Neuromodulation Devices in Migraine: The Latest

Jessica Ailani, MD, FAHS

Disclosures

January 08, 2019

Editorial Collaboration

Medscape &

Limitations of Neuromodulation

There are multiple challenges that should be noted when evaluating the evidence for neuromodulation in the treatment of migraine. Studies were conducted on a relatively small number of participants. Using these results to generalize to a larger, less homogeneous population can be difficult.[13] Maintaining blinding is another limitation of studies of neuromodulation; it is difficult to design a placebo-controlled study when you are using a device that may produce paresthesia. Sham devices need to produce some effect, but not significant enough to produce an improvement in symptoms. This could lead to difficulty maintaining blinding and lead to lower or higher placebo efficacy rates, depending on the sham device.

Cost may also be a challenge. At this time, there is limited insurance coverage for these devices in migraine. And while many devices have shown benefit in improving quality of life over time, which may possibly be translated to fewer missed work days and less need for prescription acute medications, it is often difficult for patients to take on direct costs at once.

While there are several challenges, neuromodulation can be a beneficial addition to a patient’s regimen. Patients who are overusing acute medications, patients who would like to limit the use of oral medications, or patients who have a partial response to therapeutic agents either for acute or preventive treatment are particularly good candidates for the use of neuromodulation. In clinical practice, neuromodulation is often used in women who are pregnant. Though not FDA indicated, it is considered safe, and patients often feel comfortable having an option that does not involve medications.

In conclusion, while studies showing beneficial effect of neuromodulation devices are small, they seem to indicate an improvement in severity of attacks and quality of life, and the possibility of improvement in frequency of attacks, with limited adverse events. At this time, it is difficult to determine cost/benefit for patients with migraine, and these considerations should be discussed when considering the use of neuromodulation in migraine.

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