 to 0.92). However, there were no differences in the number of patients withdrawing due to any reason in the SSRI
and tricyclic groups (OR 1.01; 95% CI 0.56 to 1.80). AUTHORS' CONCLUSIONS: Over 2 months of treatment, SSRIs are no more efficacious
than placebo in patients with migraine. In patients with chronic TTH, SSRIs are less efficacious than tricyclic antidepressants.
In comparison with SSRIs, the burden of adverse events in patients receiving tricyclics was greater. These results are based
on short-term trials and may not generalise to longer-term treatment.
PMID: 16034880 [PubMed - indexed for MEDLINE]
Headache. 2005 Jun;45(6):738-46.Click here to read Links
Physical treatments for headache: a structured review.
* Biondi DM.
Harvard Medical School, Boston, MA, USA.
BACKGROUND: Primary headache disorders, especially migraine, are commonly accompanied by neck pain or other symptoms.
Because of this, physical therapy (PT) and other physical treatments are often prescribed. This review updates and synthesizes
published clinical trial evidence, systematic reviews, and case series regarding the efficacy of selected physical modalities
in the treatment of primary headache disorders. METHODS: The National Library of Medicine (MEDLINE), The Cochrane Library,
and other sources of information were searched through June 2004 to identify clinical studies, systematic reviews, case series,
or other information published in English that assessed the treatment of headache or migraine with chiropractic, osteopathic,
PT, or massage interventions. RESULTS: PT is more effective than massage therapy or acupuncture for the treatment of TTH and
appears to be most beneficial for patients with a high frequency of headache episodes. PT is most effective for the treatment
of migraine when combined with other treatments such as thermal biofeedback, relaxation training, and exercise. Chiropractic
manipulation demonstrated a trend toward benefit in the treatment of TTH, but evidence is weak. Chiropractic manipulation
is probably more effective in the treatment of tension-type headache (TTH) than it is in the treatment of migraine. Evidence
is lacking regarding the efficacy of these treatments in reducing headache frequency, intensity, duration, and disability
in many commonly encountered clinical situations. Many of the published case series and controlled studies are of low quality.
CONCLUSIONS AND RECOMMENDATIONS: Further studies of improved quality are necessary to more firmly establish the place of physical
modalities in the treatment of primary headache disorders. With the exception of high velocity chiropractic manipulation of
the neck, the treatments are unlikely to be physically dangerous, although the financial costs and lost treatment opportunity
by prescribing potentially ineffective treatment may not be insignificant. In the absence of clear evidence regarding their
role in treatment, physicians and patients are advised to make cautious and individualized judgments about the utility of
physical treatments for headache management; in most cases, the use of these modalities should complement rather than supplant
better-validated forms of therapy.
PMID: 15953306 [PubMed - indexed for MEDLINE]
Pain. 2004 Dec;112(3):381-8.Click here to read Links
The effectiveness of physiotherapy and manipulation in patients with tension-type headache: a systematic review.
* Lenssinck ML,
* Damen L,
* Verhagen AP,
* Berger MY,
* Passchier J,
* Koes BW.
Department of General Practice, Erasmus MC, University Medical Centre Rotterdam, P.O. Box 1738, 3000 DR Rotterdam,
The study design is a systematic review of randomised clinical trials (RCTs). The objectives of the present study
are to assess the effectiveness of physiotherapy and (spinal) manipulation in patients with tension-type headache (TTH). No
systematic review exists concerning the effectiveness of physiotherapy and (spinal) manipulation primarily focussing on TTH.
Literature was searched using a computerised search of MEDLINE, EMBASE and the Cochrane library. Only RCTs including physiotherapy
and/or (spinal) manipulation used in the treatment of TTH in adults were selected. Two reviewers independently assessed the
methodological quality of the RCTs using the Delphi-list. A study was considered of high quality if it satisfied at least
six points on the methodological quality list. Twelve publications met the inclusion criteria, including three dual or overlapping
publications resulting in eight studies included. These studies showed a large variety of interventions, such as chiropractic
spinal manipulation, connective tissue manipulation or physiotherapy. Only two studies were considered to be of high quality,
but showed inconsistent results. Because of clinical heterogeneity and poor methodological quality in many studies, it appeared
to be not possible to draw valid conclusions. Therefore, we conclude that there is insufficient evidence to either support
or refute the effectiveness of physiotherapy and (spinal) manipulation in patients with TTH.
