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Specific effect of acupuncture on the neural pathway in the acute stage of migraine headache
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World Journal ofAcupuncture-Moxibustion (WJAM) Vol. 25, No.4, 30th Dec. 2015
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Mechanism Research
Specific effect of acupuncture on the neural pathway in the acute stage of migraine headache itifi6~~~J1:#§$t_U%(~lEf:l~iiIm8"J*~~f~:1fJt1: NIU Jia-yuan (4-~;ti, FAN Gang-qi (~Jji)tl~)2 1BJ 1. Second School of Clinical Medicine ofNanjing University of Chinese Medicine, Nanjing 210023, Jiangsu Province, China; 2. Third Affiliated Hospital ofNanjing University of Chinese Medicine (1. mJ¥-q:tE[~* ~m=r[{b*E[~~, U$mJ¥- 210023, q:t~; 2. mJ¥-q:tE[~*~m-='ffl}f-llE[~)
ARTICLE INFO
ABSTRACT
First author: NIU Jia-yuan (1991-), female,
To discuss the hazard of migraine in acute phase and analgesic effect, acupoint selection features, method as well as mechanism of acupuncture; to put forward relevant questions, answer these questions, propose relative specificity hypothesis on neural pathway of analgesic effect of acupoints in different nerve distribution areas (trigeminal nerve distribution area, occipital nerve distribution area, and spinal nerve distribution area) in treatment of migraine in acute phase, and analyze the deficiencies of hypothesis.
Undergraduate.
IBJ Corresponding author: FANGang-qi (1964-), male, chief physician. Research field: acupuncture in the treatment of encephalopathy and pain. E-mail: [email protected] Accepted on August 30, 2015
KEY WORDS: migraine; vascular mechanism of trigeminal nerve; neuroanatomical pathways; acupuncture effect
Migraine is a chronic "disabling" disease with higher morbidity [I], and its hazard is mainly embodied in acute phase. During the onset of headache, most patients may suffer from moderate-severe pain; light activities (such as brushing the teeth, or washing the face) may aggravate the headache, patients dare not, cannot or are unwilling to act, therefore, migraine is called "disabling" disease. Migraine attacks people repeatedly, so it is also called "chronic disabling" disease. Rapid and continuous analgesia in acute phase, and to reduce recurrence and recover patients' functions are the main purposes of treatment for migraine'", In most cases, acupuncture in treatment of migraine in acute phase can relieve headache in short time, with better efficacy at the beginning of onset of headache and less efficacy in peak phase; however, acupuncture is ineffective in a small part of patients. If acupuncture is ineffective, specific analgesic, such as triptans, will be effective!", It has not yet been reported that acupuncture is effective when triptans is ineffective.
ACUPUNCTURE SELECTION FEATURES AND REFLECTION ON ACUPUNCTURE ANALGESIA IN TREATMENT OF MIGRAIN IN ACUTE PHASE Acupoint selection features of acupuncture analgesia in treatment of migraine in acute phase are as follows: CD if the acupoints are classified based on the meridians and collaterals they belong to, hand-shaoyang and foot-shaoyang will be taken as principal'T"; ® if the acupoints are classified based on acupoint types, specific points will be taken as principal; ® if the acupoints are classified based on the specific site they locate, acupoints on face, head and occipitalia will be taken as principal, among which, scalp acupoints will take priority"?', which are located at predilection sites of migraine, such as forehead, tempora, neck, occipitalia, and etc. Body acupoints are usually selected together with scalp acupoints; ® if the acupoints are classified based on the frequency of use, the acupoints rank in the top ten are Fengchi ()5
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World Journal ofAcupuncture-Moxibustion (WJAM) Vol. 25, No.4, 30th Dec. 2015
Shuaigii ($.;f:t. GB 8), Hegii (1r;f:t. LI 4), Baihui (8 Touwei (~~t ST 8), Taichong (*{lj:t LR 3), Waiguan (jr~ TE 5), Ashi point (IWI ~1\), and Yanglingquan (~S ~JR GB 34), among which, GB 20, EX-HN 5 and GB 8 rank in the top three'"; @ the top ten acupoints are classified based on innervating areas as follows: acupoints in occipital nerve distribution area (GB 20); acupoints in trigeminal nerve distribution area (ST 8 and EX-HN 5); acupoints in juncture area of occipital nerve and trigeminal nerve (GB 8 and GV 20), and acupoints in spinal nerve distribution area (LR 3, TE 5, GB 34, etc.). ~ GV 20),
Based on current situation, we put forward the general problem of sequence on acupoint selection of acupuncture analgesia in treatment of migraine in acute phase: (1) Why are GB 20, EX-HN 5, GB 8 and ST 8 the uppermost acupoints during acupuncture analgesia in treatment of migraine in acute phase? Do they have specificity in terms of acupuncture analgesia in treatment of migraine in acute phase? (2) Why are the uppermost acupoints located at occipital nerve distribution area, trigeminal nerve distribution area or juncture area of occipital nerve and trigeminal nerve from the perspective of neuroanatomy of acupoint? Is the efficacy of acupuncture analgesia related to occipital nerve, trigeminal nerve or superior neural pathway? If they are related, which kind of relationship do they have? (3) If acupuncture analgesia mechanism in treatment of migraine in acute phase is related to trigeminal nerve or its superior neural pathway, or blood vascular system of trigeminal nerve, then, will direct irritation on trigeminal nerve obtain better efficacy? "Direct" acupuncture'" on trigeminal nerve includes acupuncture at Yuyao (iEr~ EX-HN 4, in the middle of eyebrow, just at the site out from skull of superior orbital fissure of the first nerve of trigeminal nerve), Sibai 01] B ST 2, at the depression of infraorbital foramen, just at the site out from skull of foramen rotundum of the second nerve of trigeminal nerve) and Jiachengjiang (~jJdR, just at mental foramen of the site out from skull of foramen ovale of the third nerve of trigeminal nerve). Which kind of therapy has a better analgesic effect between "direct" acupuncture and "indirect" acupuncture on trigeminal nerve (such as acupuncture at EX-HN 5, ST 8, GB 8 and GV20)? (4) According to the efficacy comparison among
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"direct" acupuncture and "indirect" acupuncture on trigeminal nerve, as well as irritation therapy on occipital nerve (such as various kinds of acupuncture methods at GB 20), which kind of therapy has a better analgesic effect? What is the mechanism of the therapy with better efficacy? (5) If acupoints are selected according to occipital nerve distribution area (GB 20), trigeminal nerve distribution area (EX-HN 5 and ST 8), juncture area of occipital nerve and trigeminal nerve (GB 8 and GV 20), spinal nerve distribution area (LR 3, TE 5 and GB 34), and other nerve distribution areas, whether are the analgesic effects in different distribution areas different? If the analgesic effects are different, whether are the analgesic effects related to different nerve conduction pathways? (6) Whether are the analgesic effects of acupuncture at different acupoints (such as shaoyang meridian GB 20; non-meridian and non-acupoint not along the meridians and near GB 20) in the same nerve distribution area the same? If there is no difference, what is the mechanism? If there are differences, what is the mechanism? In a word, the key point is the problem about relative specificity of GB 20, EX-HN 5 and LR 3 in terms of acupuncture analgesia in treatment of migraine in acute phase, while relative specificity of acupoints may be related with relative specificity of neural pathway. The answers to the abovementioned common problems contribute to the acupoint selection of acupuncture analgesia in treatment of migraine in acute phase; however, the mechanism research on acupuncture analgesia cannot solve the above problems completely.
