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Han HJ, Kim H, Kim DJ. Systematic review for VNS vs. pharmaceutical modulations for multifaceted neurological disorder management through cross-case, network meta-analysis. Brain Stimul 2025; 18:909-936. [PMID: 40220956 DOI: 10.1016/j.brs.2025.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2024] [Revised: 03/19/2025] [Accepted: 04/07/2025] [Indexed: 04/14/2025] Open
Abstract
BACKGROUND As an adjunct or alternative to conventional pharmacotherapy, vagus nerve stimulation (VNS) which is FDA-approved has arisen as a novel means for various neurological disorders. METHOD We searched multiple databases (through 2024) for randomised trials and observational studies of VNS (invasive and transcutaneous) and pharmacological treatments (e.g. cholinergic agents, antiepileptics, antidepressants) across several neurological disorders. Prior to comparing between VNS and pharmacological treatments, subgroup analyses of VNS studies were performed for disorder type, patient demographics, VNS stimulation parameters, and treatment duration to illustrate whether VNS itself can be effective to a satisfactory extent to be compared against the conventional method. Efficacy and adverse effects were evaluated, based on the proportion of patients achieving more than 50 % symptom reduction or equivalent clinical improvement, or all-cause mortality where applicable. Evaluation between VNS and pharmacological treatments was performed through network meta-analysis, followed by assessment of heterogeneity (I2) and meta-regression. Risk of bias was evaluated with Cochrane criteria, and all studies (including those with high risk of bias) were included in the primary analysis (with sensitivity analyses excluding high-bias studies). RESULTS We included 56 VNS-related studies (n = 5773 participants) and 29 pharmacological drug-based studies (n = 14827 participants) from spanning epilepsy, depression, migraine/headache, Alzheimer's disease, inflammatory disorders, and heart failure. A network meta-analysis directly comparing VNS to pharmacological drugs yielded an overall advantage for VNS (summary SMD = 0.27 favouring VNS, 95 % CI 0.19-0.35). However, the high heterogeneity and risk of bias have been assessed, indicating potential issues with the VNS studies. CONCLUSION Overall, VNS was shown to be a viable therapeutic modality across diverse neurological disorders, superior to standard pharmacological treatments with a distinct adverse effect profile. It appears particularly beneficial in conditions where conventional drugs have limited success (e.g. refractory epilepsy, depression), although patient-specific factors influence outcomes. Further high-quality trials are anticipated to optimise stimulation parameters, confirm long-term benefits, and manage patient selection for VNS.
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Affiliation(s)
- Hyun-Jee Han
- Department of Pharmacology, University of Cambridge, UK
| | - Hakseung Kim
- Department of Brain and Cognitive Engineering, Korea University, Seoul, South Korea
| | - Dong-Joo Kim
- Department of Brain and Cognitive Engineering, Korea University, Seoul, South Korea; Department of Neurology, Korea University College of Medicine, Seoul, South Korea.
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2
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Wang C, Wu B, Lin R, Cheng Y, Huang J, Chen Y, Bai J. Vagus nerve stimulation: a physical therapy with promising potential for central nervous system disorders. Front Neurol 2024; 15:1516242. [PMID: 39734634 PMCID: PMC11671402 DOI: 10.3389/fneur.2024.1516242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2024] [Accepted: 11/29/2024] [Indexed: 12/31/2024] Open
Abstract
The diseases of the central nervous system (CNS) often cause irreversible damage to the human body and have a poor prognosis, posing a significant threat to human health. They have brought enormous burdens to society and healthcare systems. However, due to the complexity of their causes and mechanisms, effective treatment methods are still lacking. Vagus nerve stimulation (VNS), as a physical therapy, has been utilized in the treatment of various diseases. VNS has shown promising outcomes in some CNS diseases and has been approved by the Food and Drug Administration (FDA) in the United States for epilepsy and depression. Moreover, it has demonstrated significant potential in the treatment of stroke, consciousness disorders, and Alzheimer's disease. Nevertheless, the exact efficacy of VNS, its beneficiaries, and its mechanisms of action remain unclear. This article discusses the current clinical evidence supporting the efficacy of VNS in CNS diseases, providing updates on the progress, potential, and potential mechanisms of action of VNS in producing effects on CNS diseases.
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Affiliation(s)
- Chaoran Wang
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine/National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
- Postgraduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Bangqi Wu
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine/National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Ruolan Lin
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine/National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
- Postgraduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yupei Cheng
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine/National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
- Postgraduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jingjie Huang
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine/National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
- Postgraduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yuyan Chen
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine/National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
- Postgraduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jing Bai
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine/National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
- Postgraduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
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3
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Naparstek S, Yeh AK, Mills-Finnerty C. Transcutaneous Vagus Nerve Stimulation (tVNS) applications in cognitive aging: a review and commentary. Front Aging Neurosci 2023; 15:1145207. [PMID: 37496757 PMCID: PMC10366452 DOI: 10.3389/fnagi.2023.1145207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 06/12/2023] [Indexed: 07/28/2023] Open
Abstract
Differentiating healthy from pathological aging trajectories is extremely timely, as the global population faces an inversion where older adults will soon outnumber younger 5:1. Many cognitive functions (e.g., memory, executive functions, and processing speed) decline with age, a process that can begin as early as midlife, and which predicts subsequent diagnosis with dementia. Although dementia is a devastating and costly diagnosis, there remains limited evidence for medications, therapies, and devices that improve cognition or attenuate the transition into dementia. There is an urgent need to intervene early in neurodegenerative processes leading to dementia (e.g., depression and mild cognitive impairment). In this targeted review and commentary, we highlight transcutaneous Vagus Nerve Stimulation (tVNS) as a neurostimulation method with unique opportunities for applications in diseases of aging, reviewing recent literature, feasibility of use with remote data collection methods/telehealth, as well as limitations and conflicts in the literature. In particular, small sample sizes, uneven age distributions of participants, lack of standardized protocols, and oversampling of non-representative groups (e.g., older adults with no comorbid diagnoses) limit our understanding of the potential of this method. We offer recommendations for how to improve representativeness, statistical power, and generalizability of tVNS research by integrating remote data collection techniques.
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Affiliation(s)
- Sharon Naparstek
- Department of Psychology, Bar-Ilan University, Ramat Gan, Israel
| | - Ashley K. Yeh
- Department of Molecular, Cellular, and Developmental Biology, University of California, Santa Barbara, Santa Barbara, CA, United States
| | - Colleen Mills-Finnerty
- VA Palo Alto Health Care System, Palo Alto, CA, United States
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA, United States
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4
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Tan C, Yan Q, Ma Y, Fang J, Yang Y. Recognizing the role of the vagus nerve in depression from microbiota-gut brain axis. Front Neurol 2022; 13:1015175. [PMID: 36438957 PMCID: PMC9685564 DOI: 10.3389/fneur.2022.1015175] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 09/12/2022] [Indexed: 08/08/2023] Open
Abstract
Depression is a worldwide disease causing severe disability, morbidity, and mortality. Despite abundant studies, the precise mechanisms underlying the pathophysiology of depression remain elusive. Recently, cumulate research suggests that a disturbance of microbiota-gut-brain axis may play a vital role in the etiology of depression while correcting this disturbance could alleviate depression symptoms. The vagus nerve, linking brain and gut through its afferent and efferent branches, is a critical route in the bidirectional communication of this axis. Directly or indirectly, the vagus afferent fibers can sense and relay gut microbiota signals to the brain and induce brain disorders including depression. Also, brain changes in response to stress may result in gut hyperpermeability and inflammation mediating by the vagal efferents, which may be detrimental to depression. Notably, vagus nerve stimulation owns an anti-inflammatory effect and was proved for depression treatment. Nevertheless, depression was accompanied by a low vagal tone, which may derive from response to stress and contribute to pathogenesis of depression. In this review, we aim to explore the role of the vagus nerve in depression from the perspective of the microbiota-gut-brain axis, highlighting the relationship among the vagal tone, the gut hyperpermeability, inflammation, and depression.
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Affiliation(s)
- Chaoren Tan
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Science, Beijing, China
| | - Qiqi Yan
- Institute of Basic Theory for Chinese Medicine, China Academy of Chinese Medical Science, Beijing, China
| | - Yue Ma
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jiliang Fang
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yongsheng Yang
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Science, Beijing, China
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5
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Asif N, Patel A, Vedantam D, Poman DS, Motwani L. Migraine With Comorbid Depression: Pathogenesis, Clinical Implications, and Treatment. Cureus 2022; 14:e25998. [PMID: 35865445 PMCID: PMC9290761 DOI: 10.7759/cureus.25998] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2022] [Indexed: 11/05/2022] Open
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Devices for Episodic Migraine: Past, Present, and Future. Curr Pain Headache Rep 2022; 26:259-265. [PMID: 35147856 PMCID: PMC8930505 DOI: 10.1007/s11916-022-01024-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Historically, therapies for migraine have generally involved pharmacological treatments using non-selective or selective analgesics and preventive treatments. However, for many patients these treatments are not effective, while others prefer to use non-pharmacological-based therapies. To fill this need, over the last 15 years, neuromodulatory devices have entered the market for migraine treatment. Here, we will review the most recent findings for the use of these devices in the treatment of migraine. RECENT FINDINGS Non-invasive vagus nerve stimulation and spring-pulse transcranial magnetic stimulation are both cleared for the treatment of migraine, supported by preclinical studies that validate efficacy and mechanism of action, and complemented with clinical trial data. Other options also authorized for use include transcutaneous supraorbital nerve stimulation and remote electrical neuromodulation. Various options are available to treat migraine using authorized neuromodulatory devices. These data support their efficacy in the treatment of episodic migraine, although further studies are necessary to elucidate their mechanism of action and to provide rigor to clinical trial data.
