Non-invasive Nerve Stimulation Modalities for Migraine Pain: A Review of Clinical Effectiveness and Cost-effectiveness [Internet]

Excerpt

Migraine is a common debilitating neurological condition characterized by the presence of unilateral pulsatile headaches with or without an aura lasting up to 72 hours. Globally, migraine was found to be the second most leading cause of years lived with disability (YLDs) amounting to 45.1 million, after low back pain. Statistics Canada reports that approximately 8.3% of Canadians have been diagnosed with migraine based on the 2010/11 Canadian Community Health Surveys. In 2017, migraine accounted for about 770 Years Lived with Disability (YLD) per 100,000 in Canada.

Based on the number of average headache attacks per month, the disorder can be grouped into episodic and chronic migraine. Episodic migraine is diagnosed when the number of migraine days per month are 14 or less whereas a migraine disorder is classified as chronic if headache symptoms are present at least 15 days per month, of which at least eight days fulfill the migraine criteria set by the International Classification of Headache Disorders (ICH).

Migraines are treated prophylactically (before an attack occurs) and abortive (for acute treatment of attacks) using various pharmacological and non-pharmacological interventions. Non-invasive Nerve Stimulation (NINS) modalities are neuromodulation methods which involve stimulating central or peripheral nervous system with a non-painful magnetic field or an electric current using electrodes/devices applied on top of skin at strategic positions over the nerves involved.^, There are several NINS devices available for migraine treatment and prevention. The modalities discussed in the current report include external trigeminal nerve stimulation (e-TNS), repetitive transcranial magnetic stimulation (rTMS) and transcutaneous occipital nerve stimulation (tONS).

e-TNS is a modality also known as Transcutaneous Supraorbital Neurostimulation (tSNS) under the brand name Cefaly®. e-TNS devices are applied on the forehead to stimulate the bilateral supraorbital nerves which are a branch of trigeminal nerve.^, TMS devices generate magnetic pulses applied directly to the back of the neck over the occipital cortex to stimulate the cerebral cortex directly. Single pulse (sTMS) and repetitive pulse (rTMS) are different types of TMS.^, tONS are relatively new NINS devices that stimulate the bilateral occipital nerve and are applied over the occipital areas of the neck.

The objective of this rapid response report is to summarize the evidence regarding the clinical effectiveness and cost effectiveness of NINS modalities for prophylactic and abortive treatment for episodic and chronic migraine pain.