METHODS OF ACUPUNCTURE ANALGESIA IN TREATMENT OF MIGRAINE IN ACUTE PHASE AND
RELEVANT PROBLEMS
Efficacy of acupuncture analgesia is closely related to the direction, angle and depth of acupuncture[Ill--II1, and the direction, angle and depth of acupuncture are closely related to the efficacy of acupuncture analgesia in treatment of migraine in acute phase[I2-I3]. In order to improve the efficacy of acupuncture analgesia in treatment of migraine in acute phase, the direction, angle, depth, and other acupuncture factors of selected acupoints should be optimized, which is also the preparation for the standardization of acupuncture treatment.
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GB 20, EX-HN 5, GB 8, etc. are most commonly used in treatment of migraine in acute phase, and penetration needling is usually adopted [14], such as penetration from Naokong (H&~ GB 19) to GB 20, from Sizhukong (~1t~ TE 23) to GB 8, and from EX-HN 5 to GB 8. For GB 20, besides penetration from GB 19 to GB 20, there are such other needling methods as perpendicular insertion at GB 20, catgut embedment in GB 20, acupoint injection in GB 20 and electrical stimulation on GB 20. Acupoint injection in GB 20 has a certain efficacy on migraine in acute phase; nerve block-like drugs are often adopted, which are not suitable for application in a long time, and there is a certain risk of injection (drugs may be injected by mistake into vertebral artery or subarachnoid space). Catgut embedment in GB 20 is not suitable for migraine in acute phase. Occipital nerve stimulation (with the stimulation site of exit of occipital nerve, just at GB 20; electrode and associated equipment embeded in GB 20 can constantly stimulate occipital nerve originated from upper cervical cord) is effective in various kinds of primary headache and cervicogenic headache'I", but it is less applied in migraine in acute phase, which is replaced by electrical stimulation that has certain effect. The features and advantages lie in relatively fixed parameters of electroacupuncture (frequency, intensity, time, etc.), which are closely related to the efficacy of acupuncture analgesia and which is repeatable. Xu WD[l61, et al conducted electroacupuncture on Xiaguan Cf ~ ST 7) and Zusanl] (JE...=:..1Il. ST 36), which are belong to the foot-yangming stomach meridian but dominated by different nerves, with high intensity and low intensity. It was indicated from the study that only low intensity electroacupuncture on ST 7 had prominent inhibiting effect, while electroacupuncture on ST 36 had no effect. However, high intensity electroacupuncture on ST 7 or ST 36 dominated by distal segment nervus peroneus communis had significant analgesic effect. It was shown from the result that low intensity electroacupuncture had specificity of acupoint in terms of analgesic effect, while high intensity electroacupuncture had a wide range of analgesic effect, which provided scientific experimental basis for selection of acupoints, manipulation and quantity of stimulus during acupuncture in treatment of pain on different sites. Vlett [17], et al has obtained that electric pulse with different frequencies might stimulate brain and spinal cord to release different kinds of neuropeptide, among which, electric pulse with frequency of 2 Hz could cause the production of enkephalin and p-endorphin in cerebrospinal
• 61 • fluid, while electric pulse with frequency of 100 Hz could cause the obvious increase of dynorphin in cerebrospinal fluid, and electric pulse with altemant frequencies of 2 Hz and 100 Hz could cause the release of three kinds of opioid peptides, reaching the best analgesic effect. Therefore, it is very necessary to optimize the direction, angle and depth of acupuncture at GB 20 and EX-HN 5, and each parameter of electroacupuncture in order to improve the efficacy of acupuncture analgesia in treatment of migraine in acute phase, and to normalize acupuncture methods. Hao [18], et al preliminarily optimized the acupuncture methods at GB 20 and EX-HN 5, and obtained the acupuncture methods of penetration from EX-HN 5 to GB 8 (GB 8 to EX-HN 5), and from GB 19 to GB 20, and preferred methods of moderate acupuncture depth (1 cun) and needle retention of 6 h. Wang[191, et al preliminarily optimized the analgesic methods in treatment of migraine in acute phase, who obtained the preferred method that taking shaoyang meridian as principal, distal acupoint selection and filiform needle acupuncture were applied combined with electroacupuncture on auricular acupoints and bloodletting at acupoints of taiyang meridian and Ashi point (~iiJ :;l!7'C), which provided thoughts and methods for the further study on optimization and standardization of acupuncture methods. Different acupuncture methods (especially the direction, angle and depth of acupuncture or the stimulus parameters of electroacupuncture) may lead to different acupuncture effects, so the effect mechanism of different acupuncture methods may be different'!", From the perspective of acupuncture method, on one hand, the most commonly used acupuncture methods at GB 20 and EX-HN 5 should be further optimized in order to improve and normalize the efficacy of acupuncture analgesia in treatment of migraine in acute phase; on this basis, the factors impacting the efficacy of acupuncture analgesia in treatment of migraine in acute phase may be optimized systematically; on the other hand, the mechanisms of different acupuncture methods should be studied deeply. At present, there are not yet authoritative and recognized acupuncture analgesia method in treatment of migraine in acute phase[12-I3], the research of problem about mechanisms of different acupuncture methods are deficient, so the study on mechanisms of preferred method is deficient, too.
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MECHANISM OF ACUPUNCTURE ANALGESIA IN TREATMENT OF MIGRAINE IN ACUTE PHASE Vascular mechanism of trigeminal nerve of headache attack of migraine in acute phase Currently, the pathogenesis of migraine has not been clarified. Scholars have put forward a series of hypotheses to explain the mechanism, and established animal models. The most famous hypothesis is vasoreflex theory of trigeminal nerve[20] and its classical model - the model of neurogenic inflammation of dura mater, which believed that the headache attack of migraine was related to the activation of trigeminal nerve blood vascular system. This theory explained the pathophysiologic process of migraine, and guided the treatment for migraine in acute phase.
Neural biochemical mechanism of acupuncture analgesia in treatment of migraine in acute phase It was indicated from many research results of Han JS that acupuncture analgesia has an indubitable neurochemical basis[2I]. Neurogenic inflammation model of dura mater is selected at home and abroad, and the mechanism of acupuncture analgesia in treatment of migraine in acute phase is explored from the perspective of neurochemistry[22-23]. It is believed from the researches that acupuncture at scalp acupoints, facial acupoints, occipital acupoints and auricular acupoints can inhibit or reduce the synthesis or release of such algogenic substances as calcitonin gene-related peptide (CGRP) and substance P (SP) in the blood or meninges, trigeminal ganglion, pontine nuclei of trigeminal nerve or spinal nuclei of trigeminal nerve of patients or animal models with migraine in acute phase; induce or promote synthesis or release of such analgesic substances as P-EP and other endogenous opioid peptides, achieving the aim of analgesia. The induction period of acupuncture analgesia (induction time is 20-40 min at least) is concurrent with the neurochemical mechanism. If induction time is removed or shortened, the neurochemical basis of acupuncture analgesia may not produce at the corresponding time point (such as the initial time of acupuncture), or produce a little. However, the clinical phenomenon of acupuncture analgesia indicates that although some pain diseases need induction period to achieve the efficacy of acupuncture analgesia, the efficacy of acupuncture analgesia in a substantial part of pain diseases may take effect rapidly, and the analgesic speed may be superior to anesthesia-'".
