Neuromodulation in migraine.

The International Neuromodulation Society defines therapeutic neuromodulation as the alteration of nerve activity through targeted delivery of a stimulus, such as electrical stimulation or chemical agents, to specific neurological sites in the body. Neuromodulation for the treatment of migraine is an evolving field offering further insight into the pathophysiology of migraine as well as advanced therapeutics. Central and peripheral neuronal targets have been explored in the efforts to reduce the frequency and severity of attacks. Invasive and noninvasive techniques have been developed, targeting either the central or peripheral nervous system. Noninvasive central neuromodulation techniques have the benefit of a low side effect profile in addition to higher level of evidence for use thanks to sham-controlled trials; however, these modalities are less clinically available for use. Noninvasive transcutaneous neuromodulation techniques that target the peripheral nervous system have provided devices that are available over the counter or by prescription. Several of these devices are effective for abortive and preventive treatment of migraine. Invasive techniques such as cranial nerve stimulation with implanted stimulator devices or spinal cord stimulation may be used for more aggressive management in patients refractory to other treatments. Overall, neuromodulation techniques can be particularly beneficial for medically complex or refractory patients, those that prefer nonmedication options, and those that have experienced adverse effects from medications.

Noninvasive Neuromodulation in Migraine.

PURPOSE OF REVIEW: The past two decades has seen an influx of noninvasive neuromodulation devices aimed at treatment of various primary headache disorders, including cluster headache and migraine. This narrative review is to summarize the current options in noninvasive neuromodulation in migraine. RECENT FINDINGS: A variety of noninvasive neuromodulation devices have been FDA cleared and marketed for use in migraine, including single-pulse transcranial magnetic stimulation (sTMS), noninvasive vagal nerve stimulators (nVNS), and external trigeminal nerve stimulators (eTNS). Newer devices include peripheral electrical stimulation devices (PES), caloric stimulation, and others. Each has varying levels of evidence supporting its use in migraine, tolerability profiles, and access issues. Noninvasive neuromodulation devices can be beneficial when used in patients with migraine, with minimal side effects. As more devices are developed, approved, and marketed in the future, rigorous research on efficacy and safety remain a top priority.