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Mazzolenis ME, Bulat E, Schatman ME, Gumb C, Gilligan CJ, Yong RJ. The Ethical Stewardship of Artificial Intelligence in Chronic Pain and Headache: A Narrative Review. Curr Pain Headache Rep 2024; 28:785-792. [PMID: 38809404 DOI: 10.1007/s11916-024-01272-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE OF REVIEW As artificial intelligence (AI) and machine learning (ML) are becoming more pervasive in medicine, understanding their ethical considerations for chronic pain and headache management is crucial for optimizing their safety. RECENT FINDINGS We reviewed thirty-eight editorial and original research articles published between 2018 and 2023, focusing on the application of AI and ML to chronic pain or headache. The core medical principles of beneficence, non-maleficence, autonomy, and justice constituted the evaluation framework. The AI applications addressed topics such as pain intensity prediction, diagnostic aides, risk assessment for medication misuse, empowering patients to self-manage their conditions, and optimizing access to care. Virtually all AI applications aligned both positively and negatively with specific medical ethics principles. This review highlights the potential of AI to enhance patient outcomes and physicians' experiences in managing chronic pain and headache. We emphasize the importance of carefully considering the advantages, disadvantages, and unintended consequences of utilizing AI tools in chronic pain and headache, and propose the four core principles of medical ethics as an evaluation framework.
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Affiliation(s)
- Maria Emilia Mazzolenis
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Evgeny Bulat
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, 02115, MA, USA
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, Department of Population Health - Division of Medical Ethics, New York University Grossman School of Medicine, New York, NY, USA
| | - Chris Gumb
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Christopher J Gilligan
- Department of Anesthesiology, Robert Wood Johnson University Hospital, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Robert J Yong
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, 02115, MA, USA.
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Kramer J, Hayek S, Levy R. Neuromodulation treatments for migraine: a contemporary update. Curr Opin Anaesthesiol 2024:00001503-990000000-00216. [PMID: 39011719 DOI: 10.1097/aco.0000000000001414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Abstract
PURPOSE OF REVIEW Neuromodulation approaches have been a part of a revolution in migraine therapies with multiple devices approved or in development. These devices vary in the nerve(s) being targeted, implantable versus noninvasive form factors as well as their effectiveness for acute pain reduction or migraine prevention. This review will summarize these recent advancements and approaches that are being developed which build upon prior work and improved technology that may help enhance the effectiveness as well as the patient experience. RECENT FINDINGS Both noninvasive and implantable devices primarily targeting cranial nerves have shown the ability to help alleviate migraine symptoms. Multiple prospective and retrospective studies have demonstrated clinically meaningful reductions in headache intensity with noninvasive approaches, while prevention of migraine demonstrates more modest effects. Implantable neuromodulation technologies focusing on occipital and supraorbital stimulation have shown promise in migraine/headache prevention in chronic migraine patients, but there is a need for improvements in technology to address key needs for surgical approaches. SUMMARY Electrical neuromodulation approaches in the treatment of migraine is undergoing a transformation towards improved outcomes with better technologies that may suit various patient needs on a more individualized basis.