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Just as mentioned above, the efficacy of acupuncture analgesia in treatment of migraine in acute phase is rapid, that is, pain can be relieved immediately after acupuncture. The neurochemical mechanism of acupuncture analgesia in treatment of migraine in acute phase cannot explain the rapid efficacy of acupuncture analgesia clearly. In the pathogenesis of migraine in acute phase, the synthesis or release of CGRP and SP induced by various factors need a few time. Since acupuncture intervention, it needs time to regulate the synthesis or release of algogenic substances, and/or induce or promote the release of analgesic substances (enkephalin, P-EP, etc.), giving play to analgesic effect. In other words, induction period is needed. Moreover, the half life of opiates is 5-20 min, but the analgesic effect of acupuncture can last for four weeks, so the theory of endorphin cannot make an appropriate explanation. The rapid analgesic effect of acupuncture in treatment of migraine in acute phase cannot be explained by the neurochemical result. It is obvious that there is another mechanism of acupuncture analgesia in treatment of migraine in acute phase [Io-II, 24]. In addition, acupuncture can adjust the synthesis and release of CGRP and SP which are secreted or elevated abnormally in migraine in acute phase, and regulate the induction, synthesis and release of analgesic substances. But it has not been clarified through which path (neural pathway especially) these adjustment functions act on dura mater vessel.
Cortex spreading depression mechanism and acupuncture effect of migraine in acute phase Cortex spreading depression (CSD) mechanism is an other important pathophysiological basis of migraine. Various factors stimulate cerebral cortex, and electrical activity depression on cortex may appear from the stimulation site to peripheral tissues. Electroacupuncture on GB 34 and LR 3 can obviously inhibit CSD amplitude induced by potassium chloride, which indicates that acupuncture can improve CSD effect [25]. However, there are few studies on CSD of acupuncture analgesia in treatment of migraine in acute phase, and the conclusions cannot solve the problems about neural pathway of acupuncture.
The mechanism of neuroanatomy and problems of acupuncture analgesia in treatment of migraine in acute phase (1) The intracranial vessel It is believed generally that the pain of migraine
is the result of activation of dura mater vessel, main
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cerebral artery and sinus nociceptor'i". The intracranial vessel and cerebromeningeal nociceptor are surrounded by amyelinic (C-fiber) and thin myelin (AO fiber) axons, which contain neurovascular bioactive peptide, such as SP and CGRP. These substances derive from trigeminal ganglion, and reach dura mater through eye branch of trigeminal nerve (V 1). Sometimes they reach dura mater through upper jawbone (V 2) or lower jawbone (V 3). The neuron of upper cervical spine dorsal root ganglion is dominated by dura mater. Wang[271, et al found that vascular reactivity of acupuncture at GB 20 was conducted through CGRP signal pathway, the depression of signal pathway of smooth muscle contraction mediated by middle meningeal artery myosinlightchainkinase (MLCK) of the rats was relieved or re-acted, which contributed to myosinlightchain (MLC) phosphorylation, and the function of contracting the blood vessels was exerted. However, it has not been clarified through which path acupuncture acts on intracranial vessels in treatment of migraine in acute phase. (2) Brainstem nociceptor Brainstem nociceptor (C-fiber and Ao fiber) and expression genes of c-fos mainly gather at the lower segment of spinal nucleus of trigeminal nerve vessel[28 1, where is the location of cervical nerve complexus of trigeminal nerve, accepting and transmitting nociception upwards, receiving regulation and controlling of regulation structure of brainstem (such as PAG region, etc.), and transmitting upwards and depressing downwards to regulate the pain[291• When the nociception is transmitted to the secondary neuron of trigeminal nerve of spinal nucleus of trigeminal nerve, the afferent nerve enters into brainstem through the central process of trigeminal nerve, acts on brainstem nociceptor, releases related substances, and depresses the descending inhibition function of cervical nerve complexus of trigeminal nerve and regulation structure of brainstem'I", Continual stimulation on occipital nerve has a certain effect in treatment of migraine, with the mechanism that the pain depression system is activated through cervical nerve complexus of trigeminal nerve, and the conduction of nociception restores balance'i", XU[I61, et al have found that ST 7, dominated by trigeminal nerve, gives play to the function of relative specificity through cervical nerve complexus of trigeminal nerve when low intensity electroacupuncture is conducted. However, in the acute phase of migraine, there are few studies about how and whether acupuncture acts on trigeminal ganglion, spinal nucleus of trigeminal nerve, or cervical nerve complexus of trigeminal nerve and the SpVC neuron of trigeminal nerve vessel.
·63 • (3) Thalamus-cerebral cortex It is indicated from studies that there is an encephalic region in the brain which can regulate pain. Thalamic nuclei and neuron of trigeminal nerve vessel are effective in the breakout of migraine and photophobia along with Phonophobia. Prefrontal cortex and cingulate gyro cortex play important roles during conduction of pain signal. It is indicated from fMRI that acupuncture effect can be expressed in corresponding encephalic region'"! Acupuncture can activate prefrontal cortex, cingulate gyru cortex at the anterior margin of medial of brain, pons, etc., and relieve pain[32-331• Different acupoint selection methods have immediate analgesic effect on migraineurs. The specific points of shaoyang meridian (GB 20, TE 5 and GB 34), non-specific points of shaoyang meridian [LUx! (?m,~ TE 19), Sanyangluo C::::::~S~ TE 8) and Xlyangguan (.Jl*~S~ GB 33)] and specific points of yangming meridian [ST 8, Pianli (fAiU)JJ LI 6) and ST 36] have marked differences in terms of influencing brain function of patients with migraine; the specific points of shaoyang meridian influence the corresponding encephalic regions of patients with migraine more significantly, such as anterior cingutate, insular lobe, hippocampus, parahippocampal gyrus, etc[341• Based on the study on the encephalic region for the efficacy of acupuncture analgesia in treatment of migraine in acute phase, the encephalic region activated by acupoint stimulation or brain network has relative specificity. However, the study design, data collection and analytical method still need to be normalized, and the result annotation needs to be synthesized [31 1• Moreover, how acupuncture acts on the encephalic region has been explained in few studies. The relative specificity of pathway and the changes of relative specificity are important for the explanation of efficacy of acupuncture analgesia in treatment of migraine in acute phase, which need to be further studied. To sum up, in the studies on mechanism of acupuncture analgesia in treatment of migraine in acute phase, it is insufficient in the fields of observing the changes of indexes of nodes [from trigeminal nerve and occipital nerve, nociceptor, trigeminal ganglion, spinal nucleus of trigeminal nerve, upper dorsal spinal cord (C I-C3), cervical nerve complexus of trigeminal nerve and SpVC of trigeminal nerve vessel to thalamus and cortex] in trigeminal nerve vascular access system and explaining the mechanism of trigeminal nerve vascular access of acupuncture analgesia by applying acupuncture and by virtue of
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RELATIVE SPECIFICITY HYPOEHESIS OF NEURAL PATHWAY OF ACUPUNCTURE EFFECT IN DIFFERENT NERVE DISTRIBUTION AREAS IN TREATMENT OF MIGRAINE IN ACUTE PHASE Hypothesis Based on the problems on researches of acupuncture analgesia in treatment of migraine in acute phase, especially the problems about acupoints and acupuncture methods, we put forward a hypothesis combining with research progress of the pathway of acupuncture effect and effector organ: the aforementioned efficacy of acupuncture analgesia in different nerve distribution areas and the mechanism of acupuncture analgesia are related to the nerve conduction path of the location where acupoints locate. The details and deduction of the hypothesis are as follows: (1) The efficacy of acupuncture analgesia of local point selection and distal point selection in treatment of migraine in acute phase are realized through different neural pathways. From the perspective of neuroanatomy, local point selection on the head and face may be relate to trigeminal nerve, occipital nerve and! or cervical nerve complexus of trigeminal nerve, while the distal point selection on upper and lower limbs may be relate to tractus spinothalarnicus and its pathway. (2) The neural pathways of efficacy of acupuncture analgesia in different nerve distribution areas are as follows: trigeminal nerve pathway: ST 8, EX-HN 5 and other scalp and facial acupoints trigeminal nerve - trigeminal ganglion - spinal nucleus of trigeminal nerve - trigeminal nerve meningeal vessel; occipital nerve pathway: GB 20 and other occipital points - occipital nerve cervical nerve complexus of trigeminal nerve trigeminal nerve meningeal vessel; peripheral spinal nerve pathway: LR 3, GB 34 and LI 4 and other points on the limbs- peripheral spinal nerve tractus spinothalamicus - cortex - brain circuits - trigeminal nerve meningeal vessel. The pathway (trigeminal nerve meningeal vessel, and etc.) of acting on diseased region of headache is short, so the efficacy of acupuncture analgesia is more direct, rapid and efficient. Scalp and facial acupoints should be selected first according to the principle of pathway.
