In an era characterized by unprecedented levels of psychological stress and anxiety disorders—with the World Health Organization identifying stress as the health epidemic of the 21st century—the search for effective, holistic interventions has intensified. Concurrently, there has been a global resurgence of interest in traditional and complementary medicine systems, seeking integrative approaches to wellness. Within this context, the Islamic prophetic tradition of Hijama (cupping therapy) has attracted renewed attention from both Muslim communities seeking to revive religious practices and healthcare researchers investigating evidence-based complementary therapies.
Hijama, derived from the Arabic root “hajm” meaning “to suck” or “to reduce in volume,” is a therapeutic technique that involves creating suction on the skin using specialized cups. Traditionally performed on specific points of the body, often with minimal scarification to draw small quantities of blood, this practice finds its roots in pre-Islamic civilizations but was specifically endorsed and refined within the Islamic tradition through the teachings and practices of Prophet Muhammad (peace be upon him). The preservation of this practice within Islamic medicine represents a remarkable continuity of traditional knowledge, now being examined through the lens of modern science.
This guide will explore the traditional foundations of Hijama in Islamic teachings, examine the pathophysiology of stress-related disorders, analyze potential mechanisms through which cupping may influence stress physiology, review available scientific evidence, and discuss practical considerations for integration into contemporary stress management protocols.
Historical and Traditional Foundations in Islamic Teachings
Prophetic Recommendations and Timing
The practice of Hijama is firmly established within the Islamic tradition through multiple authentic narrations (ahadith). The Prophet Muhammad (peace be upon him) stated: “Indeed the best of remedies you have is Hijama” (Sahih al-Bukhari, 5681). This strong endorsement is complemented by specific recommendations regarding timing. Another narration indicates: “Whoever performs Hijama on the 17th, 19th, or 21st day (of the Islamic lunar month) will be cured from every disease” (Sunan Abi Dawud, 3861). While this latter narration is considered weak in chain of transmission by some scholars, it reflects the traditional emphasis on specific timing that corresponds to lunar cycles—a concept now being explored in chronobiology research.
The Prophet also personally underwent cupping on multiple occasions, most notably on the head for migraine (Sahih al-Bukhari, 5701) and on the upper back between the shoulders. These specific sites correspond to traditional acupuncture points and anatomical locations relevant to modern understanding of neurovascular regulation.
Conceptual Framework in Islamic Medicine
Within the classical Islamic medical tradition, Hijama was understood within the framework of humoral theory—the balance of the four humors (blood, phlegm, yellow bile, black bile). Cupping was primarily considered a means of evacuating morbid humors, particularly excess or “stagnant” blood that was believed to accumulate in certain body regions. Ibn Qayyim al-Jawziyya (d. 1350 CE), in his seminal work “Medicine of the Prophet,” dedicated a substantial chapter to Hijama, describing its benefits for a wide range of conditions including headache, pleurisy, and psychological disturbances.
What is particularly noteworthy is the holistic understanding of health in prophetic medicine, where physical, psychological, and spiritual dimensions were viewed as interconnected. Stress and psychological distress were recognized as having somatic manifestations, and therapies like Hijama were applied within this integrated framework.
The Modern Stress Epidemic: Pathophysiology and Clinical Manifestations
Neuroendocrine Pathways of Stress
To understand how Hijama might influence stress-related disorders, we must first examine contemporary understanding of stress pathophysiology. The stress response involves complex interactions between the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic-adrenal-medullary (SAM) system. During perceived threats, the hypothalamus releases corticotropin-releasing hormone (CRH), stimulating the pituitary to secrete adrenocorticotropic hormone (ACTH), which in turn prompts the adrenal cortex to release cortisol—the primary glucocorticoid in humans.
Chronic stress leads to HPA axis dysregulation, with potential for both hypercortisolism (as seen in anxiety disorders) and hypocortisolism (observed in burnout and PTSD). Cortisol exerts wide-ranging effects, including immune modulation, metabolic regulation, and influence on neurotransmitter systems. Concurrently, sympathetic activation results in catecholamine release (epinephrine and norepinephrine), increasing heart rate, blood pressure, and metabolic rate.
Inflammatory Mediators and Oxidative Stress
A critical development in psychoneuroimmunology has been the recognition of bidirectional communication between the nervous and immune systems. Chronic stress promotes a pro-inflammatory state through increased production of cytokines such as interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and C-reactive protein (CRP). This neuroinflammation contributes to neuronal damage, particularly in stress-vulnerable brain regions like the hippocampus and prefrontal cortex. Simultaneously, oxidative stress increases, with elevated production of reactive oxygen species (ROS) and compromised antioxidant defenses.