PMID: 15561394 [PubMed - indexed for MEDLINE]
Spine. 2004 Jul 15;29(14):1541-8.Click here to read Links
Spine. 2005 Jan 1;30(1):166.
A Cochrane review of manipulation and mobilization for mechanical neck disorders.
* Gross AR,
* Hoving JL,
* Haines TA,
* Goldsmith CH,
* Kay T,
* Aker P,
* Bronfort G;
* Cervical Overview Group.
McMaster University, Faculty of Health Sciences, School of Rehabilitation Sciences, Institute of Applied Health Sciences,
Hamilton, Ontario, Canada. firstname.lastname@example.org
STUDY DESIGN AND OBJECTIVES: Our systematic review of randomized trials assessed whether manipulation and mobilization
relieve pain or improve function/disability, patient satisfaction, and global perceived effect in adults with mechanical neck
disorders. SUMMARY OF BACKGROUND DATA: Neck disorders are common, disabling, and costly. METHODS: Computerized bibliographic
databases were searched up to March 2002. Two independent reviewers conducted study selection, data abstraction, and methodologic
quality assessment. Relative risk and standardized mean differences were calculated. In the absence of heterogeneity, pooled
effect measures were calculated using a random effects model. RESULTS: Of the 33 selected trials, 42% were high quality trials.
Single or multiple (3-11) sessions of manipulation or mobilization showed no benefit in pain relief when assessed against
placebo, control groups, or other treatments for acute/subacute/chronic mechanical neck disorders with or without headache.
There was strong evidence of benefit favoring multimodal care (mobilization and/or manipulation plus exercise) over a waiting
list control for pain reduction [pooled standardized mean differences -0.85 (95% CI: -1.20 to -0.50)], improvement in function
[pooled SMD -0.57 (95% CI: -0.94 to -0.21)] and global perceived effect [standardized mean differences -2.73 (95% CI: -3.30
to -2.16)] for subacute/chronic mechanical neck disorders with or without headache. CONCLUSIONS: Mobilization and/or manipulation
when used with exercise are beneficial for persistent mechanical neck disorders with or without headache. Done alone, manipulation
and/or mobilization were not beneficial; when compared to one another, neither was superior. There was insufficient evidence
available to draw conclusions for neck disorder with radicular findings. Factorial design would help determine the active
agent(s) within a treatment mix.
PMID: 15247576 [PubMed - indexed for MEDLINE]
Cochrane Database Syst Rev. 2001;(1):CD001218. Links
Acupuncture for idiopathic headache.
* Melchart D,
* Linde K,
* Fischer P,
* Berman B,
* White A,
* Vickers A,
* Allais G.
Centre for Complementary Medicine Research, Department of Internal Medicine II, Technische Universitat, Kaiserstr.
9, Munich, Germany, 80801. Klaus.Linde@lrz.tu-muenchen.de
BACKGROUND: Acupuncture is widely used for the treatment of headache, but its effectiveness is controversial. OBJECTIVES:
To determine whether acupuncture is: - more effective than no treatment - more effective than 'sham' (placebo) acupuncture
- as effective as other interventions used to treat idiopathic (primary) headaches. SEARCH STRATEGY: Electronic searches were
performed in MEDLINE, EMBASE, the Cochrane Controlled Trials Register, and the database of the Cochrane Field for Complementary
Medicine. We also contacted researchers in the field and checked the bibliographies of all articles obtained. SELECTION CRITERIA:
Randomized or quasi-randomized clinical trials comparing acupuncture with any type of control intervention for the treatment
of idiopathic (primary) headaches were included. DATA COLLECTION AND ANALYSIS: Information on patients, interventions, methods,
and results was extracted by at least two independent reviewers using a pre-tested standard form. Results on headache frequency
and intensity were summarized descriptively. Responder rate ratios (responder rate in treatment group/responder rate in control
group) were calculated as a crude indicator of results for sham-acupuncture-controlled trials. Quantitative meta-analysis
was not possible due to trial heterogeneity and insufficient reporting. MAIN RESULTS: Twenty-six trials including a total
of 1151 patients (median, 37; range, 10-150) met the inclusion criteria. Sixteen trials were conducted among patients with
migraine, six among patients with tension-type headache, and four among patients with various types of headaches. The majority
of trials had methodological and/or reporting shortcomings. In eight of the 16 trials comparing true and sham (placebo) acupuncture
in migraine and tension-type headache patients, true acupuncture was reported to be significantly superior; in four trials
there was a trend in favor of true acupuncture; and in two trials there was no difference between the two interventions. (Two
trials were uninterpretable.) The 10 trials comparing acupuncture with other forms of treatment yielded contradictory results.