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(3) Relatively speaking, occipital nerve pathway is shorter obviously than trigeminal nerve pathway, and the efficacy of occipital nerve pathway is more direct, rapid and efficient than that of trigeminal nerve pathway. GB 20 and other occipital acupoints should be selected first according to the principle of pathway. (4) Relatively speaking, the efficacy of acupuncture through the first pathway of trigeminal nerve (EX-HN 4 and ST 8) is better than that of acupuncture through the second pathway of trigeminal nerve (ST 2 and EX-HN 5) and that of acupuncture through the third pathway of trigeminal nerve [Jiachengjiang (~;if.<~)]. In the cervical nerve complexus of trigeminal nerve, the first pathway may converge with upper cervical nerve due to the ordered distribution of neuron in the caudal sub-nuclei of spinal nucleus of trigeminal nerve, therefore, the headache of migraine mainly centers on forehead, temple and pars orbitalis, or occipital. The pain, allergy or hyperanalgesia in the second and the third dominant regions is not commonly seen. EX-HN 4 and ST 8 in the first dominant region and pathway of trigeminal nerve should be selected first according to the principle of pathway. (5) Relatively speaking, the efficacy of low intensity acupuncture or electroacupuncture at acupoints on the head and face has relative specificity or limitation on site of action (occipital nerve pathway or trigeminal nerve pathway) when compare with that of low intensity acupuncture at acupoints on limbs and trunk; the efficacy of high intensity acupuncture at acupoints on the head and face is similar to that of high intensity acupuncture at acupoints on limbs and trunk, which explains why the true and sham acupuncture and acupuncture with different quantities of stimulus both have effect. This hypothesis can preferably explain most questions during the study of acupuncture analgesia, guide the clinical practice of acupuncture, and contribute to the optimization of acupuncture analgesia methods in treatment of migraine in acute phase.
The deficiency of hypothesis Although the hypothesis that "the efficacy of acupuncture analgesia and the mechanism of efficacy difference in different nerve distribution areas in treatment of migraine in acute phase are related to the nerve conduction path where the acupoint locates" can well explain most questions during the study of acupuncture analgesia, it is based on the anatomy research progress of pain pathway of trigeminal nerve
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and the effect research progress of blood vascular system of trigeminal nerve in treatment of migraine in acute phase. The vascular mechanism of trigeminal nerve is not water-tight, and it cannot explain all the clinical phenomenon of migraine. The effect of this hypothesis under the main pathological conditions still needs to be further verified. Trigeminal nerve disorder is quite complicated. Some results still need to be verified. Therefore, relevant studies are necessary to verify and complete the hypothesis.
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(Chin) 2011; 26(6): 1312-1314. Burstein R, Yamamura H, Malick A, Strassman AM. Chemical stimulation of the intracranial dura induces enhanced responses to facial stimulation in brain stem trigeminal neurons. J Neurophysiol1998; 79(2): 964-982. Pei P, Liu L, Cui YX. Descending facilitation/ suppression system and its mechanism in migraine. J Apopl Nerv Dis (Chin) 2015; 32(5): 470--472. Basbaum AI, Bautista DM, Scherrer G, Julius D. Cellular and molecular mechanisms of pain. J Cell 2009; 139(2): 267-284. Fang JL, Wang XL, Rong PJ, Zhu B. International research progress of FMRI of efficacy of acupuncture at brain. Chin Imaging J Integr Tradit West Med (Chin) 2013; 11(2): 197-202.
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[32] Kong J, Gollub RL, Rosman IS, Webb JM, Vangel MG, Kirsch I, Kaptchuk TJ. Brain activity associated with expectancy-enhanced placebo analgesia as measured by functional magnetic resonance imaging. J Neurosci 2006; 26(2): 381. [33] Hu KM, Wang CP, Xie HJ, Hai N. Observation on activating effectiveness of acupuncture at acupoints and non-acupoints on different brain regions. Chin Acup-Mox (Chin) 2006; 26(3): 205-208. [34] Yang J, Liang FR. Central mechanism research on transient analgesic effect of acupuncture along meridian on patients with migraine based on PET-CT technology (Chin). Chengdu: Chengdu University of Traditional Chinese Medicine; 2011.