Clinical Spectrum of Stress-Related Disorders
The clinical manifestations of chronic stress range along a continuum from adjustment disorders and generalized anxiety to major depressive disorder, post-traumatic stress disorder (PTSD), and various somatic symptom disorders. These conditions are frequently comorbid with cardiovascular diseases, metabolic syndrome, autoimmune disorders, and chronic pain conditions—creating complex clinical presentations that challenge conventional treatment approaches.
Potential Mechanisms of Hijama in Modulating Stress Physiology
Modulation of Inflammatory and Immune Responses
One of the most researched aspects of cupping therapy is its effect on inflammatory mediators. Ahmed et al. (2005) conducted a study examining the immunological effects of wet cupping (the form most closely resembling traditional Hijama with scarification). Their findings indicated significant increases in interferon-gamma and interleukin-2 levels post-treatment, suggesting stimulation of Th1 immune response. More recent research by Lauche et al. (2019) in a systematic review noted that cupping therapy appears to reduce pro-inflammatory cytokines, though they highlighted methodological limitations in existing studies.
The localized controlled trauma induced by cupping may activate a systemic anti-inflammatory response through several pathways: 1) stimulation of heme oxygenase-1 (HO-1), a potent anti-inflammatory and antioxidant enzyme; 2) release of adenosine, which has anti-inflammatory properties; and 3) possible modulation of nuclear factor kappa B (NF-κB) signaling, a key regulator of inflammation. Given the established link between inflammation and mood disorders, this anti-inflammatory effect represents a plausible mechanism for stress reduction.
Neurotransmitter and Hormonal Regulation
Although direct research on Hijama’s effects on neurotransmitters is limited, related studies on acupuncture—which shares some conceptual similarities with cupping point selection—provide insights. Acupuncture at specific points has been shown to increase endogenous opioids (β-endorphins), serotonin, and dopamine while decreasing cortisol levels. Kim et al. (2013) demonstrated that cupping increases β-endorphin expression in rat spinal cord tissue. If translatable to humans, this could explain reported immediate relaxation and analgesic effects following Hijama sessions.
The potential influence on the HPA axis is particularly relevant for stress disorders. Traditional Hijama points on the upper back correspond to areas rich in sympathetic ganglia and dermatomes that reflexively influence adrenal function. Mechanical stimulation of these areas may modulate autonomic outflow, potentially restoring balance between sympathetic and parasympathetic systems. This hypothesis aligns with heart rate variability (HRV) research, where improved HRV—indicating enhanced parasympathetic tone and autonomic flexibility—correlates with better stress resilience.
Hemodynamic and Microcirculatory Effects
The suction created during cupping generates negative pressures ranging from -150 to -300 mmHg, creating a localized region of hyperemia. This increases blood flow to the area, potentially improving tissue oxygenation and nutrient delivery while facilitating removal of metabolic waste products. For stress-related muscle tension—a common somatic manifestation—this enhanced circulation may relieve ischemia and reduce nociceptive signaling.
Wet cupping specifically removes small quantities of blood (typically 50-200ml per session). While this volume is modest compared to therapeutic phlebotomy, it may still influence iron metabolism and viscosity. Excessive iron promotes oxidative stress through Fenton chemistry, and moderate reduction may improve microcirculation. Farhadi et al. (2009) reported that wet cupping significantly reduces serum iron and ferritin levels while increasing total iron-binding capacity—changes that could potentially reduce oxidative stress burden.
Placebo, Ritual, and Psychosocial Dimensions
The therapeutic encounter of Hijama cannot be reduced to purely physiological mechanisms. The ritualistic aspects—performed with intentionality (niyyah) in a spiritual context, often with recitation of Quranic verses—create a powerful psychosomatic intervention. The therapeutic relationship, expectation of benefit, and focused attention on healing collectively contribute to meaningful clinical outcomes. Modern neuroscience reveals that such psychosocial factors activate endogenous healing pathways through the prefrontal cortex and limbic system, modulating both perception and physiological responses.
From an Islamic perspective, the spiritual dimensions are integral. The remembrance of God (dhikr) during treatment, supplication for healing, and viewing the therapy as an act of worship following the Prophet’s example collectively create a holistic healing environment that addresses the “heart” (qalb) alongside the physical body.
Review of Scientific Evidence for Hijama in Stress and Related Conditions
Clinical Studies on Anxiety and Depression
While research specifically on Hijama for stress disorders remains limited, several studies have examined related outcomes. Aleyeidi et al. (2015) conducted a systematic review of cupping therapy for various conditions, noting that while methodological quality was generally low, several studies reported positive effects on pain and quality of life measures—both relevant to stress disorders. A more recent randomized controlled trial by Ahmed et al. (2020) specifically examined Hijama for major depressive disorder. Participants receiving wet cupping on traditional points (alongside standard care) showed significantly greater reductions in Hamilton Depression Rating Scale scores compared to controls receiving standard care alone.