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7
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Liu TT, Morais A, Takizawa T, Mulder I, Simon BJ, Chen SP, Wang SJ, Ayata C, Yen JC. Efficacy profile of noninvasive vagus nerve stimulation on cortical spreading depression susceptibility and the tissue response in a rat model. J Headache Pain 2022; 23:12. [PMID: 35062860 PMCID: PMC8903561 DOI: 10.1186/s10194-022-01384-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/29/2021] [Indexed: 11/23/2022] Open
Abstract
Background Noninvasive vagus nerve stimulation (nVNS) has recently emerged as a promising therapy for migraine. We previously demonstrated that vagus nerve stimulation inhibits cortical spreading depression (CSD), the electrophysiological event underlying migraine aura and triggering headache; however, the optimal nVNS paradigm has not been defined. Methods Various intensities and doses of nVNS were tested to improve efficacy on KCl-evoked CSD frequency and electrical threshold of CSD in a validated rat model. Chronic efficacy was evaluated by daily nVNS delivery for four weeks. We also examined the effects of nVNS on neuroinflammation and trigeminovascular activation by western blot and immunohistochemistry. Results nVNS suppressed susceptibility to CSD in an intensity-dependent manner. Two 2-minute nVNS 5 min apart afforded the highest efficacy on electrical CSD threshold and frequency of KCl-evoked CSD. Daily nVNS for four weeks did not further enhance efficacy over a single nVNS 20 min prior to CSD. The optimal nVNS also attenuated CSD-induced upregulation of cortical cyclooxygenase-2, calcitonin gene-related peptide in trigeminal ganglia, and c-Fos expression in trigeminal nucleus caudalis. Conclusions Our study provides insight on optimal nVNS parameters to suppress CSD and suggests its benefit on CSD-induced neuroinflammation and trigeminovascular activation in migraine treatment. Supplementary Information The online version contains supplementary material available at 10.1186/s10194-022-01384-1.
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8
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Peripheral Nerve Stimulation for Treatment of Headaches: An Evidence-Based Review. Biomedicines 2021; 9:biomedicines9111588. [PMID: 34829819 PMCID: PMC8615534 DOI: 10.3390/biomedicines9111588] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 10/15/2021] [Accepted: 10/26/2021] [Indexed: 01/06/2023] Open
Abstract
Headaches are one of the most common medical complaints worldwide, and treatment is often made difficult because of misclassification. Peripheral nerve stimulation has emerged as a novel treatment for the treatment of intractable headaches in recent years. While high-quality evidence does exist regarding its use, efficacy is generally limited to specific nerves and headache types. While much research remains to bring this technology to the mainstream, clinicians are increasingly able to provide safe yet efficacious pain control.
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9
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Martins DF, Viseux FJF, Salm DC, Ribeiro ACA, da Silva HKL, Seim LA, Bittencourt EB, Bianco G, Moré AOO, Reed WR, Mazzardo-Martins L. The role of the vagus nerve in fibromyalgia syndrome. Neurosci Biobehav Rev 2021; 131:1136-1149. [PMID: 34710514 DOI: 10.1016/j.neubiorev.2021.10.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 08/08/2021] [Accepted: 10/18/2021] [Indexed: 12/15/2022]
Abstract
Fibromyalgia (FM) syndrome is a common illness characterized by chronic widespread pain, sleep problems, fatigue, and cognitive difficulties. Dysfunctional neurotransmitter systems that influence the body's endogenous stress response systems are thought to underlie many of the major FM-related symptoms. A model of FM pathogenesis suggests biological and psychosocial variables interact to influence the genetic predisposition, but the precise mechanisms remain unclear. The Polyvagal Theory provides a theoretical framework from which to investigate potential biological mechanisms. The vagus nerve (VN) has anti-inflammatory properties via its afferent and efferent fibers. A low vagal tone (as assessed by low heart rate variability), has been observed in painful and inflammatory diseases, including FM, while the ventral branch of the VN is linked to emotional expression and social engagement. These anti-inflammatory and psychological (limbic system) properties of the VN may possess therapeutic potential in treating FM. This review paper summarizes the scientific literature regarding the potential role of the VN in transducing and/or therapeutically managing FM signs and symptoms.
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Affiliation(s)
- Daniel F Martins
- Experimental Neuroscience Laboratory (LaNEx), Physiotherapy Graduate Course, University of Southern Santa Catarina, Palhoça, SC, Brazil; Postgraduate Program in Health Sciences, University of Southern Santa Catarina, Palhoça, SC, Brazil.
| | - Frederic J F Viseux
- Laboratoire d'Automatique, de Mécanique et d'Informatique industrielle et Humaine (LAMIH), UMR CNRS 8201, Université Polytechnique des Hauts-de-France, Valenciennes, France; Centre d'Evaluation et de Traitement de la Douleur (CETD), Hôpital Jean Bernard, Centre Hospitalier de Valenciennes, F-59322 Valenciennes, France
| | - Daiana C Salm
- Experimental Neuroscience Laboratory (LaNEx), Physiotherapy Graduate Course, University of Southern Santa Catarina, Palhoça, SC, Brazil; Postgraduate Program in Health Sciences, University of Southern Santa Catarina, Palhoça, SC, Brazil
| | - Anny Caroline Avelino Ribeiro
- Experimental Neuroscience Laboratory (LaNEx), Physiotherapy Graduate Course, University of Southern Santa Catarina, Palhoça, SC, Brazil
| | - Helen Kassiana Lopes da Silva
- Experimental Neuroscience Laboratory (LaNEx), Physiotherapy Graduate Course, University of Southern Santa Catarina, Palhoça, SC, Brazil
| | - Lynsey A Seim
- Hospital Internal Medicine, 4500 San Pablo Road, Mayo Clinic, Jacksonville, FL, USA
| | | | - Gianluca Bianco
- Research Laboratory of Posturology and Neuromodulation RELPON, Department of Human Neuroscience, Sapienza University, Rome, Italy; Istituto di Formazione in Agopuntura e Neuromodulazione IFAN, Rome, Italy
| | - Ari Ojeda Ocampo Moré
- Integrative Medicine and Acupuncture Service, University Hospital, Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
| | - William R Reed
- Department of Physical Therapy, University of Alabama at Birmingham, Birmingham, AL, USA; Rehabilitation Science Program, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Leidiane Mazzardo-Martins
- Postgraduate Program in Neuroscience, Center of Biological Sciences, Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
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10
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Wang Y, Zhan G, Cai Z, Jiao B, Zhao Y, Li S, Luo A. Vagus nerve stimulation in brain diseases: Therapeutic applications and biological mechanisms. Neurosci Biobehav Rev 2021; 127:37-53. [PMID: 33894241 DOI: 10.1016/j.neubiorev.2021.04.018] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 04/12/2021] [Accepted: 04/18/2021] [Indexed: 12/21/2022]
Abstract
Brain diseases, including neurodegenerative, cerebrovascular and neuropsychiatric diseases, have posed a deleterious threat to human health and brought a great burden to society and the healthcare system. With the development of medical technology, vagus nerve stimulation (VNS) has been approved by the Food and Drug Administration (FDA) as an alternative treatment for refractory epilepsy, refractory depression, cluster headaches, and migraines. Furthermore, current evidence showed promising results towards the treatment of more brain diseases, such as Parkinson's disease (PD), autistic spectrum disorder (ASD), traumatic brain injury (TBI), and stroke. Nonetheless, the biological mechanisms underlying the beneficial effects of VNS in brain diseases remain only partially elucidated. This review aims to delve into the relevant preclinical and clinical studies and update the progress of VNS applications and its potential mechanisms underlying the biological effects in brain diseases.
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Affiliation(s)
- Yue Wang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Gaofeng Zhan
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Ziwen Cai
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Bo Jiao
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Yilin Zhao
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Shiyong Li
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Ailin Luo
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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11
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Evers S. Non-Invasive Neurostimulation Methods for Acute and Preventive Migraine Treatment-A Narrative Review. J Clin Med 2021; 10:3302. [PMID: 34362086 PMCID: PMC8347785 DOI: 10.3390/jcm10153302] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/18/2021] [Accepted: 07/26/2021] [Indexed: 11/17/2022] Open
Abstract
Neurostimulation methods have now been studied for more than 20 years in migraine treatment. They can be divided into invasive and non-invasive methods. In this narrative review, the non-invasive methods are presented. The most commonly studied and used methods are vagal nerve stimulation, electric peripheral nerve stimulation, transcranial magnetic stimulation, and transcranial direct current stimulation. Other stimulation techniques, including mechanical stimulation, play only a minor role. Nearly all methods have been studied for acute attack treatment and for the prophylactic treatment of migraine. The evidence of efficacy is poor for most procedures, since no stimulation device is based on consistently positive, blinded, controlled trials with a sufficient number of patients. In addition, most studies on these devices enrolled patients who did not respond sufficiently to oral drug treatment, and so the role of neurostimulation in an average population of migraine patients is unknown. In the future, it is very important to conduct large, properly blinded and controlled trials performed by independent researchers. Otherwise, neurostimulation methods will only play a very minor role in the treatment of migraine.
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Affiliation(s)
- Stefan Evers
- Faculty of Medicine, University of Münster, 48153 Münster, Germany;
- Department of Neurology, Lindenbrunn Hospital, 31863 Coppenbrügge, Germany
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12
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Di Lorenzo C, Ballerini G, Barbanti P, Bernardini A, D’Arrigo G, Egeo G, Frediani F, Garbo R, Pierangeli G, Prudenzano MP, Rebaudengo N, Semeraro G, Sirianni G, Valente M, Coppola G, Cervenka MC, Spera G. Applications of Ketogenic Diets in Patients with Headache: Clinical Recommendations. Nutrients 2021; 13:2307. [PMID: 34371817 PMCID: PMC8308539 DOI: 10.3390/nu13072307] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/23/2021] [Accepted: 06/24/2021] [Indexed: 02/07/2023] Open
Abstract
Headaches are among the most prevalent and disabling neurologic disorders and there are several unmet needs as current pharmacological options are inadequate in treating patients with chronic headache, and a growing interest focuses on nutritional approaches as non-pharmacological treatments. Among these, the largest body of evidence supports the use of the ketogenic diet (KD). Exactly 100 years ago, KD was first used to treat drug-resistant epilepsy, but subsequent applications of this diet also involved other neurological disorders. Evidence of KD effectiveness in migraine emerged in 1928, but in the last several year's different groups of researchers and clinicians began utilizing this therapeutic option to treat patients with drug-resistant migraine, cluster headache, and/or headache comorbid with metabolic syndrome. Here we describe the existing evidence supporting the potential benefits of KDs in the management of headaches, explore the potential mechanisms of action involved in the efficacy in-depth, and synthesize results of working meetings of an Italian panel of experts on this topic. The aim of the working group was to create a clinical recommendation on indications and optimal clinical practice to treat patients with headaches using KDs. The results we present here are designed to advance the knowledge and application of KDs in the treatment of headaches.
