Current treatment for migraine attacks is primarily pharmacological. But its effectiveness is sometimes limited, with a significant risk of side effects and overconsumption, which has sparked interest in other methods of treatment.
Neuromodulation has been offered in neurology for over 50 years. It occupies an increasingly important place as an alternative or complementary treatment to pharmacotherapy of primary headaches.
The possibility of carrying it out on a large scale, and in a non-invasive manner, which allows side effects to be minimized, has however been hampered by the lack of evidence of its effectiveness (in particular because it is difficult to assess it at the same time). ‘blind), but also because of the cost of the devices.
An increasingly active search
sTMS (single-pulse transcranial magnetic stimulation) has proven itself through two studies involving quality ‘decoy’ stimulation in the early treatment of migraine with aura. It also showed that its effectiveness persists over the long term in difficult-to-treat migraine patients who responded to treatment, while a real-life study showed that this method of treatment was well tolerated, with only one patient having to stop treatment for skin sensitivity.
Side effects, when present (approximately 15% of patients), were generally moderate and transient. Experts explain its activity on the aura by stopping slow waves of cortical depolarization, probably by promoting inhibitory GABAergic activity, and its action on migraine pain by inhibiting nociceptive thalamocortical neurons.
However, sTMS devices are not widely used, which led Giorgio Lambru (Kings College, London) to take a closer look at transcutaneous supraorbital stimulation. This device provides effectiveness of the same order as sTMS in preventing episodic migraine, and with excellent tolerance.
“But the lure of this equipment is difficult to achieve, which makes studies difficult to carry out”he underlines, citing 3 convincing studies. In any case, this device seems effective, even when used later during the migraine attack and in patients who do not respond to oral treatments. However, its effectiveness seems limited (and similar to that of sTMS) in cases of chronic migraine.
Transcutaneous auricular stimulation of the vagus nerve (auricular t-VNS), which allows activation via the myelinated afferent Abeta fibers of the vagus nerve, the nucleus of the solitary fasciculus, seems, in a study involving 86 patients, to give better results than other stimulation procedures.
Remote electrical neuromodulation (REN) is a new acute treatment for migraine that stimulates peripheral nerves in the arm to induce conditioned pain modulation. It has the advantage of being able to modulate the intensity of the stimulation and has shown great potential in both episodic migraine and chronic migraine.
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