Neuromodulation for the treatment of primary headache syndromes

Effectiveness of High-Frequency Repetitive Transcranial Magnetic Stimulation in Migraine: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of the study was to evaluate the effectiveness of repetitive transcranial magnetic stimulation in migraine measured by decrease in pain severity or attack frequency.

METHODS

A search at the Cochrane Controlled Trials Register (CENTRAL), MEDLINE (via PubMed), Embase, CINAHL, Web of Science, and Scopus. The risk of systematic bias was rated by using the Cochrane domain-based quality assessment tool. A random-effects model was used.

RESULTS

Of 434 identified records, 8 randomized control studies were included in the meta-synthesis. All have used a high-frequency repetitive transcranial magnetic stimulation targeting the left dorsolateral prefrontal cortex. The risk of systematic bias was low. The difference between repetitive transcranial magnetic stimulation and control groups in frequency of migraine days per month was 8.1 (95% confidence interval = 4.8 - 11.4) days in favor of repetitive transcranial magnetic stimulation. Respectively, for intensity of migraine pain (scaled from 0 to 100), this difference was 13.6 (95% confidence interval = 5.3 - 21.8) points in favor of repetitive transcranial magnetic stimulation. The heterogeneity was substantial with I2 = 86%.

CONCLUSIONS

In chronic migraine, repetitive transcranial magnetic stimulation seems to have positive effects on both migraine pain severity and attack frequency compared with sham stimulation. Although the effect on pain intensity was probably clinically insignificant, repetitive transcranial magnetic stimulation reduced pain frequency by 8 days per month on average.

Cluster Headache and Other Trigeminal Autonomic Cephalalgias

PURPOSE OF REVIEW

The trigeminal autonomic cephalalgias (TACs) are relatively rare, but they represent a distinct set of syndromes that are important to recognize. Despite their unique features, TACs often go undiagnosed or misdiagnosed for several years, leading to unnecessary pain and suffering. A significant proportion of TAC presentations may have secondary causes.

RECENT FINDINGS

The underlying pathophysiology of TACs is likely rooted in hypothalamic dysfunction and derangements in the interplay of circuitry involving trigeminovascular, trigeminocervical, trigeminoautonomic, circadian, and nociceptive systems. Recent therapeutic advancements include a better understanding of how to use older therapies more effectively and the identification of new approaches.

SUMMARY

TAC syndromes are rare but important to recognize because of their debilitating nature and greater likelihood for having potentially serious underlying causes. Although treatment options have remained somewhat limited, scientific inquiry is continually advancing our understanding of these syndromes and how best to manage them.

The bottom-up approach: Non-invasive peripheral neurostimulation methods to treat migraine: A scoping review from the child neurologist's perspective

Migraine is a common and invalidating disorder worldwide. Patients of all ages experience the disorder as very impairing regarding their personal and occupational lives. The current approach in migraine therapy is multimodal including lifestyle management, psychoeducation and, if available, psychotherapeutic interventions, and pharmacotherapy. The lack of non-pharmacological and non-invasive treatment options call for new and innovative therapeutic approaches. Peripheral neurostimulation is a relatively new method in migraine management offering a painless and non-pharmacological way of targeting specific mechanisms involved in migraine. This review summarizes 15 recent randomized clinical trials to provide an overview of non-invasive peripheral neurostimulation methods currently available for the treatment of migraine. Efficacy, tolerability, and safety of the different interventions and their feasibility in the pediatric setting are evaluated. Vagal nerve stimulation (VNS), remote electrical neuromodulation (REN) and supraorbital nerve stimulation (SNS) are considered effective in treating acute migraine attacks, the latter being more pronounced in migraine without aura. Regarding migraine prevention, occipital nerve stimulation (ONS) and supraorbital nerve stimulation (SNS) demonstrated efficacy, whereas repetitive neuromuscular magnetic stimulation (rNMS) may represent a further effective option in episodic migraine. REN and rNMS were found to be well-accepted with fewer patients discontinuing treatment than those receiving direct cranial nerve stimulation. In summary, peripheral neurostimulation represents a promising option to complement the multimodal therapy concept for pediatric migraine. In particular, rNMS opens a new field for research and treatment fitting the requirements of "non-invasiveness" for children. Given the reported efficacy, safety, and feasibility, the therapy decision should be made on an individual level.

A device review of Relivion®: an external combined occipital and trigeminal neurostimulation (eCOT-NS) system for self-administered treatment of migraine and major depressive disorder

Introduction: Many patients with migraine are non-responsive or intolerant to pharmaceutical or surgical interventions. Peripheral nerve stimulation (PNS) offers a potential solution for these patients. This review discusses the external combined occipital and trigeminal neurostimulation (eCOT-NS) provided by the Relivion®, a multi-channel head-mounted device for self-administered PNS.Areas covered: Challenges and advantages of PNS systems for the treatment of migraine and depression are introduced, followed by an overall review of clinical evidence of the efficacy of the Relivion® system in treating migraine. The supporting smartphone app and cloud-based analytics which enable remote treatment management by the health care provider are also discussed. Recent empirical indications for the potency of this PNS combination for the treatment of depression are also summarized.Expert opinion: Relivion® is an eCOT-NS system, featuring Food and Drug Administration-approved, noninvasive, self-administered, customizable, multi-focal PNS for the treatment of migraine. In accordance with current telehealth trends, the Relivion® also enhances remote disease management and personalization using digital-monitoring, cloud-based technology, and artificial intelligence. As research on this system progresses, it may become the preferred treatment for the management of a number of neurological and psychiatric diseases, with migraine and major depressive disorders as precedents.