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Affiliation(s)
- Cherubino Di Lorenzo
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, 04100 Latina, Italy;
| | - Giovanna Ballerini
- Multidisciplinary Center for Pain Therapy, Piero Palagi Hospital, USL Toscana Centro, 50122 Florence, Italy;
| | - Piero Barbanti
- Headache and Pain Unit, IRCCS San Raffaele Pisana, 00163 Rome, Italy; (P.B.); (G.E.)
- Department of Neuroscience and Rehabilitation, San Raffaele University, 00163 Rome, Italy
| | - Andrea Bernardini
- Clinical Neurology Unit, Misericordia University Hospital, Santa Maria Della Misericordia University Hospital, 33100 Udine, Italy; (A.B.); (R.G.); (M.V.)
| | - Giacomo D’Arrigo
- Headache Center, Neurology & Stroke Unit, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, 20142 Milan, Italy; (G.D.); (F.F.)
| | - Gabriella Egeo
- Headache and Pain Unit, IRCCS San Raffaele Pisana, 00163 Rome, Italy; (P.B.); (G.E.)
| | - Fabio Frediani
- Headache Center, Neurology & Stroke Unit, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, 20142 Milan, Italy; (G.D.); (F.F.)
| | - Riccardo Garbo
- Clinical Neurology Unit, Misericordia University Hospital, Santa Maria Della Misericordia University Hospital, 33100 Udine, Italy; (A.B.); (R.G.); (M.V.)
| | - Giulia Pierangeli
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy;
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, 40127 Bologna, Italy
| | - Maria Pia Prudenzano
- Headache Center, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, 70124 Bari, Italy;
| | | | - Grazia Semeraro
- Associazione Eupraxia, Dietary Section, 00171 Rome, Italy; (G.S.); (G.S.)
| | - Giulio Sirianni
- Associazione Eupraxia, Dietary Section, 00171 Rome, Italy; (G.S.); (G.S.)
| | - Mariarosaria Valente
- Clinical Neurology Unit, Misericordia University Hospital, Santa Maria Della Misericordia University Hospital, 33100 Udine, Italy; (A.B.); (R.G.); (M.V.)
- Neurology Unit, Department of Medicine (DAME), University of Udine, Piazzale Santa Maria Della Misericordia 15, 33100 Udine, Italy
| | - Gianluca Coppola
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, 04100 Latina, Italy;
| | - Mackenzie C. Cervenka
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA;
| | - Giovanni Spera
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, 00161 Rome, Italy;
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Grazzi L, Toppo C, D’Amico D, Leonardi M, Martelletti P, Raggi A, Guastafierro E. Non-Pharmacological Approaches to Headaches: Non-Invasive Neuromodulation, Nutraceuticals, and Behavioral Approaches. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:1503. [PMID: 33562487 PMCID: PMC7914516 DOI: 10.3390/ijerph18041503] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/27/2021] [Accepted: 02/02/2021] [Indexed: 02/07/2023]
Abstract
Significant side effects or drug interactions can make pharmacological management of headache disorders very difficult. Non-conventional and non-pharmacological treatments are becoming increasingly used to overcome these issues. In particular, non-invasive neuromodulation, nutraceuticals, and behavioral approaches are well tolerated and indicated for specific patient categories such as adolescents and pregnant women. This paper aims to present the main approaches reported in the literature in the management of headache disorders. We therefore reviewed the available literature published between 2010 and 2020 and performed a narrative presentation for each of the three categories (non-invasive neuromodulation, nutraceuticals, and behavioral therapies). Regarding non-invasive neuromodulation, we selected transcranial magnetic stimulation, supraorbital nerve stimulation, transcranial direct current stimulation, non-invasive vagal nerve stimulation, and caloric vestibular stimulation. For nutraceuticals, we selected Feverfew, Butterbur, Riboflavin, Magnesium, and Coenzyme Q10. Finally, for behavioral approaches, we selected biofeedback, cognitive behavioral therapy, relaxation techniques, mindfulness-based therapy, and acceptance and commitment therapy. These approaches are increasingly seen as a valid treatment option in headache management, especially for patients with medication overuse or contraindications to drug treatment. However, further investigations are needed to consider the effectiveness of these approaches also with respect to the long-term effects.
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Affiliation(s)
- Licia Grazzi
- UOC Neuroalgologia, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy;
| | - Claudia Toppo
- UOC Neurologia, Salute Pubblica e Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (C.T.); (M.L.); (A.R.); (E.G.)
| | - Domenico D’Amico
- UOC Neuroalgologia, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy;
| | - Matilde Leonardi
- UOC Neurologia, Salute Pubblica e Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (C.T.); (M.L.); (A.R.); (E.G.)
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, 00185 Rome, Italy;
| | - Alberto Raggi
- UOC Neurologia, Salute Pubblica e Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (C.T.); (M.L.); (A.R.); (E.G.)
| | - Erika Guastafierro
- UOC Neurologia, Salute Pubblica e Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (C.T.); (M.L.); (A.R.); (E.G.)
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Takizawa T, Ayata C, Chen SP. Therapeutic implications of cortical spreading depression models in migraine. PROGRESS IN BRAIN RESEARCH 2020; 255:29-67. [PMID: 33008510 DOI: 10.1016/bs.pbr.2020.05.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 02/06/2023]
Abstract
Migraine is among the most common and disabling neurological diseases in the world. Cortical spreading depression (CSD) is a wave of near-complete depolarization of neurons and glial cells that slowly propagates along the cortex creating the perception of aura. Evidence suggests that CSD can trigger migraine headache. Experimental models of CSD have been considered highly translational as they recapitulate migraine-related phenomena and have been validated for screening migraine therapeutics. Here we outline the essential components of validated experimental models of CSD and provide a comprehensive review of potential modulators and targets against CSD. We further focus on novel interventions that have been recently shown to suppress CSD susceptibility that may lead to therapeutic targets in migraine.
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Affiliation(s)
- Tsubasa Takizawa
- Department of Neurology, Keio Universrity School of Medicine, Tokyo, Japan
| | - Cenk Ayata
- Neurovascular Research Unit, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, United States; Stroke Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Shih-Pin Chen
- Department of Medical Research & Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Brain Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan.
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15
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Sokolov AY, Lyubashina OA, Vaganova YS, Amelin AV. [Peripheral neurostimulation in headache treatment]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:79-88. [PMID: 31793548 DOI: 10.17116/jnevro201911910179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
According to rough estimates, at least one third of the population in developed countries suffers, to varying degrees, from certain forms of primary headache, the modern pharmacotherapy of which is not always effective and has a number of limitations. The non-pharmacological treatment of headache can be an alternative to the prescription of pharmacological agents and the only possible assistance option for patients developing drug-resistant cephalalgias. This review describes various methods of electrical neuromodulation that are used for the management of primary headaches. The authors provide information on current stages in implementation of implantable and non-invasive equipment into clinical practice, which makes possible electrical stimulations of peripheral nerves and of the sphenopalatine ganglion, as well as allows transcranial magnetic stimulation. Also the appearance and usage of portable electrical devices available on the world market are described, and mechanisms that can underlie anticephalgic action of neuromodulation therapy are discussed. Special attention is paid to the methods that are applied for electrostimulation of the vagus nerve and occipital nerves.
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Affiliation(s)
- A Yu Sokolov
- Valdman Institute of Pharmacology, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia; Pavlov Institute of Physiology of the Russian Academy of Sciences, St. Petersburg, Russia
| | - O A Lyubashina
- Valdman Institute of Pharmacology, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia; Pavlov Institute of Physiology of the Russian Academy of Sciences, St. Petersburg, Russia
| | - Yu S Vaganova
- Valdman Institute of Pharmacology, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia; Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia
| | - A V Amelin
- Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia
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Abstract
PURPOSE OF REVIEW The purpose of this narrative review is to provide an overview of the currently available noninvasive neuromodulation devices for the treatment of migraine and cluster headache. RECENT FINDINGS Over the last decade, several noninvasive devices have undergone development and clinical trials to evaluate efficacy and safety. Based on this body of work, single-pulse transcranial magnetic stimulation, transcutaneous supraorbital neurostimulation, and noninvasive vagal nerve stimulation devices have been cleared by the United States Food and Drug Administration and are available for clinical use for the treatment of primary headache disorders. SUMMARY Overall, these novel noninvasive devices appear to be safe, well tolerated, and have demonstrated promising results in clinical trials in both migraine and cluster headache. This narrative review will provide a summary and update of the proposed mechanisms of action, evidence, safety, and future directions of various currently available modalities of noninvasive neuromodulation for the treatment of migraine and cluster headache.
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Vukovic Cvetkovic V, Jensen RH. Neurostimulation for the treatment of chronic migraine and cluster headache. Acta Neurol Scand 2019; 139:4-17. [PMID: 30291633 DOI: 10.1111/ane.13034] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 09/17/2018] [Accepted: 10/02/2018] [Indexed: 12/17/2022]
Abstract
Small subsets of patients who fail to respond to pharmacological treatment may benefit from alternative treatment methods. In the last decade, neurostimulation is being explored as a potential treatment option for the patients with chronic, severely disabling refractory primary headaches. To alleviate pain, specific nerves and brain areas have been stimulated, and various methods have been explored: deep brain stimulation, occipital nerve stimulation, and sphenopalatine ganglion stimulation are among the more invasive ones, whereas transcranial magnetic stimulation and supraorbital nerve stimulation are noninvasive. Vagal nerve stimulation can be invasive or noninvasive, though this review included only data for noninvasive VNS. Most of these methods have been tested in small open-label patient series; recently, more data from randomized, controlled, and blinded studies are available. Although neurostimulation treatments have demonstrated good efficacy in many studies, it still has not been established as a standard treatment in refractory patients. This review analyzes the available evidence regarding efficacy and safety of different neurostimulation modalities for the treatment of chronic migraine and cluster headache.
