The safety and preventive effects of a supraorbital transcutaneous stimulator in Japanese migraine patients

Non-Pharmacological Treatment for Chronic Migraine

PURPOSE OF REVIEW

Chronic migraine (CM) affects a large proportion of the population and is a significant source of disability and lost productivity. Numerous non-pharmacological approaches have been attempted during the past decades. This review discusses the most recent and evidence-based advances in acute and preventive non-pharmacological therapeutic approaches for CM, offering alternatives to drug treatment.

RECENT FINDINGS

A growing number of non-pharmacological treatment options, including non-invasive or invasive neuromodulation, acupuncture, psychotherapy, and physiotherapy, have shown promising efficacy in CM. There is strong evidence for the effectiveness of non-invasive neuromodulation such as transcranial magnetic stimulation, transcranial direct current stimulation, and transcutaneous electrical nerve stimulation (TENS) in CM, but less evidence for approaches such as invasive neuromodulation, physical therapy, or dietary approaches. Acupuncture for migraine remains controversial, with the main point of contention still being the placebo effect. Non-pharmacological approaches can be offered as a reliable alternative for patients with CM, and more research is being done to evaluate the efficacy of non-invasive neuromodulation with different parameters and the combination of different treatments in CM.

Clinical and cognitive effects of external trigeminal nerve stimulation (eTNS) in neurological and psychiatric disorders: a systematic review and meta-analysis

This pre-registered (CRD42022322038) systematic review and meta-analysis investigated clinical and cognitive outcomes of external trigeminal nerve stimulation (eTNS) in neurological and psychiatric disorders. PubMed, OVID, Web of Science, Chinese National Knowledge Infrastructure, Wanfang, and VIP database for Chinese technical periodicals were searched (until 16/03/2022) to identify trials investigating cognitive and clinical outcomes of eTNS in neurological or psychiatric disorders. The Cochrane Risk of Bias 2.0 tool assessed randomized controlled trials (RCTs), while the Risk of Bias of Non-Randomized Studies (ROBINS-I) assessed single-arm trials. Fifty-five peer-reviewed articles based on 48 (27 RCTs; 21 single-arm) trials were included, of which 12 trials were meta-analyzed (N participants = 1048; of which ~3% ADHD, ~3% Epilepsy, ~94% Migraine; age range: 10-49 years). The meta-analyses showed that migraine pain intensity (K trials = 4, N = 485; SMD = 1.03, 95% CI[0.84-1.23]) and quality of life (K = 2, N = 304; SMD = 1.88, 95% CI[1.22-2.53]) significantly improved with eTNS combined with anti-migraine medication. Dimensional measures of depression improved with eTNS across 3 different disorders (K = 3, N = 111; SMD = 0.45, 95% CI[0.01-0.88]). eTNS was well-tolerated, with a good adverse event profile across disorders. eTNS is potentially clinically relevant in other disorders, but well-blinded, adequately powered RCTs must replicate findings and support optimal dosage guidance.

The Serum Oxidative Stress Biomarkers and Selenium Levels in a Group of Migraine Patients Compared with Healthy Controls: a Case-Control Study

Migraine is one of the most common neurological disorders associated with recurrent attacks of moderate to severe headache. Oxidative stress may play an important role in migraine pathogenesis. This study aimed to measure and compare the serum levels of Selenium, total antioxidant capacity (TAC), and malondialdehyde) MDA (in migraine patients and healthy individuals. This case-control study was performed on 31 migraine patients and 30 age and gender-matched healthy controls. The severity of headache was assessed with a standard questionnaire, and the serum levels of Selenium (Se), MDA, and TAC were measured via biochemical methods. The odds of migraine were calculated across quartile of Se and oxidative stress biomarkers via binary logistic regression. Migraine patients had a significant lower Se levels (81.06 ± 8.66 vs. 88.94 ± 10.23 μg/L, P = 0.002) and a significant higher MDA levels (3.04 ± 1.74 vs. 2.06 ± 0.59 nmol/ml, P = 0.005) compared to healthy participants. Although serum TAC levels (1.34 ± 0.34 vs.1.37 ± 0.33 mmol/L, P = 0.755) were not significantly different between migraine patients rather than healthy subjects. Individuals in the lowest quartile of Se levels were about eleven times more likely to have migraine than those in the highest quartile (OR: 11.2; 95%CI: 1.57 to 80.2; P-trend: 0.016). Besides, being in the highest quartile of the serum MDA level, the odds of having migraine increases 15.4 times compared to the lowest quartile (OR = 15.4, 95%CI: 1.1 to 221, P = 0.044). No significant association was found between TAC and migraine. The lower Se and MDA levels in migraine patients gives rise to the probability which oxidant status may play an underlying role in migraine pathophysiology.