REVIEWER'S CONCLUSIONS: Overall, the existing evidence supports the value of acupuncture for the treatment of idiopathic headaches.
However, the quality and amount of evidence are not fully convincing. There is an urgent need for well-planned, large-scale
studies to assess the effectiveness and cost-effectiveness of acupuncture under real-life conditions.
PMID: 11279710 [PubMed - indexed for MEDLINE]
Cephalalgia. 1995 Oct;15(5):337-57.Click here to read Links
Migraine and cluster headache--their management with sumatriptan: a critical review of the current clinical experience.
* Wilkinson M,
* Pfaffenrath V,
* Schoenen J,
* Diener HC,
* Steiner TJ.
City of London Migraine Clinic, UK.
Sumatriptan is a potent and selective agonist at the vascular 5HT1 receptor which mediates constriction of certain
large cranial blood vessels and/or inhibits the release of vasoactive neuropeptides from perivascular trigeminal axons in
the dura mater following activation of the trigeminovascular system. The mode of action of this drug in migraine and cluster
headache is discussed. On the basis of a detailed review of all published trials and available data from post-marketing studies,
the efficacy, safety, tolerability and the place of oral and subcutaneous sumatriptan in the treatment of both conditions
are assessed. A number of double-blind clinical trials have demonstrated that sumatriptan 100 mg administered orally is clearly
superior to placebo in the acute treatment of migraine headache and achieves significantly greater response rates than ergotamine
or aspirin. In other studies, 70 to 80% of patients receiving sumatriptan 6 mg sc experienced relief of migraine headaches
by 1 or 2 h after administration, and patients consistently required less rescue medication for unresolved symptoms. Sumatriptan
was also effective in relieving associated migraine symptoms like nausea and vomiting. Sumatriptan was equally effective regardless
of migraine type or duration of migraine symptoms. Overall, approximately 40% of patients who initially responded to oral
or subcutaneous sumatriptan experienced recurrence of their headache usually within 24 h, effectively treated by a further
dose of this drug. In 75% of patients with cluster headache treated with sumatriptan 6 mg sc, relief was achieved within 15
min. Based on pooled study data, sumatriptan is generally well tolerated and most adverse events are transient. Adverse events
following oral administration include nausea, vomiting, malaise, fatigue and dizziness. With the subcutaneous injection, injection
site reactions occur in approximately 30%. Chest syumptoms are reported in 3 to 5% but have been associated with myocardial
ischaemia only in rare isolated cases. The recommended dosage of sumatriptan at the onset of migraine symptoms is 100 mg orally
or 6 mg subcutaneously. The recommended dosage for cluster headache is 6 mg sumatriptan sc. Sumatriptan must not be given
together with vasoconstrictive substances, e.g., ergotamines, or with migraine prophylactics with similar properties, e.g.,
methysergide. Sumatriptan should not be given during the migraine aura. It is contraindicated in patients with ischaemic heart
disease, previous myocardial infarction, Prinzmetal (variant) angina and uncontrolled hypertension.
PMID: 8536293 [PubMed - indexed for MEDLINE]
Cochrane Database Syst Rev. 2004;(3):CD001878.Click here to read Links
Non-invasive physical treatments for chronic/recurrent headache.
* Bronfort G,
* Nilsson N,
* Haas M,
* Evans R,
* Goldsmith CH,
* Assendelft WJ,
* Bouter LM.
Wolfe-Harris Center for Clinical Studies, Northwestern Health Sciences University, 2501 W 84th St, Bloomington, MN
55431, USA. email@example.com
BACKGROUND: Non-invasive physical treatments are often used to treat common types of chronic/recurrent headache. OBJECTIVES:
To quantify and compare the magnitude of short- and long-term effects of non-invasive physical treatments for chronic/recurrent
headaches. SEARCH STRATEGY: We searched the following databases from their inception to November 2002: MEDLINE, EMBASE, BIOSIS,
CINAHL, Science Citation Index, Dissertation Abstracts, CENTRAL, and the Specialised Register of the Cochrane Pain, Palliative
Care and Supportive Care review group. Selected complementary medicine reference systems were searched as well. We also performed
citation tracking and hand searching of potentially relevant journals. SELECTION CRITERIA: We included randomized and quasi-randomized
controlled trials comparing non-invasive physical treatments for chronic/recurrent headaches to any type of control. DATA
COLLECTION AND ANALYSIS: Two independent reviewers abstracted trial information and scored trials for methodological quality.
