What a pilot study found - and where the research goes next
A Common and Difficult Consequence of Concussion
Chronic post-traumatic headache is one of the most persistent and disabling symptoms after mild traumatic brain injury, or concussion. It may resemble migraine, tension-type headache, or a combination of the two. For some patients, it becomes nearly continuous. In the pilot study discussed here, participants reported headaches on an average of 22 out of every 28 days before treatment.
That level of symptom burden can affect far more than pain. Chronic post-traumatic headache can interfere with sleep, concentration, work, exercise, social participation, and the broader process of neurological recovery. Yet there are no medications specifically approved by the U.S. Food and Drug Administration for post-traumatic headache. Clinicians often borrow treatment strategies from primary migraine or tension-type headache, sometimes with limited benefit or unwanted side effects.
This makes the search for safe, evidence-informed, nonpharmacological options especially important. Acupuncture is already supported by a substantial body of research for migraine and tension-type headache, but it has been studied far less often in people whose headaches began after a brain injury.
The Question Behind the Study
Our research team designed this pilot randomized controlled trial to examine two practical questions: Is a standardized acupuncture protocol safe and feasible for adults with chronic post-traumatic headache after mild traumatic brain injury, and does treatment frequency matter?
Thirty-eight adults were randomized to one of two treatment schedules delivered over five weeks:
- Low-dose group: five treatments, generally once per week.
- High-dose group: ten treatments, generally twice per week.
Participants were 18 to 70 years old, had sustained a mild traumatic brain injury between three months and two years before enrollment, and had developed a headache within seven days of the injury that persisted for at least three months. The median time from mild traumatic brain injury diagnosis to study enrollment was 7.7 months. Twenty-nine participants completed the full study.
I was honored to serve as a co-author on this work and to help develop the acupuncture protocol used in the study. Because of the small size of the pilot study, serving as a preliminary data-collection study, every participant received the same point prescription rather than an individualized pattern-based treatment.
Inside the Acupuncture Protocol
Each 30-minute treatment used 18 needles. Fourteen points received manual acupuncture, and four received electroacupuncture:
- Manual acupuncture: Yintang and DU20, plus bilateral LV3, UB2, SI19, Anmian, auricular Shen Men, and auricular Point Zero.
- Electroacupuncture: bilateral LI4 and ST36 using continuous stimulation at 2 Hz, increased gradually to a comfortable, nonpainful intensity.
Needles were inserted to obtain deqi. After 10 minutes, the manually stimulated needles were rotated again to maintain the sensation, while LI4 and ST36 remained under electrical stimulation. All needles were retained for 30 minutes.
The point selection was not based on a single traditional pattern. It was designed as a pragmatic research protocol, drawing on classical indications, anatomical relationships, potential effects on pain-processing networks, and prior literature related to cerebral blood flow. This distinction is important: the study tested a standardized intervention that could be administered consistently, not the full range of individualized clinical acupuncture.
What Did the Study Find?
1. Headache days decreased
Across both groups, participants experienced a statistically significant decrease in headache days compared with pretreatment:
- At four weeks after treatment, participants averaged 7.4 fewer headache days per 28-day period.
- At 12 weeks after treatment, they averaged 5.1 fewer headache days per 28-day period.
The average number of headache days began at approximately 22 out of 28 days in both groups. Four weeks after treatment, the averages were 15 days in the five-treatment group and 18 days in the ten-treatment group. At 12 weeks, both groups averaged 17 headache days.
2. Headache intensity also improved
Average headache intensity decreased by 0.6 points on a 0-to-10 scale at four weeks and by 0.8 points at 12 weeks across study participants. These changes were statistically significant, although the clinical meaning of a change of this size should be interpreted in the context of each patient's baseline pain and overall function.
3. Five treatments performed similarly to ten
The study found no significant difference between the low-dose and high-dose groups for headache frequency or intensity. This does not prove that five treatments are equivalent to ten in every patient. The trial was small and was designed as a pilot. It does suggest, however, that some people with chronic post-traumatic headache may experience measurable benefit after a relatively short course of a standardized protocol.
4. Medication use and sleep did not significantly change during the timeframe
Acute headache medication use remained generally stable, and the Pittsburgh Sleep Quality Index did not show a significant treatment-related improvement. Several quality-of-life measures improved, including pain interference, with additional signals in areas such as communication, executive function, self-esteem, cognition, anxiety, and headache pain. Because these were exploratory analyses involving many outcomes, they should be viewed as hypothesis-generating rather than definitive.
