Migraine prevention with percutaneous mastoid electrical stimulator: A randomized double-blind controlled trial

Nonpharmacologic Treatments for Chronic and Episodic Migraine: A Systematic Review and Meta-Analysis

BACKGROUND

Minimally invasive techniques for treatment-resistant migraine have been developed on recent insights into the peripheral pathogenesis of migraines. Although there is a growing body of evidence supporting these techniques, no study has yet compared the effects of these treatments on headache frequency, severity, duration, and cost.

METHODS

PubMed, Embase, and Cochrane Library databases were searched to identify randomized placebo-controlled trials that compared radiofrequency ablation, botulinum toxin type A (BT-A), nerve block, neurostimulation, or migraine surgery to placebo for preventive treatment. Data on changes from baseline to follow-up in headache frequency, severity, duration, and quality of life were analyzed.

RESULTS

A total of 30 randomized controlled trials and 2680 patients were included. Compared with placebo, there was a significant decrease in headache frequency in patients with nerve block ( P = 0.04) and surgery ( P < 0.001). Headache severity decreased in all treatments. Duration of headaches was significantly reduced in the BT-A ( P < 0.001) and surgery cohorts ( P = 0.01). Quality of life improved significantly in patients with BT-A, nerve stimulator, and migraine surgery. Migraine surgery had the longest lasting effects (11.5 months) compared with nerve ablation (6 months), BT-A (3.2 months), and nerve block (11.9 days).

CONCLUSIONS

Migraine surgery is a cost-effective, long-term treatment to reduce headache frequency, severity, and duration without significant risk of complication. BT-A reduces headache severity and duration, but it is short-lasting and associated with greater adverse events and lifetime cost. Although efficacious, radiofrequency ablation and implanted nerve stimulators have high risks of adverse events and explantation, whereas benefits of nerve blocks are short in duration.

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.

Nonpharmacological modulation of cortical spreading depolarization

AIMS

Cortical spreading depolarization (CSD) is a wave of pathologic neuronal dysfunction that spreads through cerebral gray matter, causing neurologic disturbance in migraine and promoting lesion development in acute brain injury. Pharmacologic interventions have been found to be effective in migraine with aura, but their efficacy in acutely injured brains may be limited. This necessitates the assessment of possible adjunctive treatments, such as nonpharmacologic methods. This review aims to summarize currently available nonpharmacological techniques for modulating CSDs, present their mechanisms of action, and provide insight and future directions for CSD treatment.

MAIN METHODS

A systematic literature review was performed, generating 22 articles across 3 decades. Relevant data is broken down according to method of treatment.

KEY FINDINGS

Both pharmacologic and nonpharmacologic interventions can mitigate the pathological impact of CSDs via shared molecular mechanisms, including modulating K⁺/Ca²⁺/Na⁺/Cl^- ion channels and NMDA, GABA_A, serotonin, and CGRP ligand-based receptors and decreasing microglial activation. Preclinical evidence suggests that nonpharmacologic interventions, including neuromodulation, physical exercise, therapeutic hypothermia, and lifestyle changes can also target unique mechanisms, such as increasing adrenergic tone and myelination and modulating membrane fluidity, which may lend broader modulatory effects. Collectively, these mechanisms increase the electrical initiation threshold, increase CSD latency, slow CSD velocity, and decrease CSD amplitude and duration.

SIGNIFICANCE

Given the harmful consequences of CSDs, limitations of current pharmacological interventions to inhibit CSDs in acutely injured brains, and translational potentials of nonpharmacologic interventions to modulate CSDs, further assessment of nonpharmacologic modalities and their mechanisms to mitigate CSD-related neurologic dysfunction is warranted.

Devices for Episodic Migraine: Past, Present, and Future

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.

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.

Non-Invasive Neurostimulation Methods for Acute and Preventive Migraine Treatment-A Narrative Review

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.

Noninvasive Neuromodulation in Migraine

PURPOSE OF REVIEW

The past two decades has seen an influx of noninvasive neuromodulation devices aimed at treatment of various primary headache disorders, including cluster headache and migraine. This narrative review is to summarize the current options in noninvasive neuromodulation in migraine.