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News Activities of Second World Acupuncture Week ~=1'tlt~tt~~)!M -tlBrazil During the World Acupuncture Week, Brazilian School of Chinese Members offered a whole set of different free activities as follows: lecture on Chinese medicine diagnosis; lecture on acupuncture practice; cosmetic acupuncture free clinic; moxibustion free treatment; qi gong practice; free massage conducted by Down Syndrome massage therapists; lecture on Chinese language and so on. It was warmly welcomed by students and audiences. ~~ ~%~~~*~, ~~t~~~.~7-~~~t~~, ~#t~~~,#~~~,~t#~ ~~,~~1~~~~~$~~~~~~~~~t$~,~~~~~*, ~~~~~~~~~~%~o
-tlNew Zealand On November 16 to 22, in Wellington, New Zealand School of Acupuncture and TCM make use of free clinic treatments and presentations to disseminate and publicize acupuncture activitiy. It was warmly welcome by local people. *Ji~~ 1l}J 16 a fU22 a, ~.t.X~~;Wf~itt JK4t~~:&.i!i:t513t, /~~i1\'-J.t~i~i1\'-*~A.*-1t~ ~'G1t#~~~, $*-~~~)tti£f.o
-tlSpain On November 16 to 22, the European Foundation of TCM celebrated World Acupuncture Week 2015, in its 50 clinics was held an "open-doors week", experts introduced that the need to integrate the acupucture into the national health system, a free training session for teachers of acupuncture was devoted in which teaching techniques and content development for the training of acupuncturists were explained. ~~f>f 1l}J 16 a fU22 a, ~;1tl£~~~~J)1;f~#2015.1f-1t%JIl#~~R~~~, ~50~itJiJf~ ~"~~~"~~,~~M*t~M7#~MA~.~~~.~~~~~*,~#~~~~~7~t~ iJlj, :tJitit7 ~4t~~~ t:ijl-$Jf{t;j(~~iJrt.I..J!-~1~m 0
-tllndonesia On November 22, Indonesian Traditional Chinese Medicine Association carried out activities in Buddhist Temple "Dharma Ratna" Klungkung Regency. About 8 TCM acupuncture practitioners provided services for free-of-charge. cPJlJE~:ill!. 11}J 22 a, ~p 1tJt.~ ~ t JK tIJ.~~8-0:#~9;P~~p Jt.~Ji-*i1M7~-t Jit7tlk 7 5utJlIt.Jh
World Journal ofAcupuncture-Moxibustion (WJAM) Vol. 25, No.4, 30th Dec. 2015
• 59 •
Mechanism Research
Specific effect of acupuncture on the neural pathway in the acute stage of migraine headache itifi6~~~J1:#§$t_U%(~lEf:l~iiIm8"J*~~f~:1fJt1: NIU Jia-yuan (4-~;ti, FAN Gang-qi (~Jji)tl~)2 1BJ 1. Second School of Clinical Medicine ofNanjing University of Chinese Medicine, Nanjing 210023, Jiangsu Province, China; 2. Third Affiliated Hospital ofNanjing University of Chinese Medicine (1. mJ¥-q:tE[~* ~m=r[{b*E[~~, U$mJ¥- 210023, q:t~; 2. mJ¥-q:tE[~*~m-='ffl}f-llE[~)
ARTICLE INFO
ABSTRACT
First author: NIU Jia-yuan (1991-), female,
To discuss the hazard of migraine in acute phase and analgesic effect, acupoint selection features, method as well as mechanism of acupuncture; to put forward relevant questions, answer these questions, propose relative specificity hypothesis on neural pathway of analgesic effect of acupoints in different nerve distribution areas (trigeminal nerve distribution area, occipital nerve distribution area, and spinal nerve distribution area) in treatment of migraine in acute phase, and analyze the deficiencies of hypothesis.
Undergraduate.
IBJ Corresponding author: FANGang-qi (1964-), male, chief physician. Research field: acupuncture in the treatment of encephalopathy and pain. E-mail: [email protected] Accepted on August 30, 2015
KEY WORDS: migraine; vascular mechanism of trigeminal nerve; neuroanatomical pathways; acupuncture effect
Migraine is a chronic "disabling" disease with higher morbidity [I], and its hazard is mainly embodied in acute phase. During the onset of headache, most patients may suffer from moderate-severe pain; light activities (such as brushing the teeth, or washing the face) may aggravate the headache, patients dare not, cannot or are unwilling to act, therefore, migraine is called "disabling" disease. Migraine attacks people repeatedly, so it is also called "chronic disabling" disease. Rapid and continuous analgesia in acute phase, and to reduce recurrence and recover patients' functions are the main purposes of treatment for migraine'", In most cases, acupuncture in treatment of migraine in acute phase can relieve headache in short time, with better efficacy at the beginning of onset of headache and less efficacy in peak phase; however, acupuncture is ineffective in a small part of patients. If acupuncture is ineffective, specific analgesic, such as triptans, will be effective!", It has not yet been reported that acupuncture is effective when triptans is ineffective.
ACUPUNCTURE SELECTION FEATURES AND REFLECTION ON ACUPUNCTURE ANALGESIA IN TREATMENT OF MIGRAIN IN ACUTE PHASE Acupoint selection features of acupuncture analgesia in treatment of migraine in acute phase are as follows: CD if the acupoints are classified based on the meridians and collaterals they belong to, hand-shaoyang and foot-shaoyang will be taken as principal'T"; ® if the acupoints are classified based on acupoint types, specific points will be taken as principal; ® if the acupoints are classified based on the specific site they locate, acupoints on face, head and occipitalia will be taken as principal, among which, scalp acupoints will take priority"?', which are located at predilection sites of migraine, such as forehead, tempora, neck, occipitalia, and etc. Body acupoints are usually selected together with scalp acupoints; ® if the acupoints are classified based on the frequency of use, the acupoints rank in the top ten are Fengchi ()5
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World Journal ofAcupuncture-Moxibustion (WJAM) Vol. 25, No.4, 30th Dec. 2015
Shuaigii ($.;f:t. GB 8), Hegii (1r;f:t. LI 4), Baihui (8 Touwei (~~t ST 8), Taichong (*{lj:t LR 3), Waiguan (jr~ TE 5), Ashi point (IWI ~1\), and Yanglingquan (~S ~JR GB 34), among which, GB 20, EX-HN 5 and GB 8 rank in the top three'"; @ the top ten acupoints are classified based on innervating areas as follows: acupoints in occipital nerve distribution area (GB 20); acupoints in trigeminal nerve distribution area (ST 8 and EX-HN 5); acupoints in juncture area of occipital nerve and trigeminal nerve (GB 8 and GV 20), and acupoints in spinal nerve distribution area (LR 3, TE 5, GB 34, etc.). ~ GV 20),
Based on current situation, we put forward the general problem of sequence on acupoint selection of acupuncture analgesia in treatment of migraine in acute phase: (1) Why are GB 20, EX-HN 5, GB 8 and ST 8 the uppermost acupoints during acupuncture analgesia in treatment of migraine in acute phase? Do they have specificity in terms of acupuncture analgesia in treatment of migraine in acute phase? (2) Why are the uppermost acupoints located at occipital nerve distribution area, trigeminal nerve distribution area or juncture area of occipital nerve and trigeminal nerve from the perspective of neuroanatomy of acupoint? Is the efficacy of acupuncture analgesia related to occipital nerve, trigeminal nerve or superior neural pathway? If they are related, which kind of relationship do they have? (3) If acupuncture analgesia mechanism in treatment of migraine in acute phase is related to trigeminal nerve or its superior neural pathway, or blood vascular system of trigeminal nerve, then, will direct irritation on trigeminal nerve obtain better efficacy? "Direct" acupuncture'" on trigeminal nerve includes acupuncture at Yuyao (iEr~ EX-HN 4, in the middle of eyebrow, just at the site out from skull of superior orbital fissure of the first nerve of trigeminal nerve), Sibai 01] B ST 2, at the depression of infraorbital foramen, just at the site out from skull of foramen rotundum of the second nerve of trigeminal nerve) and Jiachengjiang (~jJdR, just at mental foramen of the site out from skull of foramen ovale of the third nerve of trigeminal nerve). Which kind of therapy has a better analgesic effect between "direct" acupuncture and "indirect" acupuncture on trigeminal nerve (such as acupuncture at EX-HN 5, ST 8, GB 8 and GV20)? (4) According to the efficacy comparison among
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"direct" acupuncture and "indirect" acupuncture on trigeminal nerve, as well as irritation therapy on occipital nerve (such as various kinds of acupuncture methods at GB 20), which kind of therapy has a better analgesic effect? What is the mechanism of the therapy with better efficacy? (5) If acupoints are selected according to occipital nerve distribution area (GB 20), trigeminal nerve distribution area (EX-HN 5 and ST 8), juncture area of occipital nerve and trigeminal nerve (GB 8 and GV 20), spinal nerve distribution area (LR 3, TE 5 and GB 34), and other nerve distribution areas, whether are the analgesic effects in different distribution areas different? If the analgesic effects are different, whether are the analgesic effects related to different nerve conduction pathways? (6) Whether are the analgesic effects of acupuncture at different acupoints (such as shaoyang meridian GB 20; non-meridian and non-acupoint not along the meridians and near GB 20) in the same nerve distribution area the same? If there is no difference, what is the mechanism? If there are differences, what is the mechanism? In a word, the key point is the problem about relative specificity of GB 20, EX-HN 5 and LR 3 in terms of acupuncture analgesia in treatment of migraine in acute phase, while relative specificity of acupoints may be related with relative specificity of neural pathway. The answers to the abovementioned common problems contribute to the acupoint selection of acupuncture analgesia in treatment of migraine in acute phase; however, the mechanism research on acupuncture analgesia cannot solve the above problems completely.
