Effectiveness of High-Frequency Repetitive Transcranial Magnetic Stimulation in Migraine: A Systematic Review and Meta-analysis

HF-rTMS of the left DLPFC relieve headaches and enhance frontal-temporal connectivity in migraine

OBJECTIVE

Migraine is a neurological disorder linked to altered cortical excitability. High-frequency repetitive transcranial magnetic stimulation (HF-rTMS) is a promising non-invasive method for modulating nociceptive circuits, yet its precise mechanisms remain unclear. This study applied HF-rTMS to the left dorsolateral prefrontal cortex (DLPFC) and assessed brain network changes using transcranial magnetic stimulation combined with electroencephalography (TMS-EEG).

METHODS

We analyzed dynamic brain connectivity in 15 migraine patients versus 15 healthy controls. A randomized, double-blind, sham-controlled trial evaluated a 14-day HF-rTMS (20 Hz) protocol in 28 migraine patients. Brain network reorganization and migraine severity, measured by the Visual Analog Scale (VAS) and monthly migraine days (MMD), were assessed both immediately after treatment and at a one-month follow-up.

RESULTS

Migraine patients exhibited reduced left DLPFC connectivity compared to healthy controls. HF-rTMS significantly increased frontal-temporal network connectivity, correlating with a marked reduction in VAS and MMD scores (p < 0.001).

CONCLUSION

These findings provide novel evidence that HF-rTMS targeting the left DLPFC effectively alleviates migraine symptoms by enhancing frontal-temporal cortical plasticity.

SIGNIFICANCE

This study highlights the potential of neuromodulation techniques in the treatment of migraine.

2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline for the Management of Headache

DESCRIPTION

Headache medicine and therapeutics evidence have been rapidly expanding and evolving since the 2020 U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) clinical practice guideline (CPG) for the management of headache. Therefore, the CPG was revised in 2023, earlier than the standard 5-year cycle. This article reviews the 2023 CPG recommendations relevant to primary care clinicians for treatment and prevention of migraine and tension-type headache (TTH).

METHODS

Subject experts from the VA and the DoD developed 12 key questions, which guided a systematic search using predefined inclusion and exclusion criteria. After reviewing evidence from 5 databases published between 6 March 2019 and 16 August 2022, the work group considered the strength and quality of the evidence, patient preferences, and benefits versus harms on critical outcomes before making consensus recommendations.

RECOMMENDATIONS

The revised CPG includes 52 recommendations on evaluation, pharmacotherapy, invasive interventions, and nonpharmacologic interventions for selected primary and secondary headache disorders. In addition to triptans and aspirin-acetaminophen-caffeine, newer calcitonin gene-related peptide (CGRP) inhibitors (gepants) are options for treatment of acute migraine. Medications to prevent episodic migraine (EM) include angiotensin-receptor blockers, lisinopril, magnesium, topiramate, valproate, memantine, the newer CGRP monoclonal antibodies, and atogepant. AbobotulinumtoxinA can be used for prevention of chronic migraine but not EM. Gabapentin is not recommended for prevention of EM. Ibuprofen (400 mg) and acetaminophen (1000 mg) can be used for treatment of TTH, and amitriptyline for prevention of chronic TTH. Physical therapy or aerobic exercise can be used in management of TTH and migraines.

Efficacy and safety of high-frequency repetitive transcranial magnetic stimulation (rTMS) for migraine: a meta-analysis of randomized controlled trials

OBJECTIVE

To assess the efficacy and safety of high-frequency repetitive transcranial magnetic stimulation in the prevention or treatment of migraine by conducting a pooled analysis of relevant randomized controlled trials.

METHODS

The PubMed, Embase, Cochrane, OVID, SCOPUS, Web of Science, and clinicaltrials.gov databases were systematically searched for randomized controlled trials (RCTs) comparing high-frequency rTMS and sham stimulation for the prevention or treatment of migraine. A meta-analysis of relevant outcome measures was performed using RevMan 5.3 software.

RESULTS

Eight RCTs with a total of 384 patients were included. A total of 23 patients dropped out, and thus, 361 patients were ultimately included for analysis. The high-frequency rTMS group had a lower frequency of attacks than the sham group (MD = - 5.10; 95% CI: - 8.10, - 2.09; P = 0.0009). The rTMS group has less intense headaches than the sham group (SMD = - 0.74; 95% CI - 1.04, - 0.44; P < 0.00001). High-frequency rTMS improved patient disability (SMD = - 0.45; 95% CI - 0.75, - 0.16; P = 0.003). High-frequency rTMS led to no advantage in reducing the number of abortive medications (MD = - 1.10; 95% CI - 3.28, 1.08; P = 0.32), but it increased the occurrence of adverse events (RR = 1.69; 95% CI 1.09, 2.64; P = 0.02).

