Neurol Sci (2014) 35 (Suppl 1):S195–S198
DOI 10.1007/s10072-014-1769-6
ORAL COMMUNICATIONS
Acupuncture in cluster headache: four cases and review
of the literature
L. Fofi • G. Allais • P. E. Quirico • S. Rolando •
P. Borgogno • P. Barbanti • C. Benedetto
Ó Springer-Verlag Italia 2014
Abstract Although cluster headache (CH) is the most
disabling form of primary headache, little evidences
regarding alternative and complementary therapies are
available. Only few dated studies and some isolated cases
are described. We describe four patients with CH treated
with acupuncture as a preventive treatment, combined with
verapamil or alone. All patients received acupuncture
treatment twice/week for 2 weeks, then once/week for
8 weeks, and then once/alternate weeks for 2 weeks.
According to Traditional Chinese Medicine the acupoints
selected were: Ex HN-5 Taiyang, GB 14 Yangbai (both
only on the affected side), GB 20 Fengchi (on both sides),
LI 4 Hegu, LR 2 Xingjiang, SP 6 Sanyinjiao, ST 36 Zusanli
(all on both sides). At each point, after the insertion of the
needle, the feeling of ‘‘De Qi’’ was evoked; after obtaining
this sensation the acupoints were not further stimulated for
a period of 20 min, until their extraction. In all patients an
interruption of cluster attacks was obtained. To our
knowledge, this is the first report concerning acupuncture
in CH patients which details the protocol approach, acu-
points and duration of the treatment. Our results offer the
opportunity to discuss the emerging role of acupuncture in
L. Fofi (&)
P. Barbanti
Headache and Pain Unit, IRCCS San Raffaele Pisana,
Via della Pisana 235, 00163 Rome, Italy
e-mail: luisa.fofi@sanraffaele.it
G. Allais
S. Rolando
P. Borgogno
C. Benedetto
Department of Surgical Sciences, Women’s Headache Center,
University of Turin, Turin, Italy
G. Allais
P. E. Quirico
P. Borgogno
Center for the Study of Natural and Physical Therapies
(CSTNF), Turin, Italy
the therapy of CH, assuming a possible influence on opioid
system.
Keywords Acupoints
Acupuncture
Cluster headache

Preventive treatment
Abbreviation
CH Cluster headache
Introduction
Cluster headache (CH) is a rare type of primary headache,
probably the most disabling and painful [1]. It is charac-
terized by strictly unilateral pain attacks in the orbital,
supraorbital and temporal region (or in any combination of
these sites), lasting 15–180 min and occurring 1–8 times/
day [2]. The pain, described as ‘burning’, ‘throbbing’ or
‘penetrating’, is so severe that CH is also called ‘suicide
headache’, because some patients contemplated commit-
ting suicide during an attack, or when afraid of another
attack [3] (Fig. 1).
Although recurrent in most cases, CH has considerable
impact on social functions, quality of life and use of
healthcare so that lifestyle changes are described in 96 %
of the patients. The use of specialists and off-hour services
was significantly higher among cluster patients in com-
parison with the general population [4].
The employment of acute symptomatic therapies (sub-
cutaneous sumatriptan, inhalation of 100 % oxygen, par-
enteral dihydroergotamine, and oral zolmitriptan) and
prophylactic treatments (steroids, verapamil, lithium, val-
proic acid, topiramate, indomethacin, and others) is well
123
S196
Fig. 1 Name and location of
the acupoints used in our
patients affected by CH
documented. However, a proportion of patients does not
respond to these conventional therapies or only partially
responds, whereas others complain of significant side
effects [1]. Some untreatable cases require invasive treat-
ments [5] such as neurosurgical approaches or prescription
of hallucinogenic substances [6].
There are little evidences about alternative and com-
plementary non-invasive therapies for CH [7–9]. No other
studies on the use of acupuncture in CH explain a detailed
protocol or acupoints utilized.
To our knowledge, this is the first report which docu-
ment the efficacy of acupuncture in CH and proposes an
acupuncture treatment protocol.
Materials and methods
We describe four patients with CH treated with acupunc-
ture as a preventive treatment, combined with verapamil or
alone. All patients were treated with the same acupuncture
protocol. During the protocol all patients collected daily
headache diaries.
