Device-based therapy is playing an increasingly important role in migraine care. Stewart J. Tepper, MD, FAHS, reviews evidence supporting the use of noninvasive neuromodulation devices for both the acute treatment and prevention of migraine and explains how they can be integrated into clinical practice to optimize patient care.

Noninvasive neuromodulators are portable peripheral devices that modulate various sensory pathways to change nervous system function and terminate migraine acutely, prevent migraine, or both. The external trigeminal nerve stimulation (eTNS) device, CEFALY (CEFALY Technology), was the first noninvasive neuromodulation device to be US Food and Drug Administration (FDA) cleared in the United States; it is cleared for acute and preventive migraine treatment in adults. There are several other eTNS and transcutaneous electrical nerve stimulation (TENS) devices that are also available for migraine prevention and/or acute migraine treatment. The mechanisms of action of eTNS and TENS are thought to be at least partially through cortical inhibition. eTNS and TENS activate trigeminal inhibitory pathways, which, over time, may result in changes in the central processing of pain.

There is also the noninvasive external combined occipital and trigeminal nerve stimulation (eCOT-NS) device available that sits on the forehead and over the greater occipital nerves posteriorly. The goal of the eCOT-NS device is to terminate migraine more effectively by inhibiting both the trigeminal and greater occipital nerve pathways to the trigeminocervical complex. Clinical studies and case series with eCOT-NS have suggested both an acute and a preventive benefit for the management of migraine.

Single-pulse transcranial magnetic stimulation (sTMS) is a different type of device for the prevention and treatment of migraine. After booting up the sTMS device, a person presses a button, and a magnet pulses the back of the head as far forward as the thalamus but not below the neck. The device was developed to terminate cortical spreading depolarization and inhibit thalamocortical pathways through the magnetic pulses. Several studies of sTMS have demonstrated its benefit in both the prevention and acute treatment of migraine.

Another type of neuromodulator available for migraine is noninvasive vagus nerve stimulation (nVNS). This device has 2 electrodes that are applied to the neck over the vagus nerve, and the user adjusts the intensity of the stimulation. The nVNS device is thought to inhibit trigeminal activation and thalamocortical pathways, as well as to terminate cortical spreading depolarization. A preponderance of the evidence was positive for the use of nVNS in both prevention and treatment across a variety of primary headache disorders.

The last type of neuromodulator is the remote electrical neuromodulation (REN) device, which sits on the arm and is held in place by a band. The REN device is thought to work by utilizing conditioned pain modulation in which subpain threshold stimulation in the arm inhibits pain in an alternative region (ie, the head). REN has also demonstrated benefit for both the prevention and acute treatment of migraine.

These noninvasive neuromodulation devices can be used at any point in migraine history (ie, early or late), in people on or off medication, or as a substitute for medication in patients with inadequate response or in those who are at risk of medication overuse. There is a lot of potential utility for noninvasive neuromodulation in different patient populations.