METHODS OF ACUPUNCTURE ANALGESIA IN TREATMENT OF MIGRAINE IN ACUTE PHASE AND
RELEVANT PROBLEMS
Efficacy of acupuncture analgesia is closely related to the direction, angle and depth of acupuncture[Ill--II1, and the direction, angle and depth of acupuncture are closely related to the efficacy of acupuncture analgesia in treatment of migraine in acute phase[I2-I3]. In order to improve the efficacy of acupuncture analgesia in treatment of migraine in acute phase, the direction, angle, depth, and other acupuncture factors of selected acupoints should be optimized, which is also the preparation for the standardization of acupuncture treatment.
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GB 20, EX-HN 5, GB 8, etc. are most commonly used in treatment of migraine in acute phase, and penetration needling is usually adopted [14], such as penetration from Naokong (H&~ GB 19) to GB 20, from Sizhukong (~1t~ TE 23) to GB 8, and from EX-HN 5 to GB 8. For GB 20, besides penetration from GB 19 to GB 20, there are such other needling methods as perpendicular insertion at GB 20, catgut embedment in GB 20, acupoint injection in GB 20 and electrical stimulation on GB 20. Acupoint injection in GB 20 has a certain efficacy on migraine in acute phase; nerve block-like drugs are often adopted, which are not suitable for application in a long time, and there is a certain risk of injection (drugs may be injected by mistake into vertebral artery or subarachnoid space). Catgut embedment in GB 20 is not suitable for migraine in acute phase. Occipital nerve stimulation (with the stimulation site of exit of occipital nerve, just at GB 20; electrode and associated equipment embeded in GB 20 can constantly stimulate occipital nerve originated from upper cervical cord) is effective in various kinds of primary headache and cervicogenic headache'I", but it is less applied in migraine in acute phase, which is replaced by electrical stimulation that has certain effect. The features and advantages lie in relatively fixed parameters of electroacupuncture (frequency, intensity, time, etc.), which are closely related to the efficacy of acupuncture analgesia and which is repeatable. Xu WD[l61, et al conducted electroacupuncture on Xiaguan Cf ~ ST 7) and Zusanl] (JE...=:..1Il. ST 36), which are belong to the foot-yangming stomach meridian but dominated by different nerves, with high intensity and low intensity. It was indicated from the study that only low intensity electroacupuncture on ST 7 had prominent inhibiting effect, while electroacupuncture on ST 36 had no effect. However, high intensity electroacupuncture on ST 7 or ST 36 dominated by distal segment nervus peroneus communis had significant analgesic effect. It was shown from the result that low intensity electroacupuncture had specificity of acupoint in terms of analgesic effect, while high intensity electroacupuncture had a wide range of analgesic effect, which provided scientific experimental basis for selection of acupoints, manipulation and quantity of stimulus during acupuncture in treatment of pain on different sites. Vlett [17], et al has obtained that electric pulse with different frequencies might stimulate brain and spinal cord to release different kinds of neuropeptide, among which, electric pulse with frequency of 2 Hz could cause the production of enkephalin and p-endorphin in cerebrospinal
• 61 • fluid, while electric pulse with frequency of 100 Hz could cause the obvious increase of dynorphin in cerebrospinal fluid, and electric pulse with altemant frequencies of 2 Hz and 100 Hz could cause the release of three kinds of opioid peptides, reaching the best analgesic effect. Therefore, it is very necessary to optimize the direction, angle and depth of acupuncture at GB 20 and EX-HN 5, and each parameter of electroacupuncture in order to improve the efficacy of acupuncture analgesia in treatment of migraine in acute phase, and to normalize acupuncture methods. Hao [18], et al preliminarily optimized the acupuncture methods at GB 20 and EX-HN 5, and obtained the acupuncture methods of penetration from EX-HN 5 to GB 8 (GB 8 to EX-HN 5), and from GB 19 to GB 20, and preferred methods of moderate acupuncture depth (1 cun) and needle retention of 6 h. Wang[191, et al preliminarily optimized the analgesic methods in treatment of migraine in acute phase, who obtained the preferred method that taking shaoyang meridian as principal, distal acupoint selection and filiform needle acupuncture were applied combined with electroacupuncture on auricular acupoints and bloodletting at acupoints of taiyang meridian and Ashi point (~iiJ :;l!7'C), which provided thoughts and methods for the further study on optimization and standardization of acupuncture methods. Different acupuncture methods (especially the direction, angle and depth of acupuncture or the stimulus parameters of electroacupuncture) may lead to different acupuncture effects, so the effect mechanism of different acupuncture methods may be different'!", From the perspective of acupuncture method, on one hand, the most commonly used acupuncture methods at GB 20 and EX-HN 5 should be further optimized in order to improve and normalize the efficacy of acupuncture analgesia in treatment of migraine in acute phase; on this basis, the factors impacting the efficacy of acupuncture analgesia in treatment of migraine in acute phase may be optimized systematically; on the other hand, the mechanisms of different acupuncture methods should be studied deeply. At present, there are not yet authoritative and recognized acupuncture analgesia method in treatment of migraine in acute phase[12-I3], the research of problem about mechanisms of different acupuncture methods are deficient, so the study on mechanisms of preferred method is deficient, too.
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MECHANISM OF ACUPUNCTURE ANALGESIA IN TREATMENT OF MIGRAINE IN ACUTE PHASE Vascular mechanism of trigeminal nerve of headache attack of migraine in acute phase Currently, the pathogenesis of migraine has not been clarified. Scholars have put forward a series of hypotheses to explain the mechanism, and established animal models. The most famous hypothesis is vasoreflex theory of trigeminal nerve[20] and its classical model - the model of neurogenic inflammation of dura mater, which believed that the headache attack of migraine was related to the activation of trigeminal nerve blood vascular system. This theory explained the pathophysiologic process of migraine, and guided the treatment for migraine in acute phase.
Neural biochemical mechanism of acupuncture analgesia in treatment of migraine in acute phase It was indicated from many research results of Han JS that acupuncture analgesia has an indubitable neurochemical basis[2I]. Neurogenic inflammation model of dura mater is selected at home and abroad, and the mechanism of acupuncture analgesia in treatment of migraine in acute phase is explored from the perspective of neurochemistry[22-23]. It is believed from the researches that acupuncture at scalp acupoints, facial acupoints, occipital acupoints and auricular acupoints can inhibit or reduce the synthesis or release of such algogenic substances as calcitonin gene-related peptide (CGRP) and substance P (SP) in the blood or meninges, trigeminal ganglion, pontine nuclei of trigeminal nerve or spinal nuclei of trigeminal nerve of patients or animal models with migraine in acute phase; induce or promote synthesis or release of such analgesic substances as P-EP and other endogenous opioid peptides, achieving the aim of analgesia. The induction period of acupuncture analgesia (induction time is 20-40 min at least) is concurrent with the neurochemical mechanism. If induction time is removed or shortened, the neurochemical basis of acupuncture analgesia may not produce at the corresponding time point (such as the initial time of acupuncture), or produce a little. However, the clinical phenomenon of acupuncture analgesia indicates that although some pain diseases need induction period to achieve the efficacy of acupuncture analgesia, the efficacy of acupuncture analgesia in a substantial part of pain diseases may take effect rapidly, and the analgesic speed may be superior to anesthesia-'".