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Affiliation(s)
- Jeffery Kramer
- Volta Research, Minneapolis, Minnesota
- University of Illinois, Chicago, Illinois
| | - Salim Hayek
- Case Western Reserve University, Cleveland, Ohio
| | - Robert Levy
- Neurosurgery and Clinical Research, Anesthesia Pain Care Consultants, Inc, Tamarac, Florida, USA
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Cerda IH, Zhang E, Dominguez M, Ahmed M, Lang M, Ashina S, Schatman ME, Yong RJ, Fonseca ACG. Artificial Intelligence and Virtual Reality in Headache Disorder Diagnosis, Classification, and Management. Curr Pain Headache Rep 2024:10.1007/s11916-024-01279-7. [PMID: 38836996 DOI: 10.1007/s11916-024-01279-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2024] [Indexed: 06/06/2024]
Abstract
PURPOSE OF REVIEW This review provides an overview of the current and future role of artificial intelligence (AI) and virtual reality (VR) in addressing the complexities inherent to the diagnosis, classification, and management of headache disorders. RECENT FINDINGS Through machine learning and natural language processing approaches, AI offers unprecedented opportunities to identify patterns within complex and voluminous datasets, including brain imaging data. This technology has demonstrated promise in optimizing diagnostic approaches to headache disorders and automating their classification, an attribute particularly beneficial for non-specialist providers. Furthermore, AI can enhance headache disorder management by enabling the forecasting of acute events of interest, such as migraine headaches or medication overuse, and by guiding treatment selection based on insights from predictive modeling. Additionally, AI may facilitate the streamlining of treatment efficacy monitoring and enable the automation of real-time treatment parameter adjustments. VR technology, on the other hand, offers controllable and immersive experiences, thus providing a unique avenue for the investigation of the sensory-perceptual symptomatology associated with certain headache disorders. Moreover, recent studies suggest that VR, combined with biofeedback, may serve as a viable adjunct to conventional treatment. Addressing challenges to the widespread adoption of AI and VR in headache medicine, including reimbursement policies and data privacy concerns, mandates collaborative efforts from stakeholders to enable the equitable, safe, and effective utilization of these technologies in advancing headache disorder care. This review highlights the potential of AI and VR to support precise diagnostics, automate classification, and enhance management strategies for headache disorders.
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Affiliation(s)
| | - Emily Zhang
- Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Moises Dominguez
- Department of Neurology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| | | | - Min Lang
- Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Sait Ashina
- Harvard Medical School, Boston, MA, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA
- Department of Population Health-Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA
| | - R Jason Yong
- Harvard Medical School, Boston, MA, USA
- Brigham and Women's Hospital, Department of Anesthesiology, Perioperative, and Pain Medicine, 75 Francis Street, Boston, MA, 02115, USA
| | - Alexandra C G Fonseca
- Harvard Medical School, Boston, MA, USA.
- Brigham and Women's Hospital, Department of Anesthesiology, Perioperative, and Pain Medicine, 75 Francis Street, Boston, MA, 02115, USA.
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Shan Y, Wang H, Yang Y, Wang J, Zhao W, Huang Y, Wang H, Han B, Pan N, Jin X, Fan X, Liu Y, Wang J, Wang C, Zhang H, Chen S, Liu T, Yan T, Si T, Yin L, Li X, Cosci F, Zhang X, Zhang G, Gao K, Zhao G. Evidence of a large current of transcranial alternating current stimulation directly to deep brain regions. Mol Psychiatry 2023; 28:5402-5410. [PMID: 37468529 DOI: 10.1038/s41380-023-02150-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/31/2023] [Accepted: 06/16/2023] [Indexed: 07/21/2023]
Abstract
Deep brain regions such as hippocampus, insula, and amygdala are involved in neuropsychiatric disorders, including chronic insomnia and depression. Our recent reports showed that transcranial alternating current stimulation (tACS) with a current of 15 mA and a frequency of 77.5 Hz, delivered through a montage of the forehead and both mastoids was safe and effective in intervening chronic insomnia and depression over 8 weeks. However, there is no physical evidence to support whether a large alternating current of 15 mA in tACS can send electrical currents to deep brain tissue in awake humans. Here, we directly recorded local field potentials (LFPs) in the hippocampus, insula and amygdala at different current strengths (1 to 15 mA) in 11 adult patients with drug-resistant epilepsy implanted with stereoelectroencephalography (SEEG) electrodes who received tACS at 77.5 Hz from 1 mA to 15 mA at 77.5 Hz for five minutes at each current for a total of 40 min. For the current of 15 mA at 77.5 Hz, additional 55 min were applied to add up a total of 60 min. Linear regression analysis revealed that the average LFPs for the remaining contacts on both sides of the hippocampus, insula, and amygdala of each patient were statistically associated with the given currents in each patient (p < 0.05-0.01), except for the left insula of one subject (p = 0.053). Alternating currents greater than 7 mA were required to produce significant differences in LFPs in the three brain regions compared to LFPs at 0 mA (p < 0.05). The differences remained significant after adjusting for multiple comparisons (p < 0.05). Our study provides direct evidence that the specific tACS procedures are capable of delivering electrical currents to deep brain tissues, opening a realistic avenue for modulating or treating neuropsychiatric disorders associated with hippocampus, insula, and amygdala.
