Pharmacological treatments aren’t effective for everyone, and some people prefer not to take medications if they aren’t absolutely needed. For these patients, external neuromodulation devices can help prevent and/or treat a migraine attack.
There are a number of neuromodulators on the market, all of which target different nerves or areas of the brain. Here’s a roundup of what’s available.
Cefaly®
Cefaly is a transcutaneous supraorbital (above the eyes on the forehead) neurostimulation device cleared by the Food and Drug Administration (FDA) in March 2014 for the prevention of migraine headaches in people 18 years and older. It’s the only neuromodulation device available without a prescription.
The device attaches to the forehead with an adhesive electrode. When you switch it on, it generates precise micro-impulses to stimulate the trigeminal nerve, which is known to be involved in most migraine headaches. Stimulation of the trigeminal nerve is believed to suppress activity in the fibers within the nerve that carry pain signals to the brain.
The manufacturer recommends you use Cefaly once a day for 20 minutes to prevent migraine attacks. The device allows you to increase the impulses’ intensity so your sessions become more and more effective as you build tolerance. Unfortunately, you’re not able to reduce the impulse intensity, so if the starting intensity is too high and causes pain, there’s nothing you can do, and you’ll have to look for something else.
You shouldn’t use Cephaly if you have a metallic or electronic implant in your head, if your pain stems from an unknown origin, or if you have a cardiac pacemaker or an implanted or a wearable defibrillator.
Side effects from using Cefaly are rare. The most notable are an uncomfortable feeling of the device on the forehead, allergic skin reaction to the electrode, fatigue both during and after the session, and a headache after the session.
Cerena transcranial magnetic stimulation (TMS)
Transcranial magnetic stimulation is a noninvasive method of brain stimulation cleared by the FDA on December 13, 2013 for use in patients who have migraine with aura. The device uses electromagnetic impulses to regulate signals in the brain. You need to get a prescription from your doctor to use it.
A plastic-insulated metal coil placed over the scalp generates pulses that can be delivered one at a time or in rapid succession. When delivered in rapid succession, the treatment is known as repetitive TMS (rTMS).
Recent studies show that single-pulse TMS therapy may be effective in treating acute migraine with aura after the first attack. An attack occurs when bursts of neural activity in the nerves that connect the brain to the face and other parts of the head are followed by a period of inactivity known as cortical spreading depression.
The brain operates through the conduction of electrical impulses, so intentionally introducing mild electrical fields through TMS may modulate the excitability of the brain’s neurons and thereby reduce cortical spreading depression. rTMS may help prevent migraine attacks by producing longer-lasting changes in brain activity.
You may be a good candidate for transcranial magnetic stimulation if your migraine attacks don’t respond to medication.
Side effects of TMS are generally mild-to-moderate and improve shortly after treatment. They may include some scalp discomfort; tingling, spasms, or twitching of facial muscles; and lightheadedness.
You shouldn’t receive TMS if you have a pacemaker, shunt, or spinal cord stimulator.
gammaCore®
gammaCore is a noninvasive vagal nerve stimulator (nVNS) that can be used for acute treatment of migraine and cluster headaches in patients 12 and older. It also comes with dosing regimens for the prevention of migraine and cluster headaches. Patients with hemicrania continua (one-sided continuous headache) and paroxysmal hemicrania (sudden, severe head pain on one side of your head, usually behind the eye) may see benefit with gammaCore as well.
Treatment duration is 4-6 minutes, and it can be repeated throughout the day if you experience additional attacks.
Possible side effects include skin irritation, muscle twitching, pain, and dizziness.
gammaCore shouldn’t be used in pregnant women or those with carotid atherosclerosis, congenital cardiac issues, prior vagal nerve surgeries, high or low blood pressure or heart rate, or an implantable electric stimulation or metallic device.
Relivion®
Relivion is a multi-channel brain neuromodulation system. It targets branches of both the occipital and trigeminal nerves with electrical stimulation designed to treat acute migraine pain in patients at least 18 years old.
As with the other neuromodulators, you shouldn’t use Relivion if you have an active implantable medical stimulator or other metal device.
Side effects may include scalp numbness, tingling sensation, pain, skin irritation, sleepiness, dizziness, and headache.
Nerivio®
Nerivio is unique in that it’s worn on the upper arm instead of the head. It stimulates small nerves that send transcutaneous electrical nerve stimulation to a pain regulation center in the brainstem. That center inhibits pain signals by releasing neurotransmitters.
Nerivio is meant to be used for patients who have episodic migraine and who are at least 18 years old. You shouldn’t use Nerivio if you have an active implantable medical device (e.g., pacemaker, vagal nerve stimulator, spinal cord stimulator). Each treatment lasts for 45 minutes, and the device is thought to be most effective if used within one hour of the onset of the pain phase of a migraine attack. Research is currently underway to determine its efficacy if used during the prodrome phase that precedes the pain.
If you’re struggling with migraine attacks, talk to your physician about which neuromodulator, if any, may be best for your individual circumstances.
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