Neuromodulators
A novel non-drug approach
Neuromodulators in general have pro's and con's to consider:
Pro's:
- Can typically be used in pregnancy, pediatric, and geriatric populations.
- Are a good solution for patients who can't tolerate, have contraindications to, or don't want to take prescription drugs.
- Great to use in patients who are in Medication Overuse Headache (aka rebound headache).
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Con's:
- Can be expensive, based on the company/model, and often are not eligible for refunds... also they aren't usually covered by insurance. This means that patients can potentially spend a lot of money upfront on these devices and if they don't work, they may have to eat the cost.
- There are a handful of options, all of which work in slightly different ways, and finding the right one for each patient can be tricky.
- Some patients can't use them--like patients with pacemakers or implanted hearing aids. Patients with hx of stroke/seizures should be cleared by their neurologist before using them, and if there is a history of severe cardiac issues, caution should be used or their cardiologist should clear them first.
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Types of neuromodulators currently available:
1. External Trigeminal Nerve Stimulation (Cefaly)
- sticks just above the nose on the forehead.
- can be used both prophylactically and acutely
- $424 upfront cost, 90 day satisfaction guarantee
Cefaly Studies/Evidence:
- Phase 3 randomized, double-blind, sham-controlled Trial of e-TNS for the Acute treatment of Migraine
- Acute migraine therapy with external trigeminal neurostimulation
- External trigeminal neurostimulation in patients with chronic migraine
2. Noninvasive Vagus Nerve Stimulation (GammaCore)
- Pt must hold up to neck during therapy sessions
- Requires Rx from provider
- Up to $600 per month - ongoing cost or it disables the device.
GammaCore Studies/Evidence:
- Non-invasive vagus nerve stimulation (nVNS) for the preventive treatment of episodic migraine
- Non-invasive vagus nerve stimulation for prevention of migraine
- Cervical Noninvasive Vagus Nerve Stimulation for Migraine and Cluster Headache
- Noninvasive vagus nerve stimulation for migraine
3. Remote Electrical Neuromodulation (Nerivio)
- Wraps around arm, stimulates alpha and C-fibers in upper arm to desensitize pain signaling mechanism of body.
- Use as both prevention and acute therapy.
- about $100 upfront, ongoing purchases of "refills"
Nerivio Studies/Evidence:
- Remote electrical neuromodulation for acute treatment of migraine in adolescents
- Safety and efficacy of remote electrical neuromodulation for the acute treatment of chronic migraine
4. External Combined Occipital & Trigeminal Neurostimulation (Relivion)
- Headband, reaches multiple sites.
- $200 for first 90 days, nonrefundable. Comes with 1:1 training sessions from manufacturer and continued on-demand support. If it works, $75/mo ongoing.
- Anecdotally may work best out of the options currently available.
Relivion Studies/Evidence:
- External Concurrent Occipital and Trigeminal Neurostimulation Relieves Migraine Headache
- A device review of Relivion®
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