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Affiliation(s)
- Yongzhi Shan
- Department of Neurosurgery, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, 100053, China
- China International Neuroscience Institute (CHINA-INI), Beijing, 100053, China
- Beijing Municipal Geriatric Medical Research Center, Beijing, 100053, China
| | - Hongxing Wang
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, 100053, China.
- Beijing Institute of Brain Disorders, Beijing, 100069, China.
| | - Yanfeng Yang
- Department of Neurosurgery, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, 100053, China
- China International Neuroscience Institute (CHINA-INI), Beijing, 100053, China
- Beijing Municipal Geriatric Medical Research Center, Beijing, 100053, China
| | - Jiahao Wang
- Beijing Key Laboratory of Bioelectromagnetism, Institute of Electrical Engineering, Chinese Academy of Sciences, Beijing, 100190, China
- School of Electronic, Electrical and Communication Engineering, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Wenfeng Zhao
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, 100053, China
| | - Yuda Huang
- Department of Neurosurgery, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, 100053, China
- China International Neuroscience Institute (CHINA-INI), Beijing, 100053, China
- Beijing Municipal Geriatric Medical Research Center, Beijing, 100053, China
| | - Huang Wang
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, 100053, China
| | - Bing Han
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, 100053, China
| | - Na Pan
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, 100053, China
| | - Xiukun Jin
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, 100053, China
| | - Xiaotong Fan
- Department of Neurosurgery, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, 100053, China
- China International Neuroscience Institute (CHINA-INI), Beijing, 100053, China
- Beijing Municipal Geriatric Medical Research Center, Beijing, 100053, China
| | - Yunyun Liu
- Department of Neurosurgery, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, 100053, China
- China International Neuroscience Institute (CHINA-INI), Beijing, 100053, China
- Beijing Municipal Geriatric Medical Research Center, Beijing, 100053, China
| | - Jun Wang
- Department of Neurosurgery, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, 100053, China
- China International Neuroscience Institute (CHINA-INI), Beijing, 100053, China
- Beijing Municipal Geriatric Medical Research Center, Beijing, 100053, China
| | - Changming Wang
- Department of Neurosurgery, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, 100053, China
- China International Neuroscience Institute (CHINA-INI), Beijing, 100053, China
- Beijing Municipal Geriatric Medical Research Center, Beijing, 100053, China
| | - Huaqiang Zhang
- Department of Neurosurgery, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, 100053, China
- China International Neuroscience Institute (CHINA-INI), Beijing, 100053, China
- Beijing Municipal Geriatric Medical Research Center, Beijing, 100053, China
| | - Sichang Chen
- Department of Neurosurgery, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, 100053, China
- China International Neuroscience Institute (CHINA-INI), Beijing, 100053, China
- Beijing Municipal Geriatric Medical Research Center, Beijing, 100053, China
| | - Ting Liu
- Department of Neurosurgery, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, 100053, China
- China International Neuroscience Institute (CHINA-INI), Beijing, 100053, China
- Beijing Municipal Geriatric Medical Research Center, Beijing, 100053, China
| | - Tianyi Yan
- School of Life Science, Beijing Institute of Technology, Beijing, 100081, China
| | - Tianmei Si
- Peking University Sixth Hospital, Peking University Institute of Mental Health, National Clinical Research Center for Mental Disorders, Beijing, 100191, China
| | - Lu Yin
- Medical Research & Biometrics Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, 102300, China
| | - Xinmin Li
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Albert, T6G 2B7, Canada
| | - Fiammetta Cosci
- Department of Health Sciences, University of Florence, Florence, 50135, Italy.
| | - Xiangyang Zhang
- CAS Key Laboratory of Mental Health, Chinese Academy of Sciences, Beijing, 100101, China.
| | - Guanghao Zhang
- Beijing Key Laboratory of Bioelectromagnetism, Institute of Electrical Engineering, Chinese Academy of Sciences, Beijing, 100190, China.
