I recently listened to a TEDx talk by health psychologist Kelly McGonigal (@kellymcgonigal) where she discusses the role of stress in our lives and how our interpretation of stress can have an impact on whether or not we are likely to die due to a stress related condition. Sounds a little dramatic doesn’t it?

Make stress your friend

She discusses interesting research which showed that those who interpret stress as being harmful to our health are more likely to develop stress related health complications and subsequent mortality. This negative consequence of stress was not seen in those who interpreted stress more positively, as a way of preparing the body for a challenging event or situation. Her line ‘make stress your friend’ may help those, including myself at times, who find managing stress an ongoing challenge.

Later in the talk she went on to discuss the role of Oxytocin in the stress response. Just to remind you, oxytocin is a a mammalian neurohypophysial hormone, secreted by the posterior pituitary gland, that acts primarily as a neuromodulator in the brain. Its often referred to as the ‘bonding’ or ‘cuddle’ hormone.

The catchy title of the post is actually the title of a very good book by Robert Sapolsky in which he describes how zebra's in the wild are very good at going about there business in a state of relaxed responsiveness, what he would call the 'green zone'.

Then a lion is on the attack, there is an immediate reactive shift into the red zone when the fight or flight response kicks in. It's all go, a primal biological response geared at self preservation. Once the attack is over and the threat removed, zebra's as well as others in the wild are pretty good at returning to the green zone as the fight or flight response winds down. The zebras then return to going about their business in a state of relative calm but alert to potential threats and ready to respond when needed.

As humans we are susceptible to many threats, some real and some imagined, both internal such as pain, infection and disease and some external such as threats to our physical or emotional well-being, perhaps a combination of both.

How does this relate to people?

Let's take pain as a perceived threat, one we are all familiar with having to deal with as therapists.

It is generally considered that the opioid analgesic response which constitutes part of the extra segmental mechanisms of Acupuncture has an ‘all over body’ effect. This may partly explain why it is possible to suppress pain, regardless of where the needle is inserted. This response is more likely to be triggered by the non specific effects of Acupuncture relating to context and expectation.

However, a very interesting study by Benedetti and his colleagues showed that we can also experience a localised anaesthesia response in response to suggestion.

In the study, localised pain was induced by injecting capsaicin into 4 different parts of the body simultaneously. An inactive placebo cream was then applied to just one of these areas which produced local analgesia ONLY in the area where the cream was applied. Furthermore the analgesic response was blocked by naloxone suggesting the opioid systems were at work.

As Benedetti went on to conclude:

There are a number of proposed central regulatory effects of Medical Acupuncture. It is the ability of Acupuncture to moderate the emotive component of pain (i.e. the extent to which it bothers, is considered to be unpleasant or evokes feelings of concern, worry or anxiety) which has received the most interest in research terms.

When considering how Acupuncture can influence our emotive state, it is the response of the limbic and paralimbic areas, in particular the anterior cingulate cortex which appear to be most important (Hui et al, 2000).

We know that in addition to the needle stimulus Acupuncture effects are partly dependant on expectation and preconditioning of the ‘reward’ centres of the brain. It is these so called central nonspecific or ‘placebo’ effects which may explain why those receiving placebo induced analgesia show reduced activity on fMRI within the anterior cingulate cortex as well as the thalamus and insula - reference.

You have a patient who you have diagnosed with primary tension type headache or who has possibly been a referred migraine sufferer with a view to providing prophylactic treatment - so what next?

Assuming the correct diagnostic criteria have been met, and there are no red flags suggesting further medical evaluation may be needed, the NICE guidelines now suggest that Medical Acupuncture has a role to play in both scenarios.

Migraine

Abortive treatments of migraine are non specific for example Paracetamol and NSAIDS. Specific treatment includes triptans which may be used concurrently with prokinetics such as domperidone or metoclopramide for associated nausea.

Preventative treatments in migraine include antidepressants, B blockers, anticonvulsants and Acupuncture with 10 sessions over 5 weeks recommended.