RECENT FINDINGS

A variety of noninvasive neuromodulation devices have been FDA cleared and marketed for use in migraine, including single-pulse transcranial magnetic stimulation (sTMS), noninvasive vagal nerve stimulators (nVNS), and external trigeminal nerve stimulators (eTNS). Newer devices include peripheral electrical stimulation devices (PES), caloric stimulation, and others. Each has varying levels of evidence supporting its use in migraine, tolerability profiles, and access issues. Noninvasive neuromodulation devices can be beneficial when used in patients with migraine, with minimal side effects. As more devices are developed, approved, and marketed in the future, rigorous research on efficacy and safety remain a top priority.

Neuromodulation techniques for acute and preventive migraine treatment: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Several neuromodulation methods exists for migraine treatment. The aim of the present study was to perform a systematic review and meta-analysis of randomized controlled trials (RCTs) focusing on migraine treatment using neurostimulation methods.

METHODS

We searched Medline and Embase up to July 1, 2020 for RCTs reporting acute or preventive treatment of migraine with either non-invasive or invasive neurostimulation methods. Two researchers independently assessed the eligibility of the retrieved studies and extracted data. Outcomes for the quantitative synthesis were 2 h pain free for acute treatment and headache days per month for preventive treatment. We performed subgroup analyses by treatment (stimulation method and site of application). Estimates were pooled using random-effects meta-analysis.

RESULTS

Thirty-eight articles were included in the qualitative analysis (7 acute, 31 preventive) and 34 in the quantitative evaluation (6 acute, 28 preventive). Remote electrical neuromodulation (REN) was effective for acute treatment. Data were insufficient to draw conclusions for any other techniques (single studies). Invasive occipital nerve stimulation (ONS) was effective for migraine prevention, with a large effect size but considerable heterogeneity, whereas supra-orbital transcutaneous electrical nerve stimulation (TENS), percutaneous electrical nerve stimulation (PENS), and high-frequency repetitive transcranial magnetic stimulation (rTMS) over the primary motor cortex (M1) were effective, with small to medium effect sizes. Vagus-nerve stimulation, left prefrontal cortex rTMS, and cathodal transcranial direct current stimulation (tDCS) over the M1 had no significant effect and heterogeneity was high.

CONCLUSION

Several neuromodulation methods are of potential interest for migraine management, but the quality of the evidence is very poor. Future large and well-conducted studies are needed and could improve on the present results.

Percutaneous mastoid electrical stimulator improves Poststroke depression and cognitive function in patients with Ischaemic stroke: a prospective, randomized, double-blind, and sham-controlled study

Background

Poststroke depression can lead to functional dependence, cognitive impairment and reduced quality of life. The aim of this study was to evaluate the effects of a percutaneous mastoid electrical stimulator (PMES) plus antidepressants on poststroke depression and cognitive function.

Methods

This study was a prospective, randomized, double-blind, and sham-controlled study. A total of 258 clinically depressed ischaemic stroke patients within 14 days of index stroke were randomly assigned to the PMES plus antidepressant (PMES group, N = 125) and sham plus antidepressant (sham group, N = 133) groups. All patients underwent the Montreal Cognitive Assessment (MoCA) and Hamilton Rating Scale for Depression (HRSD) test at 2 weeks (baseline), and 6 months(M6) after ischaemic stroke. Primary outcomes were the percentage of patients showing a treatment response (≥50% reduction in HRSD score) and depression remission (HRSD score ≤ 9) at 6 months. The secondary outcome was the percentage of patients with a MoCA score < 26.

Results

The percentages of patients showing a treatment response and depression remission were significantly higher in the PMES group than in the sham group (57.60% vs 41.35%, P = 0.009; 44.00% vs 29.32%, P = 0.014 respectively). The mean value of the HRSD score change [M (month)6-baseline] was significantly higher in the PMES group than in the sham group at 6 months (− 11.93 ± 5.32 vs − 10.48 ± 6.10, P = 0.036, respectively). The percentage of patients with MoCA scores < 26 was lower in the PEMS group than in the sham group (12.0% vs 24.06%, P = 0.012,respectively), and the mean value of the MoCA score change (M6-baseline) was higher in the PMES group than in the sham group (3.50 ± 2.55 vs 2.72 ± 2.52, P = 0.005, respectively).

Conclusion

These findings demonstrate that PMES adjunctive to antidepressant therapy is effective in reducing depression, achieving remission in the short term, and improving cognition.

Trial registration

This trial was retrospectively registered (registration number: ChiCTR1800016463) on 03 June 2018.