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Just as mentioned above, the efficacy of acupuncture analgesia in treatment of migraine in acute phase is rapid, that is, pain can be relieved immediately after acupuncture. The neurochemical mechanism of acupuncture analgesia in treatment of migraine in acute phase cannot explain the rapid efficacy of acupuncture analgesia clearly. In the pathogenesis of migraine in acute phase, the synthesis or release of CGRP and SP induced by various factors need a few time. Since acupuncture intervention, it needs time to regulate the synthesis or release of algogenic substances, and/or induce or promote the release of analgesic substances (enkephalin, P-EP, etc.), giving play to analgesic effect. In other words, induction period is needed. Moreover, the half life of opiates is 5-20 min, but the analgesic effect of acupuncture can last for four weeks, so the theory of endorphin cannot make an appropriate explanation. The rapid analgesic effect of acupuncture in treatment of migraine in acute phase cannot be explained by the neurochemical result. It is obvious that there is another mechanism of acupuncture analgesia in treatment of migraine in acute phase [Io-II, 24]. In addition, acupuncture can adjust the synthesis and release of CGRP and SP which are secreted or elevated abnormally in migraine in acute phase, and regulate the induction, synthesis and release of analgesic substances. But it has not been clarified through which path (neural pathway especially) these adjustment functions act on dura mater vessel.
Cortex spreading depression mechanism and acupuncture effect of migraine in acute phase Cortex spreading depression (CSD) mechanism is an other important pathophysiological basis of migraine. Various factors stimulate cerebral cortex, and electrical activity depression on cortex may appear from the stimulation site to peripheral tissues. Electroacupuncture on GB 34 and LR 3 can obviously inhibit CSD amplitude induced by potassium chloride, which indicates that acupuncture can improve CSD effect [25]. However, there are few studies on CSD of acupuncture analgesia in treatment of migraine in acute phase, and the conclusions cannot solve the problems about neural pathway of acupuncture.
The mechanism of neuroanatomy and problems of acupuncture analgesia in treatment of migraine in acute phase (1) The intracranial vessel It is believed generally that the pain of migraine
is the result of activation of dura mater vessel, main
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WorldJournal ofAcupuncture-Moxibustion (WJAM) Vol. 25, No.4, 30th Dec. 2015
cerebral artery and sinus nociceptor'i". The intracranial vessel and cerebromeningeal nociceptor are surrounded by amyelinic (C-fiber) and thin myelin (AO fiber) axons, which contain neurovascular bioactive peptide, such as SP and CGRP. These substances derive from trigeminal ganglion, and reach dura mater through eye branch of trigeminal nerve (V 1). Sometimes they reach dura mater through upper jawbone (V 2) or lower jawbone (V 3). The neuron of upper cervical spine dorsal root ganglion is dominated by dura mater. Wang[271, et al found that vascular reactivity of acupuncture at GB 20 was conducted through CGRP signal pathway, the depression of signal pathway of smooth muscle contraction mediated by middle meningeal artery myosinlightchainkinase (MLCK) of the rats was relieved or re-acted, which contributed to myosinlightchain (MLC) phosphorylation, and the function of contracting the blood vessels was exerted. However, it has not been clarified through which path acupuncture acts on intracranial vessels in treatment of migraine in acute phase. (2) Brainstem nociceptor Brainstem nociceptor (C-fiber and Ao fiber) and expression genes of c-fos mainly gather at the lower segment of spinal nucleus of trigeminal nerve vessel[28 1, where is the location of cervical nerve complexus of trigeminal nerve, accepting and transmitting nociception upwards, receiving regulation and controlling of regulation structure of brainstem (such as PAG region, etc.), and transmitting upwards and depressing downwards to regulate the pain[291• When the nociception is transmitted to the secondary neuron of trigeminal nerve of spinal nucleus of trigeminal nerve, the afferent nerve enters into brainstem through the central process of trigeminal nerve, acts on brainstem nociceptor, releases related substances, and depresses the descending inhibition function of cervical nerve complexus of trigeminal nerve and regulation structure of brainstem'I", Continual stimulation on occipital nerve has a certain effect in treatment of migraine, with the mechanism that the pain depression system is activated through cervical nerve complexus of trigeminal nerve, and the conduction of nociception restores balance'i", XU[I61, et al have found that ST 7, dominated by trigeminal nerve, gives play to the function of relative specificity through cervical nerve complexus of trigeminal nerve when low intensity electroacupuncture is conducted. However, in the acute phase of migraine, there are few studies about how and whether acupuncture acts on trigeminal ganglion, spinal nucleus of trigeminal nerve, or cervical nerve complexus of trigeminal nerve and the SpVC neuron of trigeminal nerve vessel.
·63 • (3) Thalamus-cerebral cortex It is indicated from studies that there is an encephalic region in the brain which can regulate pain. Thalamic nuclei and neuron of trigeminal nerve vessel are effective in the breakout of migraine and photophobia along with Phonophobia. Prefrontal cortex and cingulate gyro cortex play important roles during conduction of pain signal. It is indicated from fMRI that acupuncture effect can be expressed in corresponding encephalic region'"! Acupuncture can activate prefrontal cortex, cingulate gyru cortex at the anterior margin of medial of brain, pons, etc., and relieve pain[32-331• Different acupoint selection methods have immediate analgesic effect on migraineurs. The specific points of shaoyang meridian (GB 20, TE 5 and GB 34), non-specific points of shaoyang meridian [LUx! (?m,~ TE 19), Sanyangluo C::::::~S~ TE 8) and Xlyangguan (.Jl*~S~ GB 33)] and specific points of yangming meridian [ST 8, Pianli (fAiU)JJ LI 6) and ST 36] have marked differences in terms of influencing brain function of patients with migraine; the specific points of shaoyang meridian influence the corresponding encephalic regions of patients with migraine more significantly, such as anterior cingutate, insular lobe, hippocampus, parahippocampal gyrus, etc[341• Based on the study on the encephalic region for the efficacy of acupuncture analgesia in treatment of migraine in acute phase, the encephalic region activated by acupoint stimulation or brain network has relative specificity. However, the study design, data collection and analytical method still need to be normalized, and the result annotation needs to be synthesized [31 1• Moreover, how acupuncture acts on the encephalic region has been explained in few studies. The relative specificity of pathway and the changes of relative specificity are important for the explanation of efficacy of acupuncture analgesia in treatment of migraine in acute phase, which need to be further studied. To sum up, in the studies on mechanism of acupuncture analgesia in treatment of migraine in acute phase, it is insufficient in the fields of observing the changes of indexes of nodes [from trigeminal nerve and occipital nerve, nociceptor, trigeminal ganglion, spinal nucleus of trigeminal nerve, upper dorsal spinal cord (C I-C3), cervical nerve complexus of trigeminal nerve and SpVC of trigeminal nerve vessel to thalamus and cortex] in trigeminal nerve vascular access system and explaining the mechanism of trigeminal nerve vascular access of acupuncture analgesia by applying acupuncture and by virtue of
World Journal ofAcupuncture-Moxibustion (WJAM)
Vol. 25, No.4, 30th Dec. 2015 trigeminal nerve vasoreflex theory and model of dura mater neurogenic inflammation.