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Lendvai IS, Maier A, Scheele D, Hurlemann R, Kinfe TM. Spotlight on cervical vagus nerve stimulation for the treatment of primary headache disorders: a review. J Pain Res 2018; 11:1613-1625. [PMID: 30214271 PMCID: PMC6118287 DOI: 10.2147/jpr.s129202] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Objectives Cervical noninvasive vagus nerve stimulation (nVNS) emerged as an adjunctive neuromodulation approach for primary headache disorders with limited responsiveness to pharmacologic and behavioral treatment. This narrative review evaluates the safety and efficacy of invasive and noninvasive peripheral nerve stimulation of the cervical branch of the vagal nerve (afferent properties) for primary headache disorders (episodic/chronic migraine [EM/CM] and cluster headache [ECH/CCH]) and provides a brief summary of the preclinical data on the possible mechanism of action of cervical vagus nerve stimulation (VNS) and trigemino-nociceptive head pain transmission. Materials and methods A systematic search of published data was performed in PubMed for randomized controlled trials (RCTs) and prospective cohort clinical studies assessing the efficacy/safety and cost-effectiveness of cervical VNS in primary headache disorders and related preclinical studies. Results Three RCTs were identified for ECH/CCH (ACT-1, ACT-2 and PREVA), one RCT for migraine (EVENT) and several prospective cohort studies and retrospective analyses for both headache disorders. In ACT-1, a significantly higher response rate, a higher pain-free rate and a decrease in mean attack duration were found in nVNS-treated ECH/CCH patients compared to sham stimulation. ACT-2 confirmed these findings (e.g., significantly higher pain-free attacks, pain severity decline and increased responder-rate [defined as ≥50% reduction]). The PREVA study demonstrated the superiority of adjunctive nVNS to standard care alone and observed a significantly higher attack reduction (p=0.02) and responder rate (defined as ≥50% reduction). For CM, the EVENT study assessed a significantly higher frequency of decline in the open-label phase. Mostly transient mild/moderate adverse events were recorded, and no severe device-related adverse events occurred. Conclusion Cervical nVNS represents a novel, safe and efficient adjunctive treatment option for primary headache disorders. In particular, preliminary observations suggest enhanced nVNS responsiveness in favor of episodic subtypes (EM and ECH). However, preclinical studies are urgently warranted to dissect the mechanism of action.
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Affiliation(s)
- Ilana S Lendvai
- Department of Psychiatry, Rheinische Friedrich-Wilhelms University, Bonn, Germany, .,Department of Psychiatry and Medical Psychology, University Hospital Bonn, Rheinische Friedrich-Wilhelms University, Bonn, Germany,
| | - Ayline Maier
- Department of Psychiatry, Rheinische Friedrich-Wilhelms University, Bonn, Germany, .,Department of Psychiatry and Medical Psychology, University Hospital Bonn, Rheinische Friedrich-Wilhelms University, Bonn, Germany,
| | - Dirk Scheele
- Department of Psychiatry, Rheinische Friedrich-Wilhelms University, Bonn, Germany, .,Department of Psychiatry and Medical Psychology, University Hospital Bonn, Rheinische Friedrich-Wilhelms University, Bonn, Germany,
| | - Rene Hurlemann
- Department of Psychiatry, Rheinische Friedrich-Wilhelms University, Bonn, Germany, .,Department of Psychiatry and Medical Psychology, University Hospital Bonn, Rheinische Friedrich-Wilhelms University, Bonn, Germany,
| | - Thomas M Kinfe
- Department of Psychiatry, Rheinische Friedrich-Wilhelms University, Bonn, Germany, .,Department of Psychiatry and Medical Psychology, University Hospital Bonn, Rheinische Friedrich-Wilhelms University, Bonn, Germany,
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Klass A, Sánchez-Porras R, Santos E. Systematic review of the pharmacological agents that have been tested against spreading depolarizations. J Cereb Blood Flow Metab 2018; 38:1149-1179. [PMID: 29673289 PMCID: PMC6434447 DOI: 10.1177/0271678x18771440] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Spreading depolarization (SD) occurs alongside brain injuries and it can lead to neuronal damage. Therefore, pharmacological modulation of SD can constitute a therapeutic approach to reduce its detrimental effects and to improve the clinical outcome of patients. The major objective of this article was to produce a systematic review of all the drugs that have been tested against SD. Of the substances that have been examined, most have been shown to modulate certain SD characteristics. Only a few have succeeded in significantly inhibiting SD. We present a variety of strategies that have been proposed to overcome the notorious harmfulness and pharmacoresistance of SD. Information on clinically used anesthetic, sedative, hypnotic agents, anti-migraine drugs, anticonvulsants and various other substances have been compiled and reviewed with respect to the efficacy against SD, in order to answer the question of whether a drug at safe doses could be of therapeutic use against SD in humans.
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Affiliation(s)
- Anna Klass
- Neurosurgery Department, University of Heidelberg, Heidelberg, Germany
| | | | - Edgar Santos
- Neurosurgery Department, University of Heidelberg, Heidelberg, Germany
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Grazzi L, Sansone E, Rizzoli P. A Short Review of the Non-invasive Transcutaneous Pericranial Electrical Stimulation Techniques and their Application in Headache. Curr Pain Headache Rep 2018; 22:4. [PMID: 29350303 DOI: 10.1007/s11916-018-0654-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW In this short review, the most common non-invasive neuromodulatory techniques will be described, along with their advantages and disadvantages and their application in headache. Available preventive treatments can be unhelpful or may have unpleasant side effects; moreover, the rate of response to preventive drugs does not exceed 50%, lower in chronic migraine; alternative options would be welcome. Though the concept of neuromodulation was originally developed with invasive methods, newer non-invasive techniques are appearing. RECENT FINDINGS The novel neuromodulatory techniques have been developed with encouraging results: compared with traditional pharmacotherapy, advantages of non-invasive neuromodulation include reduced incidence of adverse effects, improved adherence, and safety and ease of use. The results are encouraging for acute or preventive treatment of different kinds of headache. A variety of neuromodulatory approaches is expanding fastly and has opened new possibilities for treatment of patients suffering from many forms of headache, especially those who have failed traditional pharmacotherapy. The non-invasive treatments can be seen as supplementing traditional management in refractory patients. Current study results are encouraging but preliminary and larger and more rigorous trials are needed to clarify benefit and mode of action.
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Affiliation(s)
- Licia Grazzi
- 3rd Neurology Unit, Neuroalgology, Fondazione I.R.C.C.S. Istituto Neurologico "Carlo Besta", Via Celoria 11, 20133, Milan, Italy.
| | - Emanuela Sansone
- 3rd Neurology Unit, Neuroalgology, Fondazione I.R.C.C.S. Istituto Neurologico "Carlo Besta", Via Celoria 11, 20133, Milan, Italy
| | - Paul Rizzoli
- John Graham Headache Centre/Faulkner Hospital, Harvard Medical School, Boston, MA, USA
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21
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22
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Errico J. The Role of Vagus Nerve Stimulation in the Treatment of Central and Peripheral Pain Disorders and Related Comorbid Somatoform Conditions. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00132-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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23
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Chen SP, Ayata C. Novel Therapeutic Targets Against Spreading Depression. Headache 2017; 57:1340-1358. [PMID: 28842982 DOI: 10.1111/head.13154] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 05/07/2017] [Accepted: 05/08/2017] [Indexed: 12/11/2022]
Abstract
Migraine is among the most prevalent and disabling neurological diseases in the world. Cortical spreading depression (SD) is an intense wave of neuronal and glial depolarization underlying migraine aura, and a headache trigger, which has been used as an experimental platform for drug screening in migraine. Here, we provide an overview of novel therapeutic targets that show promise to suppress SD, such as acid-sensing ion channels, casein kinase Iδ, P2X7-pannexin 1 complex, and neuromodulation, and outline the experimental models and essential quality measures for rigorous and reproducible efficacy testing.
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Affiliation(s)
- Shih-Pin Chen
- Neurovascular Research Lab, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA.,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Cenk Ayata
- Neurovascular Research Lab, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA.,Stroke Service and Neuroscience Intensive Care Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
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24
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Akerman S, Simon B, Romero-Reyes M. Vagus nerve stimulation suppresses acute noxious activation of trigeminocervical neurons in animal models of primary headache. Neurobiol Dis 2017; 102:96-104. [DOI: 10.1016/j.nbd.2017.03.004] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 03/03/2017] [Accepted: 03/08/2017] [Indexed: 02/04/2023] Open
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Do the psychological effects of vagus nerve stimulation partially mediate vagal pain modulation? NEUROBIOLOGY OF PAIN 2017; 1:37-45. [PMID: 29057372 PMCID: PMC5648334 DOI: 10.1016/j.ynpai.2017.03.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
There is preclinical and clinical evidence that vagus nerve stimulation modulates both pain and mood state. Mechanistic studies show brainstem circuitry involved in pain modulation by vagus nerve stimulation, but little is known about possible indirect descending effects of altered mood state on pain perception. This possibility is important, since previous studies have shown that mood state affects pain, particularly the affective dimension (pain unpleasantness). To date, human studies investigating the effects of vagus nerve stimulation on pain perception have not reliably measured psychological factors to determine their role in altered pain perception elicited by vagus nerve stimulation. Thus, it remains unclear how much of a role psychological factors play in vagal pain modulation. Here, we present a rationale for including psychological measures in future vagus nerve stimulation studies on pain.