5. Treatment was feasible and well tolerated
No serious adverse events were documented. The most common treatment-related events were expected reactions such as pain, bruising, or discomfort at a needle site. Treatment adherence was high in both groups, averaging 95% in the five-treatment group and 91% in the ten-treatment group. For a population living with frequent headache and other possible post-concussion symptoms, that level of adherence is encouraging.
How Might Acupuncture Influence Post-Traumatic Headache?
The study was designed to evaluate clinical outcomes, not to prove a specific biological mechanism. Still, the discussion offers several plausible pathways that may help acupuncturists connect the protocol with contemporary pain neuroscience.
All headache pain involves the trigeminal system. After a mild traumatic brain injury, changes within trigeminal and central pain-processing networks may contribute to persistent headache and heightened sensory sensitivity. Acupuncture stimulation has been associated in other research with modulation of the trigeminocervical complex, the rostral ventromedial medulla, descending pain-inhibitory pathways, and cortical regions such as the insula that help process the intensity and meaning of pain.
Several face and scalp points used in the protocol lie near branches of the trigeminal nerve, while the electroacupuncture pairing of LI4 and ST36 provides strong distal somatosensory input. These mechanisms remain hypotheses in the specific context of chronic post-traumatic headache, but they offer a useful framework for future mechanistic studies.
What Acupuncturists Can Take From This Study
Post-traumatic headache deserves to be studied as its own clinical condition. A headache that begins after a concussion may look like migraine or tension-type headache, but its injury context, associated symptoms, and rehabilitation needs matter.
Headache days are a useful outcome. A simple 28-day diary can reveal changes that may be lost when clinicians ask only for a current pain score.
A standardized protocol can create a reproducible research foundation. It allows investigators to test safety, feasibility, dosage, and preliminary outcomes before introducing more clinical variation.
A short initial treatment course may be worth studying further. The absence of a dose difference suggests that improvement may begin within five sessions for some patients, although this finding requires confirmation in a larger trial.
Standardization is not the same as everyday practice. Acupuncturists commonly modify treatment according to headache phenotype, examination findings, comorbid symptoms, and pattern differentiation. Future research should examine which elements should remain consistent and where individualized decision-making may improve outcomes.
Important Limitations
This was a promising pilot study, not a definitive efficacy trial. It did not include a sham acupuncture, usual-care, or no-treatment control group. We can therefore say that participants improved after acupuncture, but we cannot conclude from this study alone how much of that improvement was caused specifically by the acupuncture intervention rather than expectancy, natural symptom fluctuation, regression to the mean, or other factors.
The sample was small, the participants and practitioners could not be blinded to treatment frequency, and the standardized protocol did not reflect the individualized care commonly delivered in clinical practice. Participants were also not randomized according to headache phenotype. These limitations do not erase the findings; they define the questions the next study needs to answer.
Next Steps: A Larger Multisite Study and a Delphi Panel
The next phase of this work is intended to move beyond a single-site pilot. We are currently seeking funding for a larger study that would include treatment sites in Minnesota and Oregon. A multisite design would allow us to recruit a larger and potentially more diverse group of participants, evaluate whether the findings can be reproduced across clinical settings, and build a stronger estimate of treatment effect.
We are also working toward the creation of a Delphi panel focused on future acupuncture protocols for chronic post-traumatic headache. A Delphi process brings together a group of knowledgeable clinicians and researchers through structured rounds of review and consensus-building. The goal would not be to declare one universal point prescription. Instead, the panel could help identify which treatment elements should be standardized for research, which variables should be individualized, how headache phenotypes and common post-concussion comorbidities should influence protocol design, and which outcomes are most meaningful to patients and practitioners.
For acupuncture research to become more clinically useful, the protocols must be rigorous enough to reproduce and flexible enough to reflect how skilled acupuncturists actually practice. This pilot study provides an important starting point. The next studies can now ask more specific questions about efficacy, treatment dose, patient selection, individualized care, and the durability of improvement.
The Bottom Line
In this pilot study, a standardized acupuncture protocol was safe, well tolerated, and associated with fewer headache days and lower headache intensity in adults with chronic post-traumatic headache after mild traumatic brain injury. Five treatments produced outcomes similar to ten treatments, and the reduction in headache days remained statistically significant 12 weeks after treatment.
The results are encouraging, but they should be understood as an invitation to conduct better and larger research, not as final proof. For acupuncturists, the study offers something valuable: an evidence-informed, reproducible foundation for investigating a difficult condition for which patients urgently need more options.