This is an exciting time in migraine treatment. For the first time, there are specific pharmacological and neuromodulating options for the treatment of migraine that actually target the mechanism of migraine. Up until now, medications used for migraine prevention were medications that were designed for other purposes (anti-epileptic, anti-hypertensive, anti-depressants) that were found to be of benefit to less than 50% of migraine patients less than 50% of the time. 80% of these patients were off these medications within 1 year because of this modest effect and because these medications also carried a significant burden of side effects for many users.
This is a term used to describe devices that calm the overstimulated brain found in migraine by using electrical, magnetic or temperature-altering means.

• They work by specifically targeting the migraine’s biochemical pathway. This decreased their adverse effects profile. They have been deemed “minimal risk” which means they have no known or expected side effects.

• They have all been found to be useful in acute migraine as well as preventative migraine treatments.

• Some patients prefer to avoid medication, which will reduce the chance of medication side effects and also medication-overuse headache (MOH).

• There are currently 3 non-invasive (not requiring surgery or implantation) FDA-approved devices.

• This device targets the supraorbital nerve which will in turn affect the trigeminal nerve, a nerve that has been implicated in migraine headaches. It works by electrically decreasing the nociceptive blink reflex implicated in migraine. In a nutshell, it reduces the central nervous system’s (CNS) sensitivity to generating pain pathways. It has also been found to be useful in sleep. • Patients apply the electrodes on the forehead (some patients are sensitive to the adhesive used) and then choose the appropriate setting and duration of use (there are different settings/duration of use for acute migraine vs preventative migraine care). • Patient compliance to the prescribed regimen is important for results. For example, it should be used once a day for 20 minutes to help reduce migraine frequency and severity.
• This device magnetically reduces the “cortical spreading depression” feature identified in the biochemical pathway of migraine by interfering with the way the cortex communicates with the thalamus. • It is applied to the back of your head, you turn it on, and then the magnet starts working • Again, there is a difference in regimens between those using it for acute migraine treatment and those using it for migraine prevention. The technology is being developed to include paediatric patients too.
• This device targets the vagus nerve (a nerve of the parasympathetic autonomic nervous system). It is also thought to modulate activity in the hypothalamus. • The patient places the device on the side of the neck and then turns it on. The modulation occurs electrically. • Again, there are different treatments for different indications. It was FDA approved for acute and chronic cluster headaches and for the treatment of acute migraines. There is intention to use nVNS in the study of post-traumatic headaches.

1. Cost. It is not covered by most insurance companies and cost a few hundred dollars to rent per month.

2. Efficacy. It may not be as effective as other preventative migraine medications.

3. Portability. Some complain they are heavy or big to carry around in a purse. The sTMS weighs 3 lb.

4. Time. It can take 3 months of proper use to notice an effect.

Research & writing: Dr. Taher Chugh

Last update: December 2018