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D'Ostilio K, Magis D. Invasive and Non-invasive Electrical Pericranial Nerve Stimulation for the Treatment of Chronic Primary Headaches. Curr Pain Headache Rep 2017; 20:61. [PMID: 27678260 DOI: 10.1007/s11916-016-0589-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Chronic primary headaches are widespread disorders which cause significant quality of life and socioprofessional impairment. Available pharmacological treatments have often a limited efficacy and/or can generate unbearable side effects. Electrical nerve stimulation is a well-known non-destructive method of pain modulation which has been recently applied to headache management. In this review, we summarise recent advances in invasive and non-invasive neurostimulation techniques targeting pericranial structures for the treatment of chronic primary headaches, chiefly migraine and cluster headache: occipital nerve, supraorbital nerve, vagus nerve, and sphenopalatine ganglion stimulations. Invasive neurostimulation therapies have offered a new hope to drug-refractory headache sufferers but are not riskless and should be proposed only to chronic patients who failed to respond to most existing preventives. Non-invasive neurostimulation devices are user-friendly, safe and well tolerated and are thus taking an increasing place in the multidisciplinary therapeutical armamentarium of primary headaches.
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Affiliation(s)
- Kevin D'Ostilio
- Headache Research Unit, University Department of Neurology, CHR Citadelle, Boulevard du 12ème de Ligne 1, 4000, Liège, Belgium
| | - Delphine Magis
- Headache Research Unit, University Department of Neurology, CHR Citadelle, Boulevard du 12ème de Ligne 1, 4000, Liège, Belgium.
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Puledda F, Goadsby PJ. Current Approaches to Neuromodulation in Primary Headaches: Focus on Vagal Nerve and Sphenopalatine Ganglion Stimulation. Curr Pain Headache Rep 2017; 20:47. [PMID: 27278441 PMCID: PMC4899495 DOI: 10.1007/s11916-016-0577-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Neuromodulation is a promising, novel approach for the treatment of primary headache disorders. Neuromodulation offers a new dimension in the treatment that is both easily reversible and tends to be very well tolerated. The autonomic nervous system is a logical target given the neurobiology of common primary headache disorders, such as migraine and the trigeminal autonomic cephalalgias (TACs). This article will review new encouraging results of studies from the most recent literature on neuromodulation as acute and preventive treatment in primary headache disorders, and cover some possible underlying mechanisms. We will especially focus on vagus nerve stimulation (VNS) and sphenopalatine ganglion (SPG) since they have targeted autonomic pathways that are cranial and can modulate relevant pathophysiological mechanisms. The initial data suggests these approaches will find an important role in headache disorder management going forward.
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Affiliation(s)
- Francesca Puledda
- NIHR-Wellcome Trust King's Clinical Research Facility, King's College London, London, UK.,Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Peter J Goadsby
- NIHR-Wellcome Trust King's Clinical Research Facility, King's College London, London, UK. .,Wellcome Foundation Building, King's College Hospital, London, UK.
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Abstract
Vagus nerve stimulation has recently been reported to improve symptoms of migraine. Cortical spreading depression is the electrophysiological event underlying migraine aura and is a trigger for headache. We tested whether vagus nerve stimulation inhibits cortical spreading depression to explain its antimigraine effect. Unilateral vagus nerve stimulation was delivered either noninvasively through the skin or directly by electrodes placed around the nerve. Systemic physiology was monitored throughout the study. Both noninvasive transcutaneous and invasive direct vagus nerve stimulations significantly suppressed spreading depression susceptibility in the occipital cortex in rats. The electrical stimulation threshold to evoke a spreading depression was elevated by more than 2-fold, the frequency of spreading depressions during continuous topical 1 M KCl was reduced by ∼40%, and propagation speed of spreading depression was reduced by ∼15%. This effect developed within 30 minutes after vagus nerve stimulation and persisted for more than 3 hours. Noninvasive transcutaneous vagus nerve stimulation was as efficacious as direct invasive vagus nerve stimulation, and the efficacy did not differ between the ipsilateral and contralateral hemispheres. Our findings provide a potential mechanism by which vagus nerve stimulation may be efficacious in migraine and suggest that susceptibility to spreading depression is a suitable platform to optimize its efficacy.
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29
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Coppola G, Di Lorenzo C, Serrao M, Parisi V, Schoenen J, Pierelli F. Pathophysiological targets for non-pharmacological treatment of migraine. Cephalalgia 2016; 36:1103-1111. [PMID: 26637237 DOI: 10.1177/0333102415620908] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Migraine is the most prevalent neurological disorder worldwide and ranked sixth among all diseases in years lived with disability. Overall preventive anti-migraine therapies have an effect in one patient out of two at the most, many of them being endowed with disabling adverse effects. No new disease-modifying drugs have come into clinical practice since the application to migraine of topiramate and botulinum toxin, the latter for its chronic form. There is thus clearly a need for more effective treatments that are devoid of, or have acceptable side effects. In recent years, scientific progress in migraine research has led to substantial changes in our understanding of the pathophysiology of migraine and paved the way for novel non-drug pathophysiological-targeted treatment strategies. Overview Several such non-drug therapies have been tested in migraine, such as oxidative phosphorylation enhancers, diets and non-invasive central or peripheral neurostimulation. All of them are promising for preventive migraine treatment and are quasi-devoid of side effects. Their advantage is that they can in theory be selected for individual patients according to their pathophysiological profile and they can (and probably should) be combined with the classical pharmacological armamentarium. Conclusion We will review here how knowledge of the functional anatomy and physiology of migraine mechanisms holds the key for more specific and effective non-pharmacological treatments.
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Affiliation(s)
- Gianluca Coppola
- 1 G.B. Bietti Foundation IRCCS, Department of Neurophysiology of Vision and Neurophthalmology, Italy
| | | | - Mariano Serrao
- 3 "Sapienza" University of Rome Polo Pontino, Department of Medico-Surgical Sciences and Biotechnologies, Italy
| | - Vincenzo Parisi
- 1 G.B. Bietti Foundation IRCCS, Department of Neurophysiology of Vision and Neurophthalmology, Italy
| | - Jean Schoenen
- 4 Liège University, Headache Research Unit. University Department of Neurology, Belgium
| | - Francesco Pierelli
- 3 "Sapienza" University of Rome Polo Pontino, Department of Medico-Surgical Sciences and Biotechnologies, Italy.,5 IRCCS Neuromed, Pozzilli (IS), Italy
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Silberstein SD, Calhoun AH, Lipton RB, Grosberg BM, Cady RK, Dorlas S, Simmons KA, Mullin C, Liebler EJ, Goadsby PJ, Saper JR. Chronic migraine headache prevention with noninvasive vagus nerve stimulation: The EVENT study. Neurology 2016; 87:529-38. [PMID: 27412146 PMCID: PMC4970666 DOI: 10.1212/wnl.0000000000002918] [Citation(s) in RCA: 160] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 04/22/2016] [Indexed: 01/03/2023] Open
Abstract
Objective: To evaluate the feasibility, safety, and tolerability of noninvasive vagus nerve stimulation (nVNS) for the prevention of chronic migraine (CM) attacks. Methods: In this first prospective, multicenter, double-blind, sham-controlled pilot study of nVNS in CM prophylaxis, adults with CM (≥15 headache d/mo) entered the baseline phase (1 month) and were subsequently randomized to nVNS or sham treatment (2 months) before receiving open-label nVNS treatment (6 months). The primary endpoints were safety and tolerability. Efficacy endpoints in the intent-to-treat population included change in the number of headache days per 28 days and acute medication use. Results: Fifty-nine participants (mean age, 39.2 years; mean headache frequency, 21.5 d/mo) were enrolled. During the randomized phase, tolerability was similar for nVNS (n = 30) and sham treatment (n = 29). Most adverse events were mild/moderate and transient. Mean changes in the number of headache days were −1.4 (nVNS) and −0.2 (sham) (Δ = 1.2; p = 0.56). Twenty-seven participants completed the open-label phase. For the 15 completers initially assigned to nVNS, the mean change from baseline in headache days after 8 months of treatment was −7.9 (95% confidence interval −11.9 to −3.8; p < 0.01). Conclusions: Therapy with nVNS was well-tolerated with no safety issues. Persistent prophylactic use may reduce the number of headache days in CM; larger sham-controlled studies are needed. ClinicalTrials.gov identifier: NCT01667250. Classification of evidence: This study provides Class II evidence that for patients with CM, nVNS is safe, is well-tolerated, and did not significantly change the number of headache days. This pilot study lacked the precision to exclude important safety issues or benefits of nVNS.
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Affiliation(s)
- Stephen D Silberstein
- From Jefferson Headache Center (S.D.S.), Philadelphia, PA; Carolina Headache Institute (A.H.C.), Chapel Hill, NC; Montefiore Headache Center and Albert Einstein College of Medicine (R.B.L.), Bronx, NY; Hartford HealthCare Headache Center (B.M.G.), West Hartford, CT; Clinvest Headache Care Center (R.K.C.), Springfield, MO; MedLogix Communications, LLC (S.D.), Schaumburg, IL; electroCore, LLC (K.A.S., E.J.L.), Basking Ridge, NJ; NAMSA (C.M.), Minneapolis, MN; University of California San Francisco (P.J.G.); King's College London (P.J.G.), UK; and Michigan Headache and Neurological Institute (J.R.S.), Ann Arbor. B.M.G. was affiliated with Montefiore Headache Center, Bronx, NY, at the time of study completion.