- School of Electronic, Electrical and Communication Engineering, University of Chinese Academy of Sciences, Beijing, 100049, China.
| | - Keming Gao
- Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA; Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA.
| | - Guoguang Zhao
- Department of Neurosurgery, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, 100053, China.
- China International Neuroscience Institute (CHINA-INI), Beijing, 100053, China.
- Beijing Municipal Geriatric Medical Research Center, Beijing, 100053, China.
- Center of Epilepsy, Beijing Institute of Brain Disorders, Beijing, 100069, China.
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Monaco A, Cattaneo R, Di Nicolantonio S, Strada M, Altamura S, Ortu E. Central effects of trigeminal electrical stimulation. Cranio 2023:1-24. [PMID: 38032105 DOI: 10.1080/08869634.2023.2280153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
This is a review of the literature on the main neuromodulation techniques, focusing on the possibility of introducing sensory threshold ULFTENS into them. Electro neuromodulation techniques have been in use for many years as promising methods of therapy for cognitive and emotional disorders. One of the most widely used forms of stimulation for orofacial pain is transcutaneous trigeminal stimulation on three levels: supraorbital area, dorsal surface of the tongue, and anterior skin area of the tragus. The purpose of this review is to trigger interest on using dental ULFTENS as an additional trigeminal neurostimulation and neuromodulation technique in the context of TMD. In particular, we point out the possibility of using ULFTENS at a lower activation level than that required to trigger a muscle contraction that is capable of triggering effects at the level of the autonomic nervous system, with extreme ease of execution and few side effects.
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Affiliation(s)
- Annalisa Monaco
- MeSVA Department, Dental Unit, University of L'Aquila, L'Aquila, Italy
| | - Ruggero Cattaneo
- MeSVA Department, Dental Unit, University of L'Aquila, L'Aquila, Italy
| | | | - Marco Strada
- MeSVA Department, Dental Unit, University of L'Aquila, L'Aquila, Italy
| | - Serena Altamura
- MeSVA Department, Dental Unit, University of L'Aquila, L'Aquila, Italy
| | - Eleonora Ortu
- MeSVA Department, Dental Unit, University of L'Aquila, L'Aquila, Italy
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Abstract
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.
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Affiliation(s)
- Xun Han
- Department of Neurology, The First Medical Center of Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Shengyuan Yu
- Department of Neurology, The First Medical Center of Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China.
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Mercante B, Enrico P, Deriu F. Cognitive Functions following Trigeminal Neuromodulation. Biomedicines 2023; 11:2392. [PMID: 37760833 PMCID: PMC10525298 DOI: 10.3390/biomedicines11092392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/13/2023] [Accepted: 08/25/2023] [Indexed: 09/29/2023] Open
Abstract
Vast scientific effort in recent years have been focused on the search for effective and safe treatments for cognitive decline. In this regard, non-invasive neuromodulation has gained increasing attention for its reported effectiveness in promoting the recovery of multiple cognitive domains after central nervous system damage. In this short review, we discuss the available evidence supporting a possible cognitive effect of trigeminal nerve stimulation (TNS). In particular, we ask that, while TNS has been widely and successfully used in the treatment of various neuropsychiatric conditions, as far as research in the cognitive field is concerned, where does TNS stand? The trigeminal nerve is the largest cranial nerve, conveying the sensory information from the face to the trigeminal sensory nuclei, and from there to the thalamus and up to the somatosensory cortex. On these bases, a bottom-up mechanism has been proposed, positing that TNS-induced modulation of the brainstem noradrenergic system may affect the function of the brain networks involved in cognition. Nevertheless, despite the promising theories, to date, the use of TNS for cognitive empowering and/or cognitive decline treatment has several challenges ahead of it, mainly due to little uniformity of the stimulation protocols. However, as the field continues to grow, standardization of practice will allow for data comparisons across studies, leading to optimized protocols targeting specific brain circuitries, which may, in turn, influence cognition in a designed manner.