A Head-to-Head Comparison of Percutaneous Mastoid Electrical Stimulator and Supraorbital Transcutaneous Stimulator in the Prevention of Migraine: A Prospective, Randomized Controlled Study

INTRODUCTION

This prospective, randomized, multicenter head-to-head outcome study was performed to compare the efficacy and safety of Percutaneous Mastoid Electrical Stimulator (PMES) and Supraorbital Transcutaneous Stimulator (STS) in migraine prevention.

METHODS

This was a prospective, randomized, head-to-head outcome study that involved three medical centers. After a one-month run-in, episodic patients with at least two migraine attacks/month were randomized to receive PMES daily for 45 min or STS daily for 20 min for three months. The primary outcomes were change in monthly migraine days and the 50% response rate.

RESULTS

A total of 90 patients were included in this study. We observed statistically significant reduction of migraine days in the third month treatment both in the PMES group and STS group. The difference between the two groups was not significant (60.5% vs. 53.8%, p = 0.88). Of note, 77.8% patients in the PMES group and 62.2% patients in the STS group had a ≥50% reduction of migraine days in the third month (p = 0.070). The change in monthly migraine days, monthly migraine attacks, severity of migraine days, accompanying symptoms during migraine and monthly acute anti-migraine drug intake were not significantly different between the two groups. The change of Headache Impact Test-6 (HIT-6) from run-in to the third-month treatment in the STS group was more remarkable than that in the PMES group (36.5% vs. 25.6%, p = 0.041). The occurrence of discomfort paresthesia was higher in the STS group (13.3% vs. 0%, p = 0.026).

CONCLUSION

PMES and STS treatment were both effective in migraine prevention. The safety and efficacy of PMES and STS were comparable.

[Peripheral neurostimulation in headache treatment]

According to rough estimates, at least one third of the population in developed countries suffers, to varying degrees, from certain forms of primary headache, the modern pharmacotherapy of which is not always effective and has a number of limitations. The non-pharmacological treatment of headache can be an alternative to the prescription of pharmacological agents and the only possible assistance option for patients developing drug-resistant cephalalgias. This review describes various methods of electrical neuromodulation that are used for the management of primary headaches. The authors provide information on current stages in implementation of implantable and non-invasive equipment into clinical practice, which makes possible electrical stimulations of peripheral nerves and of the sphenopalatine ganglion, as well as allows transcranial magnetic stimulation. Also the appearance and usage of portable electrical devices available on the world market are described, and mechanisms that can underlie anticephalgic action of neuromodulation therapy are discussed. Special attention is paid to the methods that are applied for electrostimulation of the vagus nerve and occipital nerves.

Treatment of migraine attacks and prevention of migraine: Guidelines by the German Migraine and Headache Society and the German Society of Neurology

In collaboration with some of the leading headache centres in Germany, Switzerland and Austria, we have established new guidelines for the treatment of migraine attacks and the prevention of migraine. A thorough literature research of the last 10 years has been the basis of the current recommendations. At the beginning, we present therapeutic novelties, followed by a summary of all recommendations. After an introduction, we cover topics like drug therapy and practical experience, non-effective medication, migraine prevention, interventional methods, non-medicational and psychological methods for prevention and therapies without proof of efficacy.

Percutaneous mastoid electrical stimulator alleviates autonomic dysfunction in patients with acute ischemic stroke

BACKGROUND AND PURPOSE

Poststroke prognosis is associated with autonomic status. The purpose of our study was to determine whether percutaneous mastoid electrical stimulator (PMES) can alleviate abnormal heart rate variability (HRV) and improve clinical outcome.

METHODS

This prospective, randomized, double-blinded, placebo-controlled study enrolled a total of 140 patients with autonomic dysfunction within 3d after acute ischemic stroke. The patients were treated with PMES or sham stimulation once daily over a period of 2 weeks. HRV was primarily assessed by the fractal dimension (FD) at admission and 2 weeks. All patients were followed up for 3 months. The clinical outcome was death and major disability (modified Rankin Scale score≥ 3) at 3 months after acute ischemic stroke.

RESULTS

FD of the 2-week treatment period increased in PMES groups. PMES can significantly alleviate abnormal HRV. The difference in FD of the 2-week treatment period between the PMES and sham groups was significant (1.14 ± 0.27 vs. 1.00 ± 0.23; P = 0.001). In fully adjusted models, PMES was associated with reduced 3-month mortality (adjusted odds ratio, 0.32; 95% confidence interval, 0.11-0.93; P = 0.036). No significant group differences were seen in three major disability and composite outcome (P > 0.05).