Outcomes data were standardized into percentage point and effect size scores wherever possible. The strength of the evidence
of effectiveness was assessed using pre-specified rules. MAIN RESULTS: Twenty-two studies with a total of 2628 patients (age
12 to 78 years) met the inclusion criteria. Five types of headache were studied: migraine, tension-type, cervicogenic, a mix
of migraine and tension-type, and post-traumatic headache. Ten studies had methodological quality scores of 50 or more (out
of a possible 100 points), but many limitations were identified. We were unable to pool data because of study heterogeneity.For
the prophylactic treatment of migraine headache, there is evidence that spinal manipulation may be an effective treatment
option with a short-term effect similar to that of a commonly used, effective drug (amitriptyline). Other possible treatment
options with weaker evidence of effectiveness are pulsating electromagnetic fields and a combination of transcutaneous electrical
nerve stimulation [TENS] and electrical neurotransmitter modulation.For the prophylactic treatment of chronic tension-type
headache, amitriptyline is more effective than spinal manipulation during treatment. However, spinal manipulation is superior
in the short term after cessation of both treatments. Other possible treatment options with weaker evidence of effectiveness
are therapeutic touch; cranial electrotherapy; a combination of TENS and electrical neurotransmitter modulation; and a regimen
of auto-massage, TENS, and stretching. For episodic tension-type headache, there is evidence that adding spinal manipulation
to massage is not effective. For the prophylactic treatment of cervicogenic headache, there is evidence that both neck exercise
(low-intensity endurance training) and spinal manipulation are effective in the short and long term when compared to no treatment.
There is also evidence that spinal manipulation is effective in the short term when compared to massage or placebo spinal
manipulation, and weaker evidence when compared to spinal mobilization.There is weaker evidence that spinal mobilization is
more effective in the short term than cold packs in the treatment of post-traumatic headache. REVIEWERS' CONCLUSIONS: A few
non-invasive physical treatments may be effective as prophylactic treatments for chronic/recurrent headaches. Based on trial
results, these treatments appear to be associated with little risk of serious adverse effects. The clinical effectiveness
and cost-effectiveness of non-invasive physical treatments require further research using scientifically rigorous methods.
The heterogeneity of the studies included in this review means that the results of a few additional high-quality trials in
the future could easily change the conclusions of our review.
PMID: 15266458 [PubMed - indexed for MEDLINE]
BMC Public Health. 2005 Nov 3;5:115.Click here to read Click here to read Links
Homeopathic medical practice: long-term results of a cohort study with 3981 patients.
* Witt CM,
* Ludtke R,
* Baur R,
* Willich SN.
Institute for Social Medicine, Epidemiology and Health Economics, Charite University Medical Center, D-10098 Berlin,
BACKGROUND: On the range of diagnoses, course of treatment, and long-term outcome in patients who chose to receive
homeopathic medical treatment very little is known. We investigated homeopathic practice in an industrialized country under
everyday conditions. METHODS: In a prospective, multicentre cohort study with 103 primary care practices with additional specialisation
in homeopathy in Germany and Switzerland, data from all patients (age > 1 year) consulting the physician for the first
time were observed. The main outcome measures were: Patient and physician assessments (numeric rating scales from 0 to 10)
and quality of life at baseline, and after 3, 12, and 24 months. RESULTS: A total of 3,981 patients were studied including
2,851 adults (29% men, mean age 42.5 +/- 13.1 years; 71% women, 39.9 +/- 12.4 years) and 1,130 children (52% boys, 6.5 +/-
3.9 years; 48% girls, 7.0 +/- 4.3 years). Ninety-seven percent of all diagnoses were chronic with an average duration of 8.8
+/- 8 years. The most frequent diagnoses were allergic rhinitis in men, headache in women, and atopic dermatitis in children.
Disease severity decreased significantly (p < 0.001) between baseline and 24 months (adults from 6.2 +/- 1.7 to 3.0 +/-
2.2; children from 6.1 +/- 1.8 to 2.2 +/- 1.9). Physicians' assessments yielded similar results. For adults and young children,
major improvements were observed for quality of life, whereas no changes were seen in adolescents. Younger age and more severe
disease at baseline were factors predictive of better therapeutic success. CONCLUSION: Disease severity and quality of life
demonstrated marked and sustained improvements following homeopathic treatment period. Our findings indicate that homeopathic
medical therapy may play a beneficial role in the long-term care of patients with chronic diseases.