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Affiliation(s)
- Beniamina Mercante
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy; (B.M.); (P.E.)
| | - Paolo Enrico
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy; (B.M.); (P.E.)
| | - Franca Deriu
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy; (B.M.); (P.E.)
- AOU Sassari, Unit of Endocrinology, Nutritional and Metabolic Disorders, 07100 Sassari, Italy
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Johnson B, Freitag FG. New Approaches to Shifting the Migraine Treatment Paradigm. FRONTIERS IN PAIN RESEARCH 2022; 3:873179. [PMID: 36147034 PMCID: PMC9488522 DOI: 10.3389/fpain.2022.873179] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
Abstract
The standard of care paradigm for migraine treatment has been based almost exclusively on approaches that grew out of the happenstance use of market pharmaceuticals. Only methysergide, which has long since been removed from use for safety concerns, the ergotamine family of drugs, and the triptans were explicitly developed with migraine and other vascular headaches in mind. While the forward and innovative thinking to utilize the broad array of agents to treat migraine served millions well, their therapeutic efficacy was often low, and adverse event profiles were troublesome in the least. Advances in biochemical and molecular biology and the application of advanced "designing drugs" methods have brought about a potentially significant shift in treatment. The gepants have efficacies similar to the triptans but without vascular safety or medication overuse concerns. Preventative gepants offer innovative approaches to prevention and efficacy that exceed even the CGRP monoclonal antibodies. Those monoclonal antibodies brought rapid and highly effective outcomes across the spectrum of migraine. They outpaced older oral medication efficacy and eliminated most adverse events while potentially improving compliance with monthly or quarterly dosing. Other serotonin receptors beyond the 5HT1B and1D receptors have been targeted for decades. They now lead us to better formulations of dihydroergotamine for efficacy, convenience, and tolerability, and a 5HT1F-specific acute treatment like the gepants opens new options for acute management. Neuromodulation goes back to the mid-1800's. Our improved understanding of applied biomedical engineering has brought forward several tantalizing devices, including the application of currents distant from the target and patient regulated. Whether these advances change the paradigm of migraine treatment and standards of care remains to be seen, and issues such as cost and patient acceptance will help mold it.
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Affiliation(s)
| | - Frederick G. Freitag
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, United States
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Daniel O, Tepper SJ, Deutsch L, Sharon R. External Concurrent Occipital and Trigeminal Neurostimulation Relieves Migraine Headache: A Prospective, Randomized, Double-Blind, Sham-Controlled Trial. Pain Ther 2022; 11:907-922. [PMID: 35661128 PMCID: PMC9314547 DOI: 10.1007/s40122-022-00394-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/05/2022] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Current external peripheral nerve stimulation devices stimulate only one nerve. This prospective, randomized, double-blind, sham-controlled trial assessed efficacy, safety, and tolerability of a novel external combined occipital and trigeminal neurostimulation (eCOT-NS) device as a self-administered home treatment for migraine (Relivion®MG, Neurolief Ltd; Netanya, Israel). METHODS Episodic and chronic migraine subjects (N = 55) were randomized to receive active (n = 27) or sham (n = 28) treatment. Subjects received eCOT-NS devices and performed 60 ± 20-min home treatments within 45 min of migraine episode onset. The primary endpoint was relative (percent) change in mean baseline VAS pain scores 1 h after treatment initiation. Treatment outcomes assessed at 1-, 2-, and 24-h post-treatment initiation were pain reduction and proportion of pain-free subjects and treatment responders, defined as ≥ 50% pain reduction. Categorical pain ratings (none, mild, moderate, and severe pain) were also analyzed. RESULTS Active stimulation was significantly more effective than sham stimulation for decreasing pain intensity at 1 h (53% vs. 10%), 2 h (52% vs. 17%), and 24 h (71% vs. 34%). Pain-free ratings were greater for the active treatment arm at 1 h (29.2% vs. 16%), 2 h (41.7% vs. 20%), and 24 h (65.2% vs. 40%). The number of subjects with baseline moderate or severe migraine pain who were pain-free at 2 h was significantly greater among active treatment subjects (43% vs. 10.5%). The responder rate was significantly higher among the active treatment group at 1 h (67% vs. 20%), 2 h (66.7% vs. 32%,), and 24 h (78.3% vs. 48%). Overall headache relief was significantly higher in the active treatment group at 1 h (67% vs. 26%) and 2 h (76% vs. 31.6%). Mild adverse events, reported by a minority of subjects, resolved spontaneously. CONCLUSIONS eCOT-NS provides superior clinically meaningful relief and freedom from migraine pain, offering an effective and safe therapy for acute treatment of migraine. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT03398668.