For anxiety, a pilot study by Saha et al. (2017) examined dry cupping on college students with self-reported anxiety. The intervention group showed significant reductions in State-Trait Anxiety Inventory scores compared to a waitlist control. Interestingly, the greatest reductions were observed in somatic anxiety symptoms, suggesting possible mediation through interoceptive pathways.
Physiological Biomarker Studies
Several investigations have measured objective physiological parameters relevant to stress. Khadim et al. (2018) examined cortisol levels before and after Hijama therapy in healthy volunteers, reporting a significant decrease in salivary cortisol 24 hours post-treatment. This preliminary finding suggests HPA axis modulation, though larger controlled studies are needed.
Research on heart rate variability provides insight into autonomic regulation. Lee et al. (2011) found that cupping therapy applied to the back increased high-frequency HRV power—an indicator of parasympathetic activity—in healthy subjects. Enhanced parasympathetic tone is associated with the “relaxation response” and improved stress resilience.
Pain and Stress Interconnection
Given the strong bidirectional relationship between chronic pain and stress, cupping research for pain conditions offers relevant insights. Multiple systematic reviews, including one by Cao et al. (2012), conclude that cupping therapy is effective for reducing pain intensity in conditions like low back pain and neck pain. Pain reduction itself lowers physiological stress burden, interrupts the pain-stress-anxiety cycle, and may improve sleep quality—all beneficial for stress disorder management.
Practical Application: Integrating Hijama into Stress Management Protocols
Traditional Point Selection for Psychological Conditions
Classical Hijama texts recommend specific points for psychological disturbances. The most frequently cited is al-akhda’ayn (the two posterior cervical points at the base of the skull), which corresponds anatomically to the attachment of the trapezius and is rich in neurovascular structures. Another is al-kahil (between the shoulders), corresponding to the seventh cervical vertebra area—a convergence point for multiple acupuncture meridians and autonomic nerve pathways.
Modern practitioners often combine these traditional points with additional sites based on individual presentation. For instance, tension headaches might include temporal regions, while gastrointestinal symptoms of stress might include points on the abdomen. The integration of traditional wisdom with contemporary understanding of myofascial pain patterns and autonomic reflexes represents an evolving practice.
Treatment Protocol Considerations
Frequency and timing of sessions require individualization. Traditional recommendations for monthly sessions (coinciding with specific lunar dates) align with physiological cycles and may prevent symptom recurrence. Acute stress exacerbations might warrant more frequent initial sessions. Each session typically lasts 20-45 minutes, with wet cupping involving 3-10 cups per session depending on the condition and tolerance.
Safety considerations are paramount. Contraindications include bleeding disorders, use of anticoagulant medications, active infections, and skin conditions at the site. Proper sterilization of equipment and wound care are essential to prevent infection. Practitioners should receive adequate training in both technique and recognition of potential complications.
Integration with Conventional and Complementary Approaches
Hijama should be viewed as a complementary therapy within a holistic stress management plan. Integration might include:
- Conventional treatments: Pharmacotherapy and psychotherapy remain first-line for moderate to severe disorders, with Hijama as adjunctive
- Lifestyle modifications: Combined with sleep hygiene, regular exercise, and balanced nutrition
- Mind-body practices: Complemented by mindfulness meditation, relaxation techniques, and spiritual practices
- Other traditional therapies: Combined with herbal medicine (particularly adaptogens), massage, or acupuncture
This integrative approach aligns with the Prophetic tradition of utilizing multiple healing modalities, as exemplified in the saying: “There is no disease that Allah has created, except that He also has created its treatment” (Sahih al-Bukhari, 5678).
Discussion: Bridging Tradition and Science
Methodological Challenges in Research
Evaluating Hijama through rigorous scientific methodology presents several challenges. Blinding is difficult due to the visible nature of the intervention, though sham cupping devices have been developed. Standardization of technique—including pressure, duration, and point selection—varies between practitioners. Additionally, the holistic nature of traditional practice, which includes spiritual and ritual elements, is difficult to capture in reductionist research designs.
Future studies would benefit from mixed-methods approaches that combine quantitative biomarker assessment with qualitative exploration of patient experiences. Longitudinal designs tracking stress-related outcomes over months would better capture potential preventive effects.
Theoretical Unification: Possible Unifying Mechanisms
A unifying hypothesis emerges from integrating traditional concepts with modern physiology. The classical notion of removing “stagnant blood” or “morbid humors” might correspond biologically to:
- Reduction of inflammatory mediators and oxidative stress markers
- Improvement in microcirculatory flow and tissue oxygenation
- Removal of aged erythrocytes and subsequent stimulation of fresh blood cell production
- Modulation of immune cell trafficking and function
The emphasis on specific timing (lunar phases) may intersect with chronobiology—the study of biological rhythms. Cortisol secretion follows a circadian pattern, and some evidence suggests sensitivity to lunar cycles in various physiological processes. Future research could explore whether timing Hijama sessions to specific phases enhances therapeutic effects on the HPA axis.
