Efficacy of different acupuncture-related therapies for tension-type headache: a systematic review and network meta-analysis

Tension-type headache (TTH) represents one of the most common types of primary headache, affecting millions of people around the world. This condition is characterized by mild to moderate intensity pain, frequently described as a sensation of bilateral pressure or tightness in the temple region, and may extend to the forehead and occipital region. Unlike migraine, TTH presents with persistent and recurrent episodes that are particularly challenging to treat effectively. The impact goes beyond physical discomfort, as it frequently leads to negative emotional states such as irritability, insomnia, anxiety, and depression, creating a vicious cycle that may further aggravate the attacks.

This problem significantly affects patients' learning and work capacity, reducing their quality of life and generating considerable social and economic costs. Global data show that the incidence of TTH remains consistently high, with studies indicating that approximately 26% of the world population experiences this condition annually.

This study represents a comprehensive and updated analysis of the efficacy of different acupuncture-related therapies for the treatment of tension-type headache. The researchers conducted a systematic review and network meta-analysis, examining data from eight different scientific databases through April 2024. The methodology followed rigorous guidelines and included only randomized controlled clinical trials that evaluated patients diagnosed with TTH according to specific international criteria. The primary objective was to determine which acupuncture approach would be the most effective, analyzing different techniques such as manual acupuncture, electroacupuncture, scalp acupuncture, bloodletting therapy, and their combinations.

The researchers evaluated four primary outcomes: treatment response rate (defined as a reduction of at least 50% in days with pain), attack frequency, attack duration, and pain intensity. The analysis included 42 randomized controlled clinical trials, involving 4,103 participants and examining 21 different therapeutic modalities.

The results revealed important findings about the comparative effectiveness of the different acupuncture approaches. For the treatment response rate, which represents the primary outcome of the study, the combination of electroacupuncture with cupping therapy demonstrated the highest efficacy, achieving a 92.1% probability of being the most effective treatment. Other approaches that proved significantly superior to conventional Western medicine included the combination of manual acupuncture with bloodletting therapy, the plum-blossom needle technique, and scalp acupuncture. In relation to the reduction of headache frequency, electroacupuncture alone emerged as the most effective treatment, with an 85.9% probability of superiority, followed by the combination of manual acupuncture with plum-blossom needle and the combination of manual acupuncture with Western medications.

For attack duration, electroacupuncture again proved superior, with an 83.9% probability of being the most effective. With regard to pain intensity, the combination of manual acupuncture with Western medications was superior to other treatments, achieving an 89.4% probability of maximum efficacy.

The clinical implications of these findings are substantial for both patients and healthcare professionals. For patients who suffer from tension-type headache, these results offer robust scientific evidence that acupuncture and its variations represent effective and safe therapeutic alternatives. Electroacupuncture in particular stands out as an especially promising option, showing superior efficacy across multiple aspects of treatment. The mechanism of action involves the application of mild electrical currents at specific acupuncture points, promoting better local blood circulation and regulation of the nervous system.

Research indicates that electroacupuncture increases the release of endogenous opioids, inhibits the transmission of pain signals, and helps balance the sympathetic and parasympathetic nervous systems, reducing muscle tension and anxiety. For healthcare professionals, these data provide evidence-based guidance for clinical decision-making, allowing more informed choices about which acupuncture modalities to offer to patients. The study also demonstrates that combined approaches frequently outperform isolated treatments, suggesting benefits of integrated therapeutic strategies.

The study has some important limitations that should be considered in the interpretation of the results. First, some included studies did not adequately report crucial methodological aspects such as allocation concealment, blinding, or selective reporting bias, which may introduce bias in the results. Second, smaller sample sizes in some studies may affect the precision of the findings. Third, although the study involved research teams from nine different countries, a substantial proportion of the participants were of Asian origin, which may limit the generalizability of the findings to other ethnic groups.

Additionally, the funnel plot analysis revealed some asymmetry, suggesting possible publication bias or small-study effects in the research network. Despite these limitations, this represents the most recent and comprehensive network meta-analysis evaluating acupuncture methods for TTH, incorporating the largest number of studies, the most current data, and the widest variety of therapeutic modalities. The researchers conclude that electroacupuncture is the most effective for reducing the frequency and duration of attacks, while the combination of electroacupuncture with cupping therapy and the combination of manual acupuncture with Western medications are optimal for improving response rate and reducing pain intensity, respectively. However, they emphasize that clinical decisions should be individualized considering the specific needs of each patient.