A Review of the Recent Findings in Minimally Invasive Treatment Options for the Management of Occipital Neuralgia

Occipital neuralgia (ON) is unilateral or bilateral neuralgia in the dermatomal nerve distribution of the greater, lesser or third occipital nerves and is a very common presentation of neuropathic pain. ON, although common and well defined, is still a poorly understood pain syndrome. It often requires invasive treatment for long term and significant pain alleviation; however, the evidence supporting different options is still limited. Several minimally invasive techniques have proven to be efficacious and safe, and the selection depends mostly on response to nerve blocks, patient choice and provider preference. This is a comprehensive review of the latest and seminal literature available about occipital neuralgia and currently available minimally invasive treatment options. It covers the anatomical and physiologic biology at the base of neuralgia, the presentation and diagnostic process. It then reviews the available literature to provide description and comparison of the available methods for alleviation.

[Migraine in childhood and adolescence-neurostimulation as a future innovative approach in terms of a multimodal treatment regimen]

Although migraine is a relevant health issue in children and adolescents, clinical care and research are still underrepresented and underfunded in this field. Quality of life can be significantly reduced when living with frequent episodes of pain. Due to the high level of vulnerability of the developing brain during adolescence, the risk of chronification and persistence into adulthood is high. In this narrative review, we describe the corner stones of a patient-centered, multimodular treatment regimen. Further, an update on the pathophysiology of migraine is given considering the concept of a periodically oscillating functional state of the brain in migraine patients ("migraine is a brain state"). Besides central mechanisms, muscular structures with the symptoms of muscular pain, tenderness, or myofascial trigger points play an important role. Against this background, the currently available nonpharmacological and innovative neuromodulating approaches are presented focusing on the method of repetitive peripheral magnetic stimulation.

Localization of the Sphenopalatine Ganglion Within the Pterygopalatine Fossa on Computed Tomography Angiography-A Potential Role in the Setting of Sphenopalatine Ganglion Microstimulator Implantation

OBJECTIVES

A recent approach to treatment of cluster headaches (CH) employs a microstimulator device for on-demand neuromodulation of the sphenopalatine ganglion (SPG) during an acute CH attack. A precise anatomical localization of the SPG within the pterygopalatine fossa (PPF) is optimal in order to position the SPG electrode array. This study aims to investigate a novel approach for SPG localization using computed tomography angiographic studies (CTA).

MATERIALS AND METHODS

Two independent observers identified the location of the SPG on 54 computed tomography angiographic studies (CTA) and measured its position relative to the vidian canal (VC). The qualitative confidence of identification, morphology, position within the PPF and its relation to vascular structures were also recorded.

RESULTS

The SPG was detectable in 88% of cases with a variable position. The most frequent positions were superior (56%) and lateral (99%) relative to the VC with a mean (±SD) craniocaudal distance of 0.34 mm (±1.38) and a mean mediolateral distance of 3.04 mm (±1.2). However, in a considerable proportion of cases, the SPG was identified inferiorly to the VC (33%). Interobserver and intraobserver agreement for SPG location were moderate and strong respectively.

CONCLUSIONS

Since localization of SPG on CTAs is feasible and reproducible, it has future clinical potential to aid placement, optimal positioning and individualized programming of the electrode array.

Alleviation of migraine symptoms by application of repetitive peripheral magnetic stimulation to myofascial trigger points of neck and shoulder muscles - A randomized trial

Migraine is a burdensome disease with an especially high prevalence in women between the age of 15 and 49 years. Non-pharmacological, non-invasive therapeutic methods to control symptoms are increasingly in demand to complement a multimodal intervention approach in migraine. Thirty-seven subjects (age: 25.0 ± 4.1 years; 36 females) diagnosed with high-frequency episodic migraine who presented at least one active myofascial trigger point (mTrP) in the trapezius muscles and at least one latent mTrP in the deltoid muscles bilaterally prospectively underwent six sessions of repetitive peripheral magnetic stimulation (rPMS) over two weeks. Patients were randomly assigned to receive rPMS applied to the mTrPs of the trapezius (n = 19) or deltoid muscles (n = 18). Whereas the trapezius muscle is supposed to be part of the trigemino-cervical complex (TCC) and, thus, involved in the pathophysiology of migraine, the deltoid muscle was not expected to interfere with the TCC and was therefore chosen as a control stimulation site. The headache calendar of the German Migraine and Headache Society (DMKG) as well as the Migraine Disability Assessment (MIDAS) questionnaire were used to evaluate stimulation-related effects. Frequency of headache days decreased significantly in both the trapezius and the deltoid group after six sessions of rPMS (trapezius group: p = 0.005; deltoid group: p = 0.003). The MIDAS score decreased significantly from 29 to 13 points (p = 0.0004) in the trapezius and from 31 to 15 points (p = 0.002) in the deltoid group. Thus, rPMS applied to mTrPs of neck and shoulder muscles offers a promising approach to alleviate headache frequency and symptom burden. Future clinical trials are needed to examine more profoundly these effects, preferably using a sham-controlled setting.