Neuromodulation in migraine: state of the art and perspectives

Abstract

Migraine is a highly prevalent and disabling disease. The drugs prescribed for migraine prophylaxis can have intolerable side effects or can be ineffective. Neuromodulation techniques are increasingly used in neurology. Transcutaneous supraorbital nerve stimulation is effective in episodic migraine prevention, whereas vagus nerve stimulation provides interesting results in acute migraine therapy. Transcranial stimulation techniques gave variable, and sometimes contradictory, results. The visual cortex is the target of choice in migraine: studies in migraine prevention and aura acute treatment are encouraging. These noninvasive therapies appear safe with a low rate of side effects. Available studies of invasive occipital nerve stimulation in chronic migraine gave modest results; but invasive occipital nerve stimulation offers a new hope to highly disabled patients who failed to respond to any other treatment. In the future, neuromodulation will probably take an increasing place in migraine treatment, as add-on therapy or alternative to medications, especially because of its attractive safety profile.

Keywords:

• direct current stimulation
• magnetic stimulation
• migraine
• neuromodulation
• occipital nerve
• peripheral nerve
• supraorbital nerve
• treatment

Acknowledgements

The author would like to thank D Fontaine from the Department of Neurosurgery, CHU de Nice, France, for providing the Figure 4 on invasive occipital nerve stimulation.

Financial & competing interests disclosure

The author is currently involved in clinical trials with: Electrocore USA^®, Cefaly-Technology^®, Medtronic USA^®, St Jude Medical^® but did not receive any personal sponsorship or grants from these industries that could lead to a conflict of interest. This work was supported by the European Union, EUROHEADPAIN project, FP7, n 602633. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• In a significant proportion of individuals, available drugs used for migraine prevention have often disabling side effects or are not effective.

• Neuromodulation devices offer a new therapeutic alternative, besides other nonpharmacological approaches such as behavioral therapy, and are being increasingly studied in migraine prevention, and to some extent in migraine acute therapy.

• These devices can be proposed to several categories of patients with migraine: those who are drug-refractory, who do not want to take any drug or who have contraindications or side effects with usual drugs.

• Noninvasive neurostimulation treatments are generally well tolerated and have few side effects (4.3% for transcutaneous supraorbital nerve stimulation), and with the availability of portable user-friendly devices, will be soon part of the migraine therapeutic armamentarium.

• Randomized controlled trials are lacking for most devices and should be performed in the future.

• Transcutaneous supraorbital nerve stimulation has shown its effectiveness in episodic migraine prevention, whereas invasive occipital nerve stimulation can help some patients having chronic migraine.

• Invasive neurostimulation should only be considered in patients with refractory chronic migraine, after failure of noninvasive therapies and in the absence of medication overuse.

• The neuromodulation of peculiar brain areas with rTMS or tDCS could be more disease specific and offer the largest therapeutic possibilities, but these techniques have technical issues that will be a challenge for future studies.

Notes