Outcomes of transcutaneous nerve stimulation for migraine headaches: a systematic review and meta-analysis

BACKGROUND

Implanted and transcutaneous nerve stimulators have shown promise as novel non-pharmacologic treatment for episodic and chronic migraines. The purpose of this study was to summarize the reported efficacy of transcutaneous single nerve stimulators in management of migraine frequency and severity.

METHODS

A systematic review of five databases identified studies treating migraines with transcutaneous stimulation of a single nerve. Random effects model meta-analyses were conducted to establish the effect of preventive transcutaneous nerve stimulation on headache days per month and 0-10 numeric rating scale pain severity of headaches for both individuals with episodic and chronic migraines.

RESULTS

Fourteen studies, which treated 995 patients, met inclusion criteria, including 7 randomized controlled trials and 7 uncontrolled clinical trials. Transcutaneous nerve stimulators reduced headache frequency in episodic migraines (2.81 fewer headache days per month, 95% CI 2.18-3.43, I² = 21%) and chronic migraines (2.97 fewer headache days per month, 95% CI 1.66-4.28, I² = 0%). Transcutaneous nerve stimulators reduced headache severity in episodic headaches (2.23 fewer pain scale points, 95% CI 1.64-2.81, I² = 88%).

CONCLUSIONS

Preventive use of transcutaneous nerve stimulators provided clinically significant reductions in headache frequency in individuals with chronic or episodic migraines. Individuals with episodic migraines also experienced a reduction in headache pain severity following preventive transcutaneous nerve stimulation.

Neuromodulation for Chronic Daily Headache

Purpose of Review

We reviewed the literature that explored the use of central and peripheral neuromodulation techniques for chronic daily headache (CDH) treatment.

Recent Findings

Although the more invasive deep brain stimulation (DBS) is effective in chronic cluster headache (CCH), it should be reserved for extremely difficult-to-treat patients. Percutaneous occipital nerve stimulation has shown similar efficacy to DBS and is less risky in both CCH and chronic migraine (CM). Non-invasive transcutaneous vagus nerve stimulation is a promising add-on treatment for CCH but not for CM. Transcutaneous external trigeminal nerve stimulation may be effective in treating CM; however, it has not yet been tested for cluster headache. Transcranial magnetic and electric stimulations have promising preventive effects against CM and CCH.

Summary

Although the precise mode of action of non-invasive neuromodulation techniques remains largely unknown and there is a paucity of controlled trials, they should be preferred to more invasive techniques for treating CDH.

External Trigeminal Nerve Stimulation as a Non-pharmacological Option for the Prevention and Acute Treatment of Migraine

Migraine is a common condition affecting approximately 1.04 billion people worldwide. Despite the available pharmaceutical therapies, patients with migraine often prefer, or may require, non-medicinal treatments for their disease. External trigeminal nerve stimulation (e-TNS) is a non-invasive, non-drug device treatment approved by the US Food and Drug Administration for the prevention and acute treatment of migraine. The trigeminovascular system plays a key role in migraine pathophysiology; e-TNS percutaneously stimulates the supraorbital and supratrochlear branches of the ophthalmic division of the trigeminal nerve. This article reviews published studies of e-TNS in the prevention and acute treatment of migraine, highlights the versatility of e-TNS in individualizing migraine treatment and discusses future directions for research and clinical applications of e-TNS therapy.