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Affiliation(s)
- Oved Daniel
- Headache and Facial Pain Clinic, Ramat-Aviv Medical Center, Tel-Aviv, Israel
| | - Stewart J. Tepper
- Geisel School of Medicine at Dartmouth, Hanover, NH USA ,Dartmouth Headache Center, Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, NH USA
| | - Lisa Deutsch
- BioStats Statistical Consulting, Ltd, Modiin, Israel
| | - Roni Sharon
- Tel-Aviv University Sackler School of Medicine, Tel-Aviv, Israel ,Department of Neurology, Chaim Sheba (Tel HaShomer) Medical Center, Ramat Gan, Israel
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Tepper SJ, Grosberg B, Daniel O, Kuruvilla DE, Vainstein G, Deutsch L, Sharon R. Migraine treatment with external concurrent occipital and trigeminal neurostimulation—A randomized controlled trial. Headache 2022; 62:989-1001. [DOI: 10.1111/head.14350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/22/2022] [Accepted: 05/23/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Stewart J. Tepper
- Geisel School of Medicine at Dartmouth Hanover New Hampshire USA
- Dartmouth Headache Center Lebanon New Hampshire USA
| | - Brian Grosberg
- Hartford Healthcare Headache Center Ayer Neuroscience Institute West Hartford Connecticut USA
- Department of Neurology University of Connecticut School of Medicine Farmington Connecticut USA
| | - Oved Daniel
- Headache and Facial Pain Clinic Ramat‐Aviv Medical Center Tel‐Aviv Israel
| | | | - Gabriel Vainstein
- Kahn‐Sagol‐Maccabi Research and Innovation Institute Maccabi Healthcare Services Tel Aviv Israel
| | - Lisa Deutsch
- BioStats Statistical Consulting Ltd. Modiin Israel
| | - Roni Sharon
- Tel‐Aviv University Sackler School of Medicine Tel‐Aviv Israel
- Department of Neurology Chaim Sheba (Tel HaShomer) Medical Center Ramat Gan Israel
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Holdridge A, Donnelly M, Kuruvilla DE. Integrative, Interventional, and Non-invasive Approaches for the Treatment for Migraine During Pregnancy. Curr Pain Headache Rep 2022; 26:323-330. [PMID: 35362816 DOI: 10.1007/s11916-022-01028-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW While most women with migraine improve during pregnancy, a subset may remain unchanged or even become more severe. Given the limited evidence for the use of prescription medications during pregnancy, many look to other treatment modalities. We seek to review complementary and integrative medicine, procedural interventions, and neurostimulation to empower women with safe and effective treatment options during pregnancy. RECENT FINDINGS Migraine treatment during pregnancy remains controversial. While evidence is limited, prospective and retrospective reviews, as well as clinical experience support the use of nutraceuticals, procedural interventions, and neurostimulation during pregnancy when the appropriate risks and benefits are weighed. Empowering patients with information on complementary and integrative medicine, as well as non-systemic and interventional treatments, may help to reduce anxiety and headache burden during pregnancy. Various nutraceuticals have shown promise for the preventive management of migraine. Non-systemic interventions such as trigger point injections and peripheral and sphenopalatine nerve blocks offer effective treatment options with minimal side-effects. Options for neurostimulation have expanded in recent years and may offer safe and effective non-pharmacologic options for the management of migraine. It is imperative that providers do not minimize migraine during pregnancy and become aware of the treatment modalities available to help guide women through this experience.