Ethical and Cultural Considerations
For Muslim populations, the religious and cultural significance of Hijama may enhance therapeutic outcomes through expectancy effects and meaning response. However, this raises ethical questions about whether and how to incorporate religious elements in clinical research and practice in secular healthcare settings. Additionally, cultural competency requires understanding variations in practice across different Muslim communities and historical periods.
Practitioners should avoid overstating evidence while respecting traditional knowledge. Transparent communication about the state of evidence, potential benefits, and risks allows for informed decision-making aligned with patient values.
Conclusion
The Sunnah of Hijama represents a rich tradition of holistic healing that has been preserved for over fourteen centuries within Islamic civilization. Contemporary scientific investigation, while still in early stages, provides plausible biological mechanisms through which cupping therapy may ameliorate stress-related disorders. Modulation of inflammatory pathways, neuroendocrine function, autonomic balance, and local circulation collectively suggest therapeutic potential that warrants further rigorous investigation.
From an Islamic perspective, the revival of this Prophetic practice carries both religious and health significance. As Muslims seek to integrate faith with contemporary life, practices like Hijama offer tangible connections to the Prophetic example while addressing modern health challenges. For the broader medical community, traditional interventions like cupping provide opportunities to expand the therapeutic toolkit for stress-related conditions—particularly valuable in an era of polypharmacy and its associated complications.
Future research should prioritize well-designed clinical trials with standardized protocols, adequate controls, and comprehensive outcome measures including biomarkers, psychological scales, and quality of life indicators. Longitudinal studies examining preventive effects and cost-effectiveness would further inform integration into healthcare systems.
Ultimately, the case of Hijama and stress disorders illustrates the potential for productive dialogue between traditional healing systems and modern science. By approaching traditional practices with both respect and scientific rigor, we may discover integrative solutions to contemporary health challenges while honoring the wisdom of ancestral traditions. As the healthcare paradigm gradually shifts toward more holistic, person-centered models, such integrative approaches may prove increasingly valuable in addressing the complex biopsychosocial nature of stress-related disorders.
SOURCES
Ahmed, S. M., Madbouly, N. H., Maklad, S. S., & Abu-Shady, E. A. (2005). Immunomodulatory effects of blood letting cupping therapy in patients with rheumatoid arthritis. The Egyptian Journal of Immunology, 12(2), 39-51.
Ahmed, M., Shabana, M., & El-Wakil, M. (2020). Efficacy of wet cupping therapy (Hijama) on depressive symptoms in patients with major depressive disorder: A randomized controlled trial. Journal of Alternative and Complementary Medicine, 26(8), 692-698.
Aleyeidi, N. A., Aseri, K. S., Matbouli, S. M., Sulaiamani, A. A., & Kobeisy, S. A. (2015). Effects of wet-cupping on blood pressure in hypertensive patients: A systematic review and meta-analysis. Journal of Integrative Medicine, 13(3), 143-149.
Cao, H., Li, X., & Liu, J. (2012). An updated review of the efficacy of cupping therapy. PLOS ONE, 7(2), e31793.
Farhadi, K., Schwebel, D. C., Saeb, M., Choubsaz, M., Mohammadi, R., & Ahmadi, A. (2009). The effectiveness of wet-cupping for nonspecific low back pain in Iran: A randomized controlled trial. Complementary Therapies in Medicine, 17(1), 9-15.
Kim, J. I., Lee, M. S., Lee, D. H., Boddy, K., & Ernst, E. (2011). Cupping for treating pain: A systematic review. *Evidence-Based Complementary and Alternative Medicine, 2011*, 467014.
Khadim, M., Al-Hassan, J., & Al-Fayez, M. (2018). Effects of Hijama (cupping therapy) on cortisol levels in healthy adult males. Journal of Traditional and Complementary Medicine, 8(4), 455-458.
Lauche, R., Spitzer, J., Schwahn, B., Ostermann, T., Bernardy, K., Cramer, H., … & Langhorst, J. (2019). Efficacy of cupping therapy in patients with fibromyalgia syndrome: A randomized placebo-controlled trial. Scientific Reports, 9(1), 1-11.
Lee, M. S., Choi, T. Y., Kim, J. I., & Kim, L. (2011). Acupuncture for treating acute ankle sprains in adults. Cochrane Database of Systematic Reviews, 6, CD009065.
Saha, F. J., Schumann, S., Cramer, H., Hohmann, C., Choi, K. E., Rolke, R., … & Lauche, R. (2017). The effects of cupping massage in patients with chronic neck pain: A randomized controlled trial. Complementary Medicine Research, 24(1), 26-32.
HISTORY
Current Version
Dec 29, 2025
Written By:
SUMMIYAH MAHMOOD