Impact of transdermal trigeminal electrical neuromodulation on subjective and objective sleep parameters in patients with insomnia: a pilot study

PURPOSE

Transcutaneous trigeminal electrical neuromodulation (TTEN) is a new treatment modality that has a potential to improve sleep through the suppression of noradrenergic activity. This study aimed to explore the changes of subjective and objective sleep parameters after 4-weeks of daily session of transcutaneous trigeminal electrical neuromodulation in a group of patients with insomnia.

METHODS

In a group of patients with insomnia, TTEN targeting the ophthalmic division of the trigeminal nerve was utilized to test the effects of transcutaneous trigeminal electrical neuromodulation. Patients went through daily 20-min sessions of TTEN for 4 weeks. Polysomnography parameters, Pittsburgh sleep quality index, insomnia severity index, and Epworth sleepiness scale were obtained pre- and post-intervention. Changes in these parameters were compared and analyzed.

RESULTS

Among 13 patients with insomnia there was a statistically significant reduction in Pittsburgh sleep quality index, insomnia severity index, and Epworth sleepiness scale scores after 4-week daily sessions of TTEN. There were no differences in polysomnography parameters pre- and post-intervention.

CONCLUSION

This is the first study to demonstrate the effects of TTEN in a group of insomnia patients. TTEN may improve subjective parameters in patients with insomnia. Further replication studies are needed to support this finding.

TRIAL REGISTRATION

The data presented in the study are from a study exploring the effect of TTEN on insomnia ( www.clinicaltrials.gov , registration number: NCT04838067, date of registration: April 8, 2021, "retrospectively registered").

The Use of Electrical Nerve Stimulation to Treat Migraines: A Systematic Review

Migraines have been defined as an intense unilateral throbbing or pulsating sensation lasting anywhere between a few hours to multiple days. They are the sixth most prevalent disease in the United States, with approximately 18% of women and 6% of men experiencing some form of a migraine throughout their lifetime. In addition, they pose a significant economic burden, accounting for anywhere between $13 and $17 billion in medical costs annually in the United States. While there are a wide variety of treatments for migraines on the market, such as nonsteroidal anti-inflammatory drugs (NSAIDS), beta-blockers, and anti-epileptics, there is still no standard treatment. Moreover, each of these medications has a wide range of side effects, ranging from stomach ulcers to light-headedness. Within the last few decades, the presence of electrical nerve stimulation has emerged as a possible treatment option. These methods are almost free of harmful side effects and may be able to reduce the economic burden on those who suffer from migraines. However, studies have shown mixed results in regard to their efficacy. In this paper, we performed a systematic review to detail the current state of the literature regarding electrical nerve stimulation as a treatment modality for migraines.

Long-Term Trigeminal Nerve Stimulation as a Treatment for Ocular Pain

OBJECTIVES

Ocular pain symptoms (e.g., hypersensitivity to light and wind, "burning" sensations) can be debilitating and difficult to treat. Neuromodulatory therapies targeting sensory trigeminal and central pain pathways may help treat chronic ocular pain refractory to traditional therapies. The current study evaluates the long-term effects of a trigeminal neurostimulator (TNS) on ocular pain.

MATERIALS AND METHODS

Retrospective review of 18 individuals at the Miami Veterans Affairs Eye Clinic with chronic, severe ocular pain who were prescribed and used TNS at home for ≥3 months. The primary outcome measures were 1) ocular symptom intensity over a 24-hour recall period (dryness, pain, light sensitivity, wind sensitivity, burning; rated on 0-10 scales) captured pre-TNS and at monthly follow-up intervals and 2) side effects. The frequency and duration of TNS was a secondary outcome measure.