Acupuncture points and treatment protocol
The Traditional Chinese Medicine (TCM) describes a
syndromic picture very similar to the CH called ‘‘Liver
Fire’’, characterized by severe headache with ‘‘burning,
throbbing, distending or penetrating’’ pain located in the
oculo-temporal region, conjunctival injection, nausea,
vomiting, runny nose, tearing, agitation, sensation of heat
and sweating of the face.
For the acupunctural treatment we selected the acupoints
according to TCM, as follows:
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Neurol Sci (2014) 35 (Suppl 1):S195–S198
Local points: Ex HN-5 Taiyang, GB 14 Yangbai (both
only on the affected side).
Regional points: GB 20 Fengchi (on both sides).
Distal points: LI 4 Hegu, LR 2 Xingjiang, SP 6 San-
yinjiao, ST 36 Zusanli (all on both sides).
All points were punctured by experienced acupunctur-
ists with 0.3 mm diameter sterile disposable steel needles
(lenght: 52 mm), that were inserted to a depth of
10–30 mm and manipulated until the patient reported the
characteristic irradiating sensation, said to indicate effec-
tive needling, that is commonly called De Qi; after
obtaining this sensation the acupoints were not further
stimulated for a period of 20 min, until their extraction.
All patients received acupuncture treatment twice/week
for 2 weeks, then once/week for 8 weeks, and then once/
alternate weeks for 2 weeks.
Case report no. 1
A 39-year-old male, reporting a 20 years history of episodic
CH happening in July–August or November–December.
Until 2008 he had one cluster period every 2 years (2–3
attacks/week), then the frequency increased and became
annual. The pain was stabbing, strictly unilateral, localized
on right orbital-supraorbital region, lasting 15–20 min and
usually occurred during the night. Associated symptoms
were photophobia, phonofobia, agitation, restlessness, and
marked autonomic signs (ipsilateral tearing, rhinorrhea,
conjunctival injection, miosis, forehead and facial sweating
and flushing). During the last 3 years, verapamil (360 mg/
day) was effective in suppressing the cluster period, until the
last time when the attack frequency remained four per week,
despite this treatment. For this reason he started acupuncture
Neurol Sci (2014) 35 (Suppl 1):S195–S198
according to our protocol while continuing verapamil. After
the third acupuncture treatment a reduction of the number of
attacks was observed, after the sixth treatment the verapamil
dose was reduced to 240 mg/day, after the ninth treatment to
120 mg/day and stopped completely after the tenth treat-
ment. Remission was maintained with one acupuncture/
week for another 4 weeks.
A new cluster started after 45 days from the last treat-
ment, so that acupuncture alone with the same protocol was
promptly initiated with immediate benefit.
Case report no. 2
A 23-year-old male was diagnosed with chronic CH ab initio
5 years prior. The cluster frequency was 1–4 attacks/day and
the attack duration was 120 min; the pain, localized on left
orbital and fronto-temporal areas, was associated with ipsi-
lateral tearing, conjunctival injection, palpebral oedema,
agitation and irritability. Sumatriptan s.c. was rapidly effec-
tive for attacks, while oxigen mask therapy was not. For
prevention, prednisone, lithium and verapamil (360 mg/day)
were not effective; only verapamil (600 mg/day) was able to
reduce the attacks, but not to induce remission (one attack on
alternate days). The combination of acupuncture and verap-
amil (360 mg/day) led to a frequency of 1–4 attacks/month.
The remission was maintained for 2 months after the end of
the acupuncture treatment. Cluster headache attacks then
returned with a frequency of one attack daily. Reintroducing
acupunture, the frequency fell to one attack/week.
Case report no. 3
A 38-year-old male, presented the onset of episodic CH
when he was 19 years old; cluster period: March–June;
frequency from 2–3 attacks/day to 6–7/day with a duration
of 20 min. The pain site was left temporo-parietal, frontal,
orbital, rarely on upper dental arch. Pain was severe,
throbbing and associated with rhinorrea, tearing, conjunc-
tival hyperemia and palpebra oedema. Sumatritpan s.c. was
effective as acute treatment. Generally at the beginning of
the attacks he took verapamil (360 mg/day) which was able
to progressively reduce the frequency to 1/day in 2 weeks
and to stop the cluster. During a second cluster period,
verapamil combined with acupuncture was prescribed and
a complete remission was obtained. The following year, at
the beginning of the cluster, he immediately started acu-
puncture alone, without verapamil, with the same sched-
uled protocol and after 2 weeks CH went into remission.