RELATIVE SPECIFICITY HYPOEHESIS OF NEURAL PATHWAY OF ACUPUNCTURE EFFECT IN DIFFERENT NERVE DISTRIBUTION AREAS IN TREATMENT OF MIGRAINE IN ACUTE PHASE Hypothesis Based on the problems on researches of acupuncture analgesia in treatment of migraine in acute phase, especially the problems about acupoints and acupuncture methods, we put forward a hypothesis combining with research progress of the pathway of acupuncture effect and effector organ: the aforementioned efficacy of acupuncture analgesia in different nerve distribution areas and the mechanism of acupuncture analgesia are related to the nerve conduction path of the location where acupoints locate. The details and deduction of the hypothesis are as follows: (1) The efficacy of acupuncture analgesia of local point selection and distal point selection in treatment of migraine in acute phase are realized through different neural pathways. From the perspective of neuroanatomy, local point selection on the head and face may be relate to trigeminal nerve, occipital nerve and! or cervical nerve complexus of trigeminal nerve, while the distal point selection on upper and lower limbs may be relate to tractus spinothalarnicus and its pathway. (2) The neural pathways of efficacy of acupuncture analgesia in different nerve distribution areas are as follows: trigeminal nerve pathway: ST 8, EX-HN 5 and other scalp and facial acupoints trigeminal nerve - trigeminal ganglion - spinal nucleus of trigeminal nerve - trigeminal nerve meningeal vessel; occipital nerve pathway: GB 20 and other occipital points - occipital nerve cervical nerve complexus of trigeminal nerve trigeminal nerve meningeal vessel; peripheral spinal nerve pathway: LR 3, GB 34 and LI 4 and other points on the limbs- peripheral spinal nerve tractus spinothalamicus - cortex - brain circuits - trigeminal nerve meningeal vessel. The pathway (trigeminal nerve meningeal vessel, and etc.) of acting on diseased region of headache is short, so the efficacy of acupuncture analgesia is more direct, rapid and efficient. Scalp and facial acupoints should be selected first according to the principle of pathway.
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(3) Relatively speaking, occipital nerve pathway is shorter obviously than trigeminal nerve pathway, and the efficacy of occipital nerve pathway is more direct, rapid and efficient than that of trigeminal nerve pathway. GB 20 and other occipital acupoints should be selected first according to the principle of pathway. (4) Relatively speaking, the efficacy of acupuncture through the first pathway of trigeminal nerve (EX-HN 4 and ST 8) is better than that of acupuncture through the second pathway of trigeminal nerve (ST 2 and EX-HN 5) and that of acupuncture through the third pathway of trigeminal nerve [Jiachengjiang (~;if.<~)]. In the cervical nerve complexus of trigeminal nerve, the first pathway may converge with upper cervical nerve due to the ordered distribution of neuron in the caudal sub-nuclei of spinal nucleus of trigeminal nerve, therefore, the headache of migraine mainly centers on forehead, temple and pars orbitalis, or occipital. The pain, allergy or hyperanalgesia in the second and the third dominant regions is not commonly seen. EX-HN 4 and ST 8 in the first dominant region and pathway of trigeminal nerve should be selected first according to the principle of pathway. (5) Relatively speaking, the efficacy of low intensity acupuncture or electroacupuncture at acupoints on the head and face has relative specificity or limitation on site of action (occipital nerve pathway or trigeminal nerve pathway) when compare with that of low intensity acupuncture at acupoints on limbs and trunk; the efficacy of high intensity acupuncture at acupoints on the head and face is similar to that of high intensity acupuncture at acupoints on limbs and trunk, which explains why the true and sham acupuncture and acupuncture with different quantities of stimulus both have effect. This hypothesis can preferably explain most questions during the study of acupuncture analgesia, guide the clinical practice of acupuncture, and contribute to the optimization of acupuncture analgesia methods in treatment of migraine in acute phase.
The deficiency of hypothesis Although the hypothesis that "the efficacy of acupuncture analgesia and the mechanism of efficacy difference in different nerve distribution areas in treatment of migraine in acute phase are related to the nerve conduction path where the acupoint locates" can well explain most questions during the study of acupuncture analgesia, it is based on the anatomy research progress of pain pathway of trigeminal nerve
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and the effect research progress of blood vascular system of trigeminal nerve in treatment of migraine in acute phase. The vascular mechanism of trigeminal nerve is not water-tight, and it cannot explain all the clinical phenomenon of migraine. The effect of this hypothesis under the main pathological conditions still needs to be further verified. Trigeminal nerve disorder is quite complicated. Some results still need to be verified. Therefore, relevant studies are necessary to verify and complete the hypothesis.
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World Journal ofAcupuncture-Moxibustion (WJAM)
Vol. 25, No.4, 30th Dec. 2015
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ELSEVIER
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News Activities of Second World Acupuncture Week ~=1'tlt~tt~~)!M -tlBrazil During the World Acupuncture Week, Brazilian School of Chinese Members offered a whole set of different free activities as follows: lecture on Chinese medicine diagnosis; lecture on acupuncture practice; cosmetic acupuncture free clinic; moxibustion free treatment; qi gong practice; free massage conducted by Down Syndrome massage therapists; lecture on Chinese language and so on. It was warmly welcomed by students and audiences. ~~ ~%~~~*~, ~~t~~~.~7-~~~t~~, ~#t~~~,#~~~,~t#~ ~~,~~1~~~~~$~~~~~~~~~t$~,~~~~~*, ~~~~~~~~~~%~o
-tlNew Zealand On November 16 to 22, in Wellington, New Zealand School of Acupuncture and TCM make use of free clinic treatments and presentations to disseminate and publicize acupuncture activitiy. It was warmly welcome by local people. *Ji~~ 1l}J 16 a fU22 a, ~.t.X~~;Wf~itt JK4t~~:&.i!i:t513t, /~~i1\'-J.t~i~i1\'-*~A.*-1t~ ~'G1t#~~~, $*-~~~)tti£f.o
-tlSpain On November 16 to 22, the European Foundation of TCM celebrated World Acupuncture Week 2015, in its 50 clinics was held an "open-doors week", experts introduced that the need to integrate the acupucture into the national health system, a free training session for teachers of acupuncture was devoted in which teaching techniques and content development for the training of acupuncturists were explained. ~~f>f 1l}J 16 a fU22 a, ~;1tl£~~~~J)1;f~#2015.1f-1t%JIl#~~R~~~, ~50~itJiJf~ ~"~~~"~~,~~M*t~M7#~MA~.~~~.~~~~~*,~#~~~~~7~t~ iJlj, :tJitit7 ~4t~~~ t:ijl-$Jf{t;j(~~iJrt.I..J!-~1~m 0
-tllndonesia On November 22, Indonesian Traditional Chinese Medicine Association carried out activities in Buddhist Temple "Dharma Ratna" Klungkung Regency. About 8 TCM acupuncture practitioners provided services for free-of-charge. cPJlJE~:ill!. 11}J 22 a, ~p 1tJt.~ ~ t JK tIJ.~~8-0:#~9;P~~p Jt.~Ji-*i1M7~-t Jit7tlk 7 5utJlIt.Jh