PMID: 16266440 [PubMed - indexed for MEDLINE]
J Psychosom Res. 2004 Feb;56(2):189-97.Click here to read Links
J Psychosom Res. 2004 Nov;57(5):503; author reply 504.
A randomised, controlled, triple-blind trial of the efficacy of homeopathic treatment for chronic fatigue syndrome.
* Weatherley-Jones E,
* Nicholl JP,
* Thomas KJ,
* Parry GJ,
* McKendrick MW,
* Green ST,
* Stanley PJ,
* Lynch SP.
Medical Care Research Unit, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent
Street, Sheffield S1 4DA, UK. firstname.lastname@example.org
OBJECTIVE: There is no management regime for chronic fatigue syndrome (CFS) that has been found to be universally
beneficial and no treatment can be considered a "cure". Patients with CFS may use complementary and alternative
medicine (CAM). Our aim was to evaluate homeopathic treatment in reducing subjective symptoms of CFS. METHOD: Using a triple-blind
design (patient and homeopath blind to group assignment and data analyst blind to group until after initial analyses to reduce
the possibility of bias due to data analyst), we randomly assigned patients to homeopathic medicine or identical placebo.
One hundred and three patients meeting the Oxford criteria for CFS were recruited from two specialist hospital out patient
departments. Patients had monthly consultations with a professional homeopath for 6 months. Main outcome measures were scores
on the subscales of the Multidimensional Fatigue Inventory (MFI) and proportions of each group attaining clinically significant
improvements on each subscale. Secondary outcome measures were the Fatigue Impact Scale (FIS) and the Functional Limitations
Profile (FLP). Ninety-two patients completed treatment in the trial (47 homeopathic treatment, 45 placebo). Eighty-six patients
returned fully or partially completed posttreatment outcome measures (41 homeopathic treatment group who completed treatment,
2 homeopathic treatment group who did not complete treatment, 38 placebo group who completed treatment, and 5 placebo group
who did not complete treatment). RESULTS: Seventeen of 103 patients withdrew from treatment or were lost to follow-up. Patients
in the homeopathic medicine group showed significantly more improvement on the MFI general fatigue subscale (one of the primary
outcome measures) and the FLP physical subscale but not on other subscales. Although group differences were not statistically
significant on four out of the five MFI subscales (the primary outcome measures), more people in the homeopathic medicine
group showed clinically significant improvement. More people in the homeopathic medicine group showed clinical improvement
on all primary outcomes (relative risk=2.75, P=.09). CONCLUSIONS: There is weak but equivocal evidence that the effects of
homeopathic medicine are superior to placebo. Results also suggest that there may be nonspecific benefits from the homeopathic
consultation. Further studies are needed to determine whether these differences hold in larger samples.
PMID: 15016577 [PubMed - indexed for MEDLINE]
Homeopathy. 2003 Apr;92(2):108-14. Links
Homeopathic treatment of Japanese patients with intractable atopic dermatitis.
* Itamura R,
* Hosoya R.
Department of Dermatology, Obitsu Sankei Hospital, Saitama, Japan. email@example.com
The objective of the study was to evaluate the efficacy of homeopathic treatment of intractable atopic dermatitis
(IAD). Seventeen IAD patients were given individualized homeopathic treatment in addition to conventional dermatological therapy
from 6 months to 2 years and 7 months. Although all of the patients had previously been treated with conventional medicine
and various psychological approaches, they had had severe conditions and shown no significant sign of improvement. The efficacy
of homeopathic treatment was measured by objective assessments of the skin condition and the patients' own assessments, using
a 9 point scale similar to the Glasgow Homeopathic Outcome Scale, was used. Over 50% improvement was reported in overall impression
and in their skin conditions by all patients, in itchiness by 15 of the patients, in sleep disturbance by 10 out of 13 patients,
in satisfaction in daily life by nine out of 12, in fulfillment at work by seven out of 11 and in satisfaction with human
relations by 10 out of 14. Two detailed case histories are reported.
PMID: 12725253 [PubMed - indexed for MEDLINE]
Headache. 2003 Jun;43(6):601-10.Click here to read Links
Headache. 2004 May;44(5):445-6.
Oral magnesium oxide prophylaxis of frequent migrainous headache in children: a randomized, double-blind, placebo-controlled
* Wang F,
* Van Den Eeden SK,
* Ackerson LM,
* Salk SE,
* Reince RH,
* Elin RJ.
