What is the optimal number of acupuncture treatments for migraine patients? Clinicians must consider a combination of factors to answer this question, including the type or severity of the disease being treated, the patient’s characteristics and circumstances, and the frequency of acupuncture. For policy makers, this issue is meaningful because it can affect costs associated with treatment. Acupuncture researchers are not only exposed to this question quite often, but are also expected to provide an appropriate answer. Too few or too many acupuncture sessions may not produce adequate treatment effects, or may compromise the validity of the study.

The study conducted by Thanan Supasiri and colleagues¹⁾, recently published in Acupuncture in medicine, aimed to investigate whether 5 sessions of acupuncture treatment for migraine (Group A: 2 sessions per week for 2.5 weeks) was non-inferior to 10 sessions (Group B: 2 sessions per week for 5 weeks). The number of headache days, which is generally used as the primary outcome for migraine, should be closely monitored over a specific period of time. In this study, the values were evaluated for 4 weeks immediately before and after treatment. In addition, in Group A, the evaluation results at 6.5 weeks after the end of treatment were also presented. According to Table 3 in original article, Group A ended acupuncture immediately after the fifth treatment, but treatment for Group B was still in progress at that time, so comparison between groups was not possible. The question is, what should be compared with the results immediately after treatment in Group B (74% responders, result of headaches recorded for 6 to 9 weeks)? Should Group B be 1) compared with the results immediately after treatment in Group A (75% responders, results of headaches recorded for 2.5 to 6.5 weeks), or 2) compared with the point when a certain amount of time has passed since the end of treatment in Group A (83% responders, result of headaches recorded for 6 to 9 weeks)? The first option focuses on the meaning of directly comparing the effect “immediately after treatment” and, in addition to the “number of treatments”, the “duration of treatment” acts as a variable, which has inherent positive or negative effects. In the second choice, the purpose is to compare the results after the same amount of time has elapsed since the start of treatment; however, a problem arises in that the “effect immediately after treatment (Group B)” must be compared with “the effect maintained until after 6.5 weeks after the end of treatment (Group A)”.

Several clinical studies have been conducted to confirm evidence of acupuncture as an effective treatment for migraine. Most of those studies aimed to determine whether acupuncture was more effective than placebo acupuncture, usual care or no treatment, rather than to determine which acupuncture treatment protocol was more effective. One study recently reported that an acupuncture group that received 20 treatments experienced more effects than the sham control group²⁾, and also that acupuncture had a long-term effect³⁾. In a Cochrane review, a treatment protocol to establish the quality of acupuncture treatment was carried outs at least once a week, with a total of 6 treatment sessions. In the subgroup analysis, the effect size of the verum acupuncture group was consistently larger than that of the sham control group in studies of patients that received 16 or more acupuncture treatments⁴⁾.

Discussion of appropriate acupuncture treatment has not had a leading role in previous acupuncture research and has not even been given a chance to be staged. This is because it was assumed that it was already well-considered in the study design process. Although rare, studies on dose components of acupuncture are still ongoing and their importance is being re-evaluated. For example, studies have been conducted on optimal stimulation intensity and number or frequency of treatment sessions⁵⁾. A recent study published in British Medical Journal⁶⁾ emphasised the design of high- quality acupuncture studies, and proposed the formation of an expert committee to define the optimal strategy for the details of acupuncture as a consideration. Welcome to the opportunity to have this topic on stage.

This commentary contains some of my contributions to the “expert summary & commentary” prepared at the request of the Korean Medicine Convergence Research Information Centre (KMCRIC). I would like to thank Prof. Hyangsook Lee, director of the KMCRIC, for giving me the opportunity to write a commentary.

None.

The authors can provide upon reasonable request.

The author has declared that no conflicts of interest exists.