| | - Anne H Calhoun
- From Jefferson Headache Center (S.D.S.), Philadelphia, PA; Carolina Headache Institute (A.H.C.), Chapel Hill, NC; Montefiore Headache Center and Albert Einstein College of Medicine (R.B.L.), Bronx, NY; Hartford HealthCare Headache Center (B.M.G.), West Hartford, CT; Clinvest Headache Care Center (R.K.C.), Springfield, MO; MedLogix Communications, LLC (S.D.), Schaumburg, IL; electroCore, LLC (K.A.S., E.J.L.), Basking Ridge, NJ; NAMSA (C.M.), Minneapolis, MN; University of California San Francisco (P.J.G.); King's College London (P.J.G.), UK; and Michigan Headache and Neurological Institute (J.R.S.), Ann Arbor. B.M.G. was affiliated with Montefiore Headache Center, Bronx, NY, at the time of study completion
| | - Richard B Lipton
- From Jefferson Headache Center (S.D.S.), Philadelphia, PA; Carolina Headache Institute (A.H.C.), Chapel Hill, NC; Montefiore Headache Center and Albert Einstein College of Medicine (R.B.L.), Bronx, NY; Hartford HealthCare Headache Center (B.M.G.), West Hartford, CT; Clinvest Headache Care Center (R.K.C.), Springfield, MO; MedLogix Communications, LLC (S.D.), Schaumburg, IL; electroCore, LLC (K.A.S., E.J.L.), Basking Ridge, NJ; NAMSA (C.M.), Minneapolis, MN; University of California San Francisco (P.J.G.); King's College London (P.J.G.), UK; and Michigan Headache and Neurological Institute (J.R.S.), Ann Arbor. B.M.G. was affiliated with Montefiore Headache Center, Bronx, NY, at the time of study completion
| | - Brian M Grosberg
- From Jefferson Headache Center (S.D.S.), Philadelphia, PA; Carolina Headache Institute (A.H.C.), Chapel Hill, NC; Montefiore Headache Center and Albert Einstein College of Medicine (R.B.L.), Bronx, NY; Hartford HealthCare Headache Center (B.M.G.), West Hartford, CT; Clinvest Headache Care Center (R.K.C.), Springfield, MO; MedLogix Communications, LLC (S.D.), Schaumburg, IL; electroCore, LLC (K.A.S., E.J.L.), Basking Ridge, NJ; NAMSA (C.M.), Minneapolis, MN; University of California San Francisco (P.J.G.); King's College London (P.J.G.), UK; and Michigan Headache and Neurological Institute (J.R.S.), Ann Arbor. B.M.G. was affiliated with Montefiore Headache Center, Bronx, NY, at the time of study completion
| | - Roger K Cady
- From Jefferson Headache Center (S.D.S.), Philadelphia, PA; Carolina Headache Institute (A.H.C.), Chapel Hill, NC; Montefiore Headache Center and Albert Einstein College of Medicine (R.B.L.), Bronx, NY; Hartford HealthCare Headache Center (B.M.G.), West Hartford, CT; Clinvest Headache Care Center (R.K.C.), Springfield, MO; MedLogix Communications, LLC (S.D.), Schaumburg, IL; electroCore, LLC (K.A.S., E.J.L.), Basking Ridge, NJ; NAMSA (C.M.), Minneapolis, MN; University of California San Francisco (P.J.G.); King's College London (P.J.G.), UK; and Michigan Headache and Neurological Institute (J.R.S.), Ann Arbor. B.M.G. was affiliated with Montefiore Headache Center, Bronx, NY, at the time of study completion
| | - Stefanie Dorlas
- From Jefferson Headache Center (S.D.S.), Philadelphia, PA; Carolina Headache Institute (A.H.C.), Chapel Hill, NC; Montefiore Headache Center and Albert Einstein College of Medicine (R.B.L.), Bronx, NY; Hartford HealthCare Headache Center (B.M.G.), West Hartford, CT; Clinvest Headache Care Center (R.K.C.), Springfield, MO; MedLogix Communications, LLC (S.D.), Schaumburg, IL; electroCore, LLC (K.A.S., E.J.L.), Basking Ridge, NJ; NAMSA (C.M.), Minneapolis, MN; University of California San Francisco (P.J.G.); King's College London (P.J.G.), UK; and Michigan Headache and Neurological Institute (J.R.S.), Ann Arbor. B.M.G. was affiliated with Montefiore Headache Center, Bronx, NY, at the time of study completion
| | - Kristy A Simmons
- From Jefferson Headache Center (S.D.S.), Philadelphia, PA; Carolina Headache Institute (A.H.C.), Chapel Hill, NC; Montefiore Headache Center and Albert Einstein College of Medicine (R.B.L.), Bronx, NY; Hartford HealthCare Headache Center (B.M.G.), West Hartford, CT; Clinvest Headache Care Center (R.K.C.), Springfield, MO; MedLogix Communications, LLC (S.D.), Schaumburg, IL; electroCore, LLC (K.A.S., E.J.L.), Basking Ridge, NJ; NAMSA (C.M.), Minneapolis, MN; University of California San Francisco (P.J.G.); King's College London (P.J.G.), UK; and Michigan Headache and Neurological Institute (J.R.S.), Ann Arbor. B.M.G. was affiliated with Montefiore Headache Center, Bronx, NY, at the time of study completion
| | - Chris Mullin
- From Jefferson Headache Center (S.D.S.), Philadelphia, PA; Carolina Headache Institute (A.H.C.), Chapel Hill, NC; Montefiore Headache Center and Albert Einstein College of Medicine (R.B.L.), Bronx, NY; Hartford HealthCare Headache Center (B.M.G.), West Hartford, CT; Clinvest Headache Care Center (R.K.C.), Springfield, MO; MedLogix Communications, LLC (S.D.), Schaumburg, IL; electroCore, LLC (K.A.S., E.J.L.), Basking Ridge, NJ; NAMSA (C.M.), Minneapolis, MN; University of California San Francisco (P.J.G.); King's College London (P.J.G.), UK; and Michigan Headache and Neurological Institute (J.R.S.), Ann Arbor. B.M.G. was affiliated with Montefiore Headache Center, Bronx, NY, at the time of study completion
| | - Eric J Liebler
- From Jefferson Headache Center (S.D.S.), Philadelphia, PA; Carolina Headache Institute (A.H.C.), Chapel Hill, NC; Montefiore Headache Center and Albert Einstein College of Medicine (R.B.L.), Bronx, NY; Hartford HealthCare Headache Center (B.M.G.), West Hartford, CT; Clinvest Headache Care Center (R.K.C.), Springfield, MO; MedLogix Communications, LLC (S.D.), Schaumburg, IL; electroCore, LLC (K.A.S., E.J.L.), Basking Ridge, NJ; NAMSA (C.M.), Minneapolis, MN; University of California San Francisco (P.J.G.); King's College London (P.J.G.), UK; and Michigan Headache and Neurological Institute (J.R.S.), Ann Arbor. B.M.G. was affiliated with Montefiore Headache Center, Bronx, NY, at the time of study completion
| | - Peter J Goadsby
- From Jefferson Headache Center (S.D.S.), Philadelphia, PA; Carolina Headache Institute (A.H.C.), Chapel Hill, NC; Montefiore Headache Center and Albert Einstein College of Medicine (R.B.L.), Bronx, NY; Hartford HealthCare Headache Center (B.M.G.), West Hartford, CT; Clinvest Headache Care Center (R.K.C.), Springfield, MO; MedLogix Communications, LLC (S.D.), Schaumburg, IL; electroCore, LLC (K.A.S., E.J.L.), Basking Ridge, NJ; NAMSA (C.M.), Minneapolis, MN; University of California San Francisco (P.J.G.); King's College London (P.J.G.), UK; and Michigan Headache and Neurological Institute (J.R.S.), Ann Arbor. B.M.G. was affiliated with Montefiore Headache Center, Bronx, NY, at the time of study completion
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Abstract
Chronic migraine has a great detrimental influence on a patient's life, with a severe impact on socioeconomic functioning and quality of life. Chronic migraine affects 1-2% of the general population, and about 8% of patients with migraine; it usually develops from episodic migraine at an annual conversion rate of about 3%. The chronification is reversible: about 26% of patients with chronic migraine go into remission within 2 years of chronification. The most important modifiable risk factors for chronic migraine include overuse of acute migraine medication, ineffective acute treatment, obesity, depression and stressful life events. Moreover, age, female sex and low educational status increase the risk of chronic migraine. The pathophysiology of migraine chronification can be understood as a threshold problem: certain predisposing factors, combined with frequent headache pain, lower the threshold of migraine attacks, thereby increasing the risk of chronic migraine. Treatment options include oral medications, nerve blockade with local anaesthetics or corticoids, and neuromodulation. Well-defined diagnostic criteria are crucial for the identification of chronic migraine. The International Headache Society classification of chronic migraine was recently updated, and now allows co-diagnosis of chronic migraine and medication overuse headache. This Review provides an up-to-date overview of the classification of chronic migraine, basic mechanisms and risk factors of migraine chronification, and the currently established treatment options.
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Affiliation(s)
- Arne May
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
| | - Laura H Schulte
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
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Abstract
Migraine and other chronic headache disorders are common and if inadequately treated, can lead to significant disability. The effectiveness of medications can be limited by side effects, drug interactions, and comorbid diseases necessitating alternative methods. Technological developments in the past 5 years have made it possible to use non-invasive methods of neuromodulation to treat primary headache disorders. This field includes technologies such as supraorbital transcutaneous stimulation (STS), transcranial magnetic stimulation (TMS), and non-invasive vagal nerve stimulation (nVNS). Existing trials show these modalities are safe and well tolerated and can be combined with standard pharmacotherapy. We review the technologies, biological rationales, and trials involving non-invasive neuromodulation for the treatment of primary headache disorders.
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Affiliation(s)
- Shuhan Zhu
- Jefferson Headache Center, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA
| | - Michael J Marmura
- Jefferson Headache Center, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA.