Department of Neurology, Kaiser Permanente, Hayward, CA, USA.
OBJECTIVE: To assess whether, in children, oral magnesium oxide reduces migrainous headache frequency, severity, and
associated features compared to placebo. BACKGROUND: There is no single, safe, widely well-tolerated, and effective prophylactic
treatment for all children and adolescents with frequent migrainous headache. DESIGN: Randomized, double-blind, placebo-controlled,
parallel-group trial. METHODS: This study was conducted between June 1997 and January 2000 using 7 selected Northern California
Kaiser Permanente sites. We recruited children of ages 3 to 17 years who reported a 4-week history of at least weekly, moderate-to-severe
headache with a throbbing or pulsatile quality, associated anorexia/nausea, vomiting, photophobia, sonophobia, or relief with
sleep, but no fever or evidence of infection. Subjects were randomly assigned to receive either magnesium oxide (9 mg/kg per
day by mouth divided 3 times a day with food) (n = 58) or matching placebo (n = 60) for 16 weeks. The number of headache days
(days with at least one headache) during each of eight 2-week intervals was chosen to be the primary outcome variable. RESULTS:
Of those enrolled, 86 (73%) completed the study (42 received magnesium oxide and 44 placebo); 74 of 192 eligible subjects
declined to participate. Baseline information on demographic factors, health status, and headache history was similar comparing
the 2 groups. By intention-to-treat analysis, we found a statistically significant decrease over time in headache frequency
in the magnesium oxide group (P =.0037) but not in the placebo group (P =.086), although the slopes of these 2 lines were
not statistically significantly different from each other (P =.88). The group treated with magnesium oxide had significantly
lower headache severity (P =.0029) relative to the placebo group. CONCLUSIONS: This study does not unequivocally determine
whether oral magnesium oxide is or is not superior to placebo in preventing frequent migrainous headache in children, but
treatment with the active agent did lead to a significant reduction in headache days. Larger trials involving this safe, appealing
complementary therapy are needed.
PMID: 12786918 [PubMed - indexed for MEDLINE]
J Intern Med. 2003 Feb;253(2):181-8.Click here to read Links
Acupuncture versus placebo versus sumatriptan for early treatment of migraine attacks: a randomized controlled trial.
* Melchart D,
* Thormaehlen J,
* Hager S,
* Liao J,
* Linde K,
* Weidenhammer W.
Department of Internal Medicine II, Center for Complementary Medicine Research, Technical University, Kaiserstrasse
9, 80801 Munich, Germany. firstname.lastname@example.org
OBJECTIVES: To investigate whether acupuncture is superior to placebo and equivalent to sumatriptan for the early
treatment of an acute migraine attack. DESIGN: Randomized, partly double-blind (sumatriptan versus placebo) trial. SETTING:
Two hospitals in Germany (one specialized in traditional Chinese medicine and one in the treatment of headache). SUBJECTS:
A total of 179 migraineurs experiencing the first symptoms of a developing migraine attack. INTERVENTIONS: Traditional Chinese
acupuncture, sumatriptan (6 mg subcutaneously) or placebo injection. MAIN OUTCOME MEASURE: Number of patients in whom a full
migraine attack (defined as severe migraine headache) within 48 h was prevented. In patients who developed a migraine attack
in spite of early treatment, acupuncture and sumatriptan were applied a second time, whilst patients initially randomized
to placebo received sumatriptan. RESULTS: A full migraine attack was prevented in 21 of 60 (35%) patients receiving acupuncture,
21 of 58 (36%) patients receiving sumatriptan and 11 of 61 (18%) patients receiving placebo (relative risk of having a full
attack 0.79 (95% CI, 0.64-0.99) for acupuncture versus placebo, and 0.78 (95% CI, 0.62-0.98) for sumatriptan versus placebo).
Response to the second intervention in patients who developed a full attack was better with sumatriptan (17/31 patients who
received sumatriptan twice and 37/46 patients who had had placebo first) than with acupuncture (4/31). The number of patients
reporting side-effects was 14 in the acupuncture group, 23 in the sumatriptan group and 10 in the placebo group. CONCLUSIONS:
In this trial acupuncture and sumatriptan were more effective than a placebo injection in the early treatment of an acute
migraine attack. When an attack could not be prevented, sumatriptan was more effective than acupuncture at relieving headache.
PMID: 12542558 [PubMed - indexed for MEDLINE]