CONCLUSIONS

PMES was a safe, effective, and low-cost therapy to alleviate HRV and could significantly reduce mortality in the early recovery phase after acute ischemic stroke.

Emerging Treatments in Episodic Migraine

PURPOSE OF REVIEW

The purpose of this review is to evaluate and describe recent and emerging treatment options for episodic migraine.

RECENT FINDINGS

Recent advances have been made in better understanding the pathophysiology of migraine, which has led to further investigation of potential new pharmacologic and non-pharmacologic treatment options. A number of new medications are emerging for the acute and preventive treatment of migraine, including CGRP monoclonal antibodies, CGRP receptor antagonists, serotonin 5-HT_1F agonists, and PACAP receptor monoclonal antibodies. Additionally, newer studies on existing non-invasive neuromodulation devices including transcranial magnetic stimulation, supraorbital transcutaneous nerve stimulation, and transcutaneous vagus nerve stimulation have recently received FDA approval for use in migraine. Neuromodulation devices including percutaneous mastoid electrical stimulation, non-painful remote electrical stimulation, and caloric vestibular stimulation are undergoing further investigation and have shown promising results thus far. These new developments are expected to contribute to better treatment and decreased disability in migraine.

Efficacy and mode of action of external trigeminal neurostimulation in migraine

INTRODUCTION

Available preventive drug treatments for migraine lack complete efficacy and often have unpleasant adverse effects. Hence, their clinical utility and therapeutic adherence are limited. Noninvasive neurostimulation methods applied over various peripheral sites (forehead, mastoid, upper arm, cervical vagus nerve) have raised great interest because of their excellent efficacy/tolerance profile. Among them external trigeminal nerve stimulation (eTNS) was first to obtain FDA approval for migraine therapy. Areas covered: All clinical trials of eTNS as preventive or acute migraine treatment published in extenso or presented at congresses are reviewed. The paper analyzes neuroimaging and neurophysiological studies on mechanisms of action of eTNS. As many of these studies point toward the anterior cingulate cortex (ACC) as a likely eTNS target, the paper scrutinizes the available literature on the ACC implication in migraine pathophysiology. Expert commentary: eTNS is a viable alternative to standard pharmacological antimigraine strategies both for prevention and abortive therapy. eTNS could chiefly exert its action by modulating the perigenual ACC, which might also be of interest for treating other disorders like fibromyalgia or depression. It remains to be determined if this might be a common mechanism to other peripheral noninvasive neurostimulation methods.

Non-Pharmacological Approaches for Migraine

Migraine is one of the most common and debilitating neurological disorders. However, the efficacy of pharmacological therapies may have unsatisfactory efficacy and can be poorly tolerated. There is a strong need in clinical practice for alternative approaches for both acute and preventive treatment. Occasionally, this need might arise in the context of low-frequency migraneurs who are not keen to use medication or fear the potential side effects. At the opposite end of the spectrum, clinicians might be faced with patients who have proven refractory to numerous medications. These patients may benefit from invasive treatment strategies. In recent years, promising strategies for migraine therapy have emerged alongside a progressively better understanding of the complex pathophysiology underlying this disease. This review discusses the most recent and evidence-based advances in non-pharmacological therapeutic approaches for migraine, offering alternatives to drug treatment for both the commonly encountered episodic cases as well as the more complex migraine phenotypes, which are capable of challenging even the headache specialist.

An Update on Non-Pharmacological Neuromodulation for the Acute and Preventive Treatment of Migraine

OBJECTIVE

To review current neuromodulation treatments available for migraine therapy, both in the acute and preventive setting.

METHODS

The published literature was reviewed for studies reporting the effects of different neuromodulation strategies in migraine with and without aura. The use of non-invasive: single pulse transcranial magnetic stimulation, non-invasive vagal nerve stimulation, supraorbital nerve stimulation, and transcranial direct current stimulation, as well as invasive methods such as occipital nerve stimulation and sphenopalatine ganglion stimulation, are assessed.

RESULTS

The available evidence shows that non-invasive techniques represent promising treatment strategies, whereas an invasive approach should only be used where patients are refractory to other preventives, including non-invasive methods.

CONCLUSIONS

Neuromodulation is emerging as an exciting approach to migraine therapy, especially in the context of failure of commonly used medicines or for patients who do not tolerate common side effects. More studies with appropriate blinding strategies are needed to confirm the results of these new treatment opportunities.