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Rossi S, Santarnecchi E, Valenza G, Ulivelli M. The heart side of brain neuromodulation. PHILOSOPHICAL TRANSACTIONS. SERIES A, MATHEMATICAL, PHYSICAL, AND ENGINEERING SCIENCES 2016; 374:rsta.2015.0187. [PMID: 27044999 DOI: 10.1098/rsta.2015.0187] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/11/2016] [Indexed: 05/03/2023]
Abstract
Neuromodulation refers to invasive, minimally invasive or non-invasive techniques to stimulate discrete cortical or subcortical brain regions with therapeutic purposes in otherwise intractable patients: for example, thousands of advanced Parkinsonian patients, as well as patients with tremor or dystonia, benefited by deep brain stimulation (DBS) procedures (neural targets: basal ganglia nuclei). A new era for DBS is currently opening for patients with drug-resistant depression, obsessive-compulsive disorders, severe epilepsy, migraine and chronic pain (neural targets: basal ganglia and other subcortical nuclei or associative fibres). Vagal nerve stimulation (VNS) has shown clinical benefits in patients with pharmacoresistant epilepsy and depression. Non-invasive brain stimulation neuromodulatory techniques such as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) are also being increasingly investigated for their therapeutic potential in several neurological and psychiatric disorders. In this review, we first address the most common neural targets of each of the mentioned brain stimulation techniques, and the known mechanisms of their neuromodulatory action on stimulated brain networks. Then, we discuss how DBS, VNS, rTMS and tDCS could impact on the function of brainstem centres controlling vital functions, critically reviewing their acute and long-term effects on brain sympathetic outflow controlling heart function and blood pressure. Finally, as there is clear experimental evidence in animals that brain stimulation can affect autonomic and heart functions, we will try to give a critical perspective on how it may enhance our understanding of the cortical/subcortical mechanisms of autonomic cardiovascular regulation, and also if it might find a place among therapeutic opportunities in patients with otherwise intractable autonomic dysfunctions.
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Affiliation(s)
- Simone Rossi
- Gaetano Valenza, Monica Ulivelli Department of Medicine, Surgery and Neuroscience, Unit of Neurology and Clinical Neurophysiology, Brain Investigation and Neuromodulation Lab. (Si-BIN Lab.), Azienda Ospedaliera Universitaria Senese, University of Siena, 53100 Siena, Italy
| | - Emiliano Santarnecchi
- Gaetano Valenza, Monica Ulivelli Department of Medicine, Surgery and Neuroscience, Unit of Neurology and Clinical Neurophysiology, Brain Investigation and Neuromodulation Lab. (Si-BIN Lab.), Azienda Ospedaliera Universitaria Senese, University of Siena, 53100 Siena, Italy Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Gaetano Valenza
- Department of Information Engineering, and Research Center E. Piaggio, University of Pisa, 56122 Pisa, Italy Neuroscience Statistics Research Lab, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02115, USA Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Monica Ulivelli
- Gaetano Valenza, Monica Ulivelli Department of Medicine, Surgery and Neuroscience, Unit of Neurology and Clinical Neurophysiology, Brain Investigation and Neuromodulation Lab. (Si-BIN Lab.), Azienda Ospedaliera Universitaria Senese, University of Siena, 53100 Siena, Italy
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34
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Robbins MS, Lipton RB. Transcutaneous and Percutaneous Neurostimulation for Headache Disorders. Headache 2016; 57 Suppl 1:4-13. [DOI: 10.1111/head.12829] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 11/05/2015] [Accepted: 11/07/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Matthew S. Robbins
- Department of Neurology, Montefiore Headache Center; Albert Einstein College of Medicine; Bronx NY USA
- Departments of Epidemiology and Population Health, and Psychiatry and Behavioral Science; Albert Einstein College of Medicine; Bronx NY USA
| | - Richard B. Lipton
- Departments of Epidemiology and Population Health, and Psychiatry and Behavioral Science; Albert Einstein College of Medicine; Bronx NY USA
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35
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Diener HC, Charles A, Goadsby PJ, Holle D. New therapeutic approaches for the prevention and treatment of migraine. Lancet Neurol 2015; 14:1010-22. [PMID: 26376968 DOI: 10.1016/s1474-4422(15)00198-2] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 07/27/2015] [Accepted: 07/29/2015] [Indexed: 02/03/2023]
Abstract
The management of patients with migraine is often unsatisfactory because available acute and preventive therapies are either ineffective or poorly tolerated. The acute treatment of migraine attacks has been limited to the use of analgesics, combinations of analgesics with caffeine, ergotamines, and the triptans. Successful new approaches for the treatment of acute migraine target calcitonin gene-related peptide (CGRP) and serotonin (5-hydroxytryptamine, 5-HT1F) receptors. Other approaches targeting the transient receptor potential vanilloid (TRPV1) receptor, glutamate, GABAA receptors, or a combination of 5-HT1B/1D receptors and neuronal nitric oxide synthesis have been investigated but have not been successful in clinical trials thus far. In migraine prevention, the most promising new approaches are humanised antibodies against CGRP or the CGRP receptor. Non-invasive and invasive neuromodulation approaches also show promise as both acute and preventive therapies, although further studies are needed to define appropriate candidates for these therapies and optimum protocols for their use.
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Affiliation(s)
- Hans-Christoph Diener
- Department of Neurology and Headache Center, University of Duisburg-Essen, Essen, Germany.
| | - Andrew Charles
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Peter J Goadsby
- NIHR-Wellcome Trust King's Clinical Research Facility, King's College London, London, UK
| | - Dagny Holle
- Department of Neurology and Headache Center, University of Duisburg-Essen, Essen, Germany
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36
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Yuan H, Silberstein SD. Vagus Nerve Stimulation and Headache. Headache 2015; 57 Suppl 1:29-33. [DOI: 10.1111/head.12721] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Hsiangkuo Yuan
- Jefferson Headache Center, Department of Neurology; Thomas Jefferson University; Philadelphia PA USA
| | - Stephen D. Silberstein
- Jefferson Headache Center, Department of Neurology; Thomas Jefferson University; Philadelphia PA USA
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Schwedt TJ, Vargas B. Neurostimulation for Treatment of Migraine and Cluster Headache. PAIN MEDICINE (MALDEN, MASS.) 2015; 16:1827-34. [PMID: 26177612 PMCID: PMC4572909 DOI: 10.1111/pme.12792] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective of this narrative review is to summarize the current state of neurostimulation therapies for the treatment of migraine and/or cluster. METHODS For this narrative review, publications were identified by searching PubMed using the search terms "migraine" or "cluster" combined with "vagal nerve stimulation," "transcranial magnetic stimulation," "supraorbital nerve stimulation," "sphenopalatine ganglion stimulation," "occipital nerve stimulation," "deep brain stimulation," "neurostimulation," or "neuromodulation." Publications were chosen based on the quality of data that were provided and their relevance to the chosen topics of interest for this review. Reference lists of chosen articles and the authors' own files were used to identify additional publications. Current clinical trials were identified by searching clinicaltrials.org. RESULTS AND CONCLUSIONS Neurostimulation of the vagal nerve, supraorbital nerve, occipital nerve and sphenopalatine ganglion, transcranial magnetic stimulation (TMS), and deep brain stimulation have been investigated for the treatment of migraine and/or cluster. Whereas invasive methods of neurostimulation would be reserved for patients with very severe and treatment refractory migraine or cluster, noninvasive methods of stimulation might serve as useful adjuncts to more conventional therapies. Currently, transcutaneous supraorbital nerve stimulation is FDA approved and commercially available for migraine prevention and TMS is FDA approved for the treatment of migraine with aura. The potential utility of each type of neurostimulation has yet to be completely defined.
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Affiliation(s)
- Todd J. Schwedt
- Royalties: Up To Date, Cambridge University Press, Consulting/Advisory Boards: Allergan, Zogenix, Supernus, Pfizer, Clinical Trial Investigator: eNeura, Boston Scientific, Alder, Biopharmaceuticals, Autonomic Technologies, Labrys Biologics, Arteaus, Therapeutics, OptiNose US
| | - Bert Vargas
- Consulting/Advisory Boards: Allergan, Zogenix, Avanir, Clinical Trial Investigator: Boston Scientific, Autonomic Technologies, eNeura, Alder Biopharmaceuticals, OptiNose US, Alder, Biopharmaceuticals, Labrys Biologics, Arteaus
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38
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Goldberg SW, Nahas SJ. Supratrochlear and Supraorbital Nerve Stimulation for Chronic Headache: a Review. Curr Pain Headache Rep 2015; 19:26. [DOI: 10.1007/s11916-015-0496-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Lambru G, Giakoumakis E, Al-Kaisy A. Advanced technologies and novel neurostimulation targets in trigeminal autonomic cephalalgias. Neurol Sci 2015; 36 Suppl 1:125-9. [PMID: 26017527 DOI: 10.1007/s10072-015-2171-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The trigeminal autonomic cephalalgias (TACs) are a group of rare but disabling primary headache disorders. Their management is challenging, since only few effective treatments are available and high doses may be required to control the headache, compromising patients' adherence to treatments. A significant minority of patients, who fail to respond to or tolerate established treatments, are left with enormous level of disability and disruption to their quality of life. A growing body of evidence demonstrates the efficacy of central and peripheral neuromodulation approaches for management of patients with refractory TACs. In view of the potential risks related to deep brain stimulation of the posterior hypothalamic region, occipital nerve stimulation is currently considered the first treatment option for refractory chronic TACs. However, in view of the presence of paraesthesia induced by the stimulator, no robust controlled trials have been possible so far. Additionally, the equipment used for occipital nerve stimulation is not designed specifically for peripheral nerve stimulation, thus a significant proportion of patients experience device-related complications that often require surgical revisions. To overcome these issues, new neurostimulation technologies using less invasive or non-invasive approaches and modulating different neuroanatomical targets have been recently studied.
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Affiliation(s)
- Giorgio Lambru
- Headache Service, Pain Management and Neuromodulation Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK,
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40
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Deer TR, Mekhail N, Petersen E, Krames E, Staats P, Pope J, Saweris Y, Lad SP, Diwan S, Falowski S, Feler C, Slavin K, Narouze S, Merabet L, Buvanendran A, Fregni F, Wellington J, Levy RM. The appropriate use of neurostimulation: stimulation of the intracranial and extracranial space and head for chronic pain. Neuromodulation Appropriateness Consensus Committee. Neuromodulation 2015; 17:551-70; discussion 570. [PMID: 25112890 DOI: 10.1111/ner.12215] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 04/17/2014] [Accepted: 05/13/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The International Neuromodulation Society (INS) has identified a need for evaluation and analysis of the practice of neurostimulation of the brain and extracranial nerves of the head to treat chronic pain. METHODS The INS board of directors chose an expert panel, the Neuromodulation Appropriateness Consensus Committee (NACC), to evaluate the peer-reviewed literature, current research, and clinical experience and to give guidance for the appropriate use of these methods. The literature searches involved key word searches in PubMed, EMBASE, and Google Scholar dated 1970-2013, which were graded and evaluated by the authors. RESULTS The NACC found that evidence supports extracranial stimulation for facial pain, migraine, and scalp pain but is limited for intracranial neuromodulation. High cervical spinal cord stimulation is an evolving option for facial pain. Intracranial neurostimulation may be an excellent option to treat diseases of the nervous system, such as tremor and Parkinson's disease, and in the future, potentially Alzheimer's disease and traumatic brain injury, but current use of intracranial stimulation for pain should be seen as investigational. CONCLUSIONS The NACC concludes that extracranial nerve stimulation should be considered in the algorithmic treatment of migraine and other disorders of the head. We should strive to perfect targets outside the cranium when treating pain, if at all possible.