Case report no. 4
A 43-year-old female, with CH onset when she was
25 years-old. The attacks happened annually, in the period
S197
from January to March with a frequency of 1–2 attacks/
day, mainly during the night and with a duration of
60–120 min. The pain site was localized on right ocular
region, with irradiation to the root of the nose and to
ipsilateral side of the head. The pain was penetrating,
burning and associated with photophobia, body sweating,
rhinorrea and omolateral tearing, nasal congestion and
irritability. She obtained a complete resolution of pain with
sumatriptan s.c., but did not respond to oxygen-therapy.
For prophilactic therapy methysergide was prescribed, but
it was immediately stopped for adverse effects. A 20 day
verapamil treatment (360 mg/day) was effective in inter-
rupting the cluster but the patient did not tolerate the drug.
So, at the onset of a new cluster period, a combined
treatment of acupuncture and a low dose of verapamil
(240 mg/day) was started. After 2 weeks verapamil was
reduced to 120 mg/day because attacks decreased to 1
every 3 days. CH remission was obtained after 20 days of
acupuncture and verapamil was discontinued.
She needed acupunture plus verapamil (120 mg/day) for
six CH periods, after that, acupuncture alone was admin-
istered when necessary for the following 3 years.
Discussion
Acupuncture is nowadays one of the most widespread
forms of complementary medicine [10, 11] used for the
treatment of chronic pain, including headaches [12, 13]. In
the 1990s it was demonstrated that acupuncture was more
effective than placebo for the treatment of headache and
migraine [14]. In the last decade, acupuncture plus routine
care in patients with headache, has been associated with
marked clinical improvements compared with routine care
alone [15]. The recent Cochrane Database Systematic
review [13] suggests that acupuncture should be considered
an effective treatment and a valuable option for patients
suffering from migraine or tension-type headache, with
fewer adverse effects.
Thereafter, during these years an increased use of
complementary and alternative medicine in the treatment
of primary headache disorders has been observed, but less
is known about acupuncture in CH patients. Only few and
dated cases [7–9] about acupuncture in CH patients are
described. Melchart et al. [16], in an observational study on
acupuncture in 2,022 patients with headache included 33
patients with CH, demonstrating an overall effect with
relevant improvement after 8.6 ± 3.0 acupuncture treat-
ments, but no specific results are available for the subgroup
of patients with CH.
Our study proposed a protocol of acupuncture alone or
combined with verapamil in four patients affected by CH,
three with episodic CH and one with chronic CH. All
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patients followed the same protocol (14 treatments) with a
standardized set of acupuncture points and had a good
response.
Acupuncture was identified as a possible alternative
therapy in these patients, who responded to subcutaneous
sumatriptan as acute treatment, but who did not respond
well to common pharmacological preventive therapy. In
our three patients with episodic CH, acupuncture was
started because either the verapamil dose was not effective
(2 pts) or, the verapamil caused side effects (1 pt). In these
patients, acupuncture, initially started with verapamil and
then continued alone, was effective in stopping cluster
attacks.
In chronic CH (1 pt) acupuncture was started in asso-
ciation with low dose of verapamil because it could not
completely stop the attacks.
The action mechanism of acupuncture therapy is com-
plex. Studies demonstrated that electrical acupunture can
increase endogenous opioid peptides (enkephalin, beta-
endorphin) in supraspinal CNS regions and in the spinal
cord [17, 18] while manual acupuncture can lead to the
activations of the diffuse noxious inhibitory controls
(DNIC) with an immediate suppression of pain transmis-
sion in neurons of the trigeminal caudalis and/or the spinal
dorsal horn [19, 20].
Some biochemical studies evidenced significantly lower
met-enkephalin levels in CSF [21] and lower peripheral
blood beta-endorphin [22] in 65 patients with CH as
compared to control, during the pain-free period as well.
The authors speculated that these findings reflect reduced
CNS levels of beta-endorphin due to an opioid system
hypofunction [22]. On the other hand, CSF opioid levels
may rise following manual acupuncture or electroacu-
puncture, as confirmed by Hardebo et al. [21] who evi-
denced that CSF met-enkephalin levels rose after
acupuncture treatment.
Until now, the role of how acupuncture can act in CH
patients is not known. Although the series is limited, this
study provides good evidence of the integration of western
medicine and traditional chinese medicine in the preventive
treatment of CH.
Conflict of interest All the authors certify that there is no actual or
potential conflict of interest in relation to this article.
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