RESULTS

The mean age of the population (n = 18) was 57.5 years (range, 34-85 years) with a male majority (67%). Two individuals discontinued use due to lack of efficacy and one due to confounding health issues. Initial mean weekly frequency of TNS use was 3.7 ± 1.9 sessions of 25.8 min at month 1 and 2.7 ± 2.3 sessions of 28.0 min at month 6. At six months, pain intensity (↓ 31.4%), light sensitivity (↓ 36.3%), wind sensitivity (↓ 32.6%), and burning sensation (↓ 53.9%) were all decreased compared to baseline (p < 0.01 for all); greater decreases in ocular pain were noted in individuals with migraine (n = 10) than those without migraine (n = 8). No significant change was noted in mean dryness scores. Fifteen subjects experienced sedation with TNS use, persisting throughout the follow-up visits. No other adverse effects were communicated by any subjects.

CONCLUSION

Our study suggests TNS is a safe, adjunctive treatment option in individuals with severe, chronic ocular pain. Individuals demonstrated gradual, continual improvement in pain symptoms over time within a multimodal approach.

Long-Term Effects of Self-Administered Transcranial Direct Current Stimulation in Episodic Migraine Prevention: Results of a Randomized Controlled Trial

BACKGROUND

Migraine is a multifactorial neurovascular disorder, which affects about 12% of the general population. In episodic migraine, the visual cortex revealed abnormal processing, most likely due to decreased preactivation level. Transcranial direct current stimulation (tDCS) is able to modify cortical excitability and might result in an alleviation of migraine occurrence if used repetitively.

OBJECTIVE

To test the hypothesis that self-administered anodal tDCS over the visual cortex significantly decreases the number of monthly migraine days in episodic migraine.

MATERIALS AND METHODS

The study was single-blind, randomized, and sham-controlled. Inclusion criteria were age 18-80 years and an ICHD-3 diagnosis of episodic migraine. Exclusion criteria were pregnancy, presence of a neurodegenerative disorder, a contraindication against MRI examinations, and less than two migraine days during the 28-day baseline period. Patients in whom the baseline period suggested chronic migraine were excluded. After baseline, participants applied daily either verum (anodal-1 mA to 20 min) or sham tDCS (anodal-1 mA to 30 sec) at Oz (reference Cz electrode) for 28 days. Headache diaries were used to record the number of migraine days at baseline, during the stimulation period, and during four subsequent 28-day periods.

RESULTS

Twenty-eight patients were included; two were excluded after the baseline period because less than two migraine days occurred; three were excluded because their headache diaries suggested the diagnosis of chronic migraine. Twenty-three datasets were taken for further analysis. Compared to sham tDCS (n = 12), verum tDCS (n = 11) resulted in a lower number of migraine days (p = 0.010) across all follow-up periods. We found no significant change in total headache days (p = 0.165), anxiety (p = 0.884), or depression scores (p = 0.535). No serious adverse events occurred; minor side effects were similar in both groups.

CONCLUSIONS

This study provides Class II evidence that self-administered anodal tDCS over the visual cortex in episodic migraine results in a significantly lower number of monthly migraine days. However, it has neither an immediate nor a long-term effect.

Peripheral neuromodulation for the treatment of migraine and headache: recent advances

Noninvasive neuromodulation is a rapidly developing field that offers an attractive nonpharmacologic treatment option for headache patients. Devices that stimulate peripheral nerves (e.g., vagus nerve, trigeminal sensory nerve, somatic sensory nerve) or brain parenchyma (e.g., occipital cortex) have been developed for this purpose, with promising results in clinical trials. There are currently four US FDA-cleared devices for the treatment of migraine and/or cluster headache: Cefaly®, a trigeminal nerve stimulator; gammaCore™, a vagus nerve stimulator; sTMS mini™, a transcranial magnetic stimulator and Nerivio™, a remote electrical neurostimulator. This narrative review will provide an overview of FDA-cleared neuromodulatory devices, including their proposed mechanisms of action as well as device safety and efficacy as demonstrated in clinical trials.