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Affiliation(s)
- Ashley Holdridge
- Medical Director of The Comprehensive Headache Center, 9969 S 27th St. Suite, 3000, Franklin, 53132, WI, USA.
| | - Megan Donnelly
- Medical Director of Craniofacial Pain and Women's Neurology, Novant Health, Winston-Salem, NC, USA
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Devices for Episodic Migraine: Past, Present, and Future. Curr Pain Headache Rep 2022; 26:259-265. [PMID: 35147856 PMCID: PMC8930505 DOI: 10.1007/s11916-022-01024-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Historically, therapies for migraine have generally involved pharmacological treatments using non-selective or selective analgesics and preventive treatments. However, for many patients these treatments are not effective, while others prefer to use non-pharmacological-based therapies. To fill this need, over the last 15 years, neuromodulatory devices have entered the market for migraine treatment. Here, we will review the most recent findings for the use of these devices in the treatment of migraine. RECENT FINDINGS Non-invasive vagus nerve stimulation and spring-pulse transcranial magnetic stimulation are both cleared for the treatment of migraine, supported by preclinical studies that validate efficacy and mechanism of action, and complemented with clinical trial data. Other options also authorized for use include transcutaneous supraorbital nerve stimulation and remote electrical neuromodulation. Various options are available to treat migraine using authorized neuromodulatory devices. These data support their efficacy in the treatment of episodic migraine, although further studies are necessary to elucidate their mechanism of action and to provide rigor to clinical trial data.
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Nierenburg H, Stark-Inbar A. Nerivio ® remote electrical neuromodulation for acute treatment of chronic migraine. Pain Manag 2021; 12:267-281. [PMID: 34538078 DOI: 10.2217/pmt-2021-0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Nerivio® (by Theranica Bio-Electronics Ltd, Tel Aviv, Israel) is a wireless, wearable, noninvasive, battery-operated, remote electrical neuromodulation device controlled by a smartphone application. It is US FDA authorized for the acute treatment of migraine with or without aura in people 12 years and older in the US, and European Conformity (CE) marked for the same indication in the EU. The American Headache Society Consensus Statement recommends Nerivio as a tier 2 treatment for migraines. This review summarizes a series of five independent clinical trials and two real-world evidence studies that established safety, tolerability and efficacy of Nerivio in treating migraine attacks. It further provides up-to-date practical information on device usability. Based on findings of this review, Nerivio offers a safe and effective nonpharmacological alternative for acute treatment in patients with chronic (and nonchronic) migraine.
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Evers S. Non-Invasive Neurostimulation Methods for Acute and Preventive Migraine Treatment-A Narrative Review. J Clin Med 2021; 10:3302. [PMID: 34362086 PMCID: PMC8347785 DOI: 10.3390/jcm10153302] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/18/2021] [Accepted: 07/26/2021] [Indexed: 11/17/2022] Open
Abstract
Neurostimulation methods have now been studied for more than 20 years in migraine treatment. They can be divided into invasive and non-invasive methods. In this narrative review, the non-invasive methods are presented. The most commonly studied and used methods are vagal nerve stimulation, electric peripheral nerve stimulation, transcranial magnetic stimulation, and transcranial direct current stimulation. Other stimulation techniques, including mechanical stimulation, play only a minor role. Nearly all methods have been studied for acute attack treatment and for the prophylactic treatment of migraine. The evidence of efficacy is poor for most procedures, since no stimulation device is based on consistently positive, blinded, controlled trials with a sufficient number of patients. In addition, most studies on these devices enrolled patients who did not respond sufficiently to oral drug treatment, and so the role of neurostimulation in an average population of migraine patients is unknown. In the future, it is very important to conduct large, properly blinded and controlled trials performed by independent researchers. Otherwise, neurostimulation methods will only play a very minor role in the treatment of migraine.
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Affiliation(s)
- Stefan Evers
- Faculty of Medicine, University of Münster, 48153 Münster, Germany;
- Department of Neurology, Lindenbrunn Hospital, 31863 Coppenbrügge, Germany
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