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41
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Abstract
Migraine and cluster headache are primary headache disorders commonly encountered in clinical practice. Despite the profound disability caused by these primary headache disorders, available acute and preventive treatment options are limited. Recent understanding of headache pathophysiology has led to the development of new drug formulations and novel drug targets that are extremely promising. This article will highlight several of the new treatments that are currently under investigation including novel delivery mechanisms of already existing medications, calcitonin gene-related peptide (CGRP) receptor antagonists, antibodies to CGRP and its receptor, serotonin receptor agonists, transient receptor potential vanilloid receptor modulators, orexin receptor antagonists, glial cell modulators, and neuromodulation. If data is supportive, these therapies will be welcome additions to the headache specialist's armamentarium.
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43
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Abstract
Migraine is commonly associated with nausea and vomiting, though, interestingly, vomiting has also been reported by some patients to be therapeutic, and may actually stop a migraine attack. In this review, we will first discuss the epidemiology of nausea and vomiting in migraine. Further, we will briefly review the connections between the enteric nervous system, the autonomic nervous system, and the central nervous system as they pertain to understanding the question of "Why does vomiting stop a migraine attack?"
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Goadsby PJ, Grosberg BM, Mauskop A, Cady R, Simmons KA. Effect of noninvasive vagus nerve stimulation on acute migraine: An open-label pilot study. Cephalalgia 2014; 34:986-93. [DOI: 10.1177/0333102414524494] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background We sought to assess a novel, noninvasive, portable vagal nerve stimulator (nVNS) for acute treatment of migraine. Methods Participants with migraine with or without aura were eligible for an open-label, single-arm, multiple-attack study. Up to four migraine attacks were treated with two 90-second doses, at 15-minute intervals delivered to the right cervical branch of the vagus nerve within a six-week time period. Subjects were asked to self-treat at moderate or severe pain, or after 20 minutes of mild pain. Results Of 30 enrolled patients (25 females, five males, median age 39), two treated no attacks, and one treated aura only, leaving a Full Analysis Set of 27 treating 80 attacks with pain. An adverse event was reported in 13 patients, notably: neck twitching ( n = 1), raspy voice ( n = 1) and redness at the device site ( n = 1). No unanticipated, serious or severe adverse events were reported. The pain-free rate at two hours was four of 19 (21%) for the first treated attack with a moderate or severe headache at baseline. For all moderate or severe attacks at baseline, the pain-free rate was 12/54 (22%). Conclusions nVNS may be an effective and well-tolerated acute treatment for migraine in certain patients.
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Affiliation(s)
- PJ Goadsby
- Headache Group-Department of Neurology, University of California, San Francisco, CA, USA
- Headache Group, NIHR-Wellcome Clinical Research Facility, King’s College London, UK
| | | | - A Mauskop
- New York Headache Center, New York, NY, USA
| | - R Cady
- Clinvest, Headache Care Center, Springfield, MO, USA
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Oshinsky ML, Murphy AL, Hekierski H, Cooper M, Simon BJ. Noninvasive vagus nerve stimulation as treatment for trigeminal allodynia. Pain 2014; 155:1037-1042. [PMID: 24530613 DOI: 10.1016/j.pain.2014.02.009] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 01/22/2014] [Accepted: 02/10/2014] [Indexed: 01/01/2023]
Abstract
Implanted vagus nerve stimulation (VNS) has been used to treat seizures and depression. In this study, we explored the mechanism of action of noninvasive vagus nerve stimulation (nVNS) for the treatment of trigeminal allodynia. Rats were repeatedly infused with inflammatory mediators directly onto the dura, which led to chronic trigeminal allodynia. Administration of nVNS for 2 minutes decreased periorbital sensitivity in rats with periorbital trigeminal allodynia for up to 3.5 hours after stimulation. Using microdialysis, we quantified levels of extracellular neurotransmitters in the trigeminal nucleus caudalis (TNC). Allodynic rats showed a 7.7±0.9-fold increase in extracellular glutamate in the TNC after i.p. administration of the chemical headache trigger glyceryl trinitrate (GTN; 0.1 mg/kg). Allodynic rats that received nVNS had only a 2.3±0.4-fold increase in extracellular glutamate after GTN, similar to the response in control naive rats. When nVNS was delayed until 120 minutes after GTN treatment, the high levels of glutamate in the TNC were reversed after nVNS. The nVNS stimulation parameters used in this study did not produce significant changes in blood pressure or heart rate. These data suggest that nVNS may be used to treat trigeminal allodynia.
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Affiliation(s)
- Michael L Oshinsky
- Thomas Jefferson University, Department of Neurology, Philadelphia, PA, USA Electrocore, LLC, Basking Ridge, NJ, USA
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47
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Abstract
CONTEXT A variety of neuromodulatory approaches available today has broadened our therapeutic options significantly especially in drug refractory patients with chronic cluster headache and chronic migraine. OVERVIEW It is a dynamic field with a current trend to non-invasive transcutaneous stimulation approaches. However, sound studies providing evidence for the widespread use of these novel approaches are sparse. For invasive approaches, occipital nerve stimulation is now widely considered the treatment of first choice in chronic trigeminal autonomic cephalgias and - with limitations - chronic migraine. Although equally effective, deep brain stimulation is considered second-line treatment in cluster headache because of its potentially life-threatening side effects. Most recently, stimulation of the sphenopalatine ganglion has also been shown to effectively abort acute cluster headache attacks. Interesting other upcoming approaches include transcutaneous supraorbital nerve stimulation and transcutaneous vagal nerve stimulation. CONCLUSION Pearls and pitfalls of common invasive and non-invasive neuromodulatory approaches and open questions are summarised in this review along with recommendations for future studies.
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Affiliation(s)
- Tim P Jürgens
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, D-22046 Hamburg, Germany.
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48
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De Ridder D, Vanneste S, Engineer ND, Kilgard MP. Safety and Efficacy of Vagus Nerve Stimulation Paired With Tones for the Treatment of Tinnitus: A Case Series. Neuromodulation 2013; 17:170-9. [DOI: 10.1111/ner.12127] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Revised: 08/15/2013] [Accepted: 09/06/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Dirk De Ridder
- Brai n, Tinnitus Research Initiative Clinic Antwerp & Department of Neurosurgery; University Hospital Antwerp; Belgium
- Department of Surgical Sciences, Dunedin School of Medicine; University of Otago; New Zealand
| | - Sven Vanneste
- Brai n, Tinnitus Research Initiative Clinic Antwerp & Department of Neurosurgery; University Hospital Antwerp; Belgium
- Department of Translational Neuroscience, Faculty of Medicine; University of Antwerp; Belgium
| | | | - Michael P. Kilgard
- School of Behavioral and Brain Sciences; University of Texas at Dallas; Richardson TX USA
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49
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Abstract
Migraine is a common, disabling, neurovascular disorder characterized by episodic attacks of head pain and associated disability plus systemic autonomic and neurologic symptoms. The advent of the triptan class of medication in the 1990s revolutionized the acute treatment of migraine, but many migraineurs do not respond optimally or at all to triptans, have intolerable adverse effects, or have contraindications to their use. Preventive pharmacotherapy has advanced mostly through serendipity, with new drugs being found effective while being used for other indications. There remains a significant need for new medications and devices that can provide effective, rapid, and sustained pain relief without adverse effects or recurrence. Several new acute and preventive therapies for the treatment of migraine and cluster headaches have shown promise and are currently under investigation. This article covers innovative delivery mechanisms, calcitonin gene-related peptide receptor antagonists, antibodies to calcitonin gene-related peptide and its receptor, 5-HT1F receptor agonists, transient receptor potential vanilloid receptor modulators, orexin receptor antagonists, glial cell modulators, and neurostimulation.
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50
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Leone M, Cecchini AP, Franzini A, Bussone G. Neurostimulators for the treatment of primary headaches. FUTURE NEUROLOGY 2013. [DOI: 10.2217/fnl.13.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Neurostimulation techniques have increased our therapeutic armamentarium, providing additional options for the treatment of patients with drug-resistant headache. Occipital nerve stimulation can be considered in drug-resistant chronic cluster headache and, with more caution, in drug-resistant chronic migraine. Approximately 12 years after its introduction, hypothalamic stimulation is a valid option for drug-resistant chronic cluster headache to be considered when occipital nerve stimulation fails. Several other peripheral stimulation approaches (in addition to occipital nerve stimulation) have been introduced in recent years; however, for the most part, appropriate studies supporting their efficacy are lacking. Transcranial magnetic stimulation, transcutaneous supraorbital nerve stimulation, sphenopalatine ganglion stimulation and vagal nerve stimulation have all been tried, but results are not wholly convincing, and more extensive evaluations are required.
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Affiliation(s)
- Massimo Leone
- Department of Neurology, Headache Centre & Pain Neuromodulation Unit, Fondazione Istituto Nazionale Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy.
| | - Alberto Proietti Cecchini
- Department of Neurology, Headache Centre & Pain Neuromodulation Unit, Fondazione Istituto Nazionale Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy
| | - Angelo Franzini
- Department of Neurosurgery, Fondazione Istituto Nazionale Neurologico Carlo Besta, Milan, Italy
| | - Gennaro Bussone
- Department of Neurology, Headache Centre & Pain Neuromodulation Unit, Fondazione Istituto Nazionale Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy
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