CONCLUSIONS

High-frequency rTMS reduces the frequency of attacks and headache intensity in migraine patients and improves the patient's disability, but it also increases adverse events.

Navigating the Neurobiology of Migraine: From Pathways to Potential Therapies

Migraine is a debilitating neurological disorder characterized by recurring episodes of throbbing headaches that are frequently accompanied by sensory disturbances, nausea, and sensitivity to light and sound [...].

Neuromodulation Techniques for Headache Management

This narrative review aims to summarize evidence regarding the current utilization and future applications of neuromodulation in patients with headaches, with special attention paid to migraine and chronic cluster headache. A search was conducted in PubMed in August of 2023 to survey the current literature on neuromodulation for the treatment of headache. In total, the search yielded 1989 results, which were further filtered to include only systematic reviews published between 2022 to 2023 to capture the most up-to-date and comprehensive research on this topic. The citation lists of these articles were reviewed to find additional research on neuromodulation and supplement the results presented in this paper with primary literature. Research on the use of neuromodulation for the treatment of headache has predominantly focused on four neuromodulation techniques: peripheral nerve stimulation (PNS), transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), and spinal cord stimulation (SCS). Outcome measures reported in this article include impact on migraine and headache frequency and/or pain intensity, adverse effects of the neuromodulation technique, and associated costs, when available. We found that neuromodulation has developed utility as an alternative treatment for both chronic cluster headaches and migraines, with a reduction in frequency and intensity of headache most elucidated from the articles mentioned in this review.

Transcranial Magnetic Stimulation as a Therapy for Migraine: An Overview of Systematic Reviews

Introduction

This overview of systematic reviews (SRs) systematically collected, evaluated, and combined the evidence for migraine treatment with transcranial magnetic stimulation (TMS).

Methods

We conducted a systematic literature search in various databases, such as PubMed, The Cochrane Library, Web of Science, Embase, the China National Knowledge Infrastructure, Wanfang, VIP, and China Biomedical Literature. Two reviewers independently assessed the methodological quality, risk of bias, reporting quality, and strength of evidence of the included studies using AMSTAR-2, ROBIS, the PRISMA checklist, and the GRADE system.

Results

We performed an overview of 7 relevant SRs, of which 4 were of moderate quality and 3 were of low quality according to AMSTAR 2. All SRs had low risk of bias in Phase 1 (Assessing relevance), Domain 1 (Study eligibility criteria), and Domain 4 (Synthesis and findings) as evaluated by ROBIS. In Domain 2 (Identification and selection of studies), 4 SRs (57.1%) had low risk of bias, while in Domain 3 (data collection and study appraisal) and Risk of Bias in the Review Phase 3, 4 SRs (57.1%) had low risk of bias. The PRISMA reporting standards were generally comprehensive, but some limitations were observed in the assessments, pooled results, evidence reliability, registration and protocols, and funding sources. The GRADE levels ranged from moderate to low, with 10 outcomes of moderate quality and 6 outcomes of low quality. The main reason for the low quality of evidence was the small sample size and high heterogeneity of the available studies.

Conclusion

TMS may improve migraine severity and frequency, but the evidence is limited due to methodological flaws and heterogeneity. Future studies should standardize use, assess side effects, and compare with other treatments.

Repetitive transcranial magnetic stimulation in the treatment of middle-aged and elderly major depressive disorder: A randomized controlled trial

BACKGROUND

Studies have reported the use of repetitive transcranial magnetic stimulation (rTMS) in patients with major depressive disorder (MDD). However, most studies focus on antidepressant effect of rTMS, but few on cognitive aspects. The present study aimed to explore the effect of rTMS on BDNF levels and cognitive function in the treatment of middle-aged and elderly MDD.

METHODS

This was a randomized controlled trial. A total of 120 elderly patients with MDD treated in The Second Affiliated Hospital of Xi'an Medical University from January 2021 to January 2023 were selected as research subjects. The patients were randomly divided into control group (n = 60, patients received simple oral treatment with escitalopram and sham rTMS) and study group (n = 60, patients received oral treatment with escitalopram combined with rTMS) according to the random number table method. We compared the clinical efficacy, serum BDNF levels, and cognitive function between the 2 groups.

RESULTS

After treatment, the HAMD-17 score in the study group was lower than that in the control group [13.00 (12.00-16.00) vs 17.00 (15.00-19.00), P < .05], and the RBANS score was higher than that in the control group [166.00 (161.25-171.75) vs 133.00 (130.00-136.75), P < .05]. The total effective rate of the research group was 95.0%, which was higher than the 82.0% of the control group (P < .05). The serum BDNF levels [36.00 (33.00-38.00) vs 30.00 (28.00-32.00), P < .05] and MoCA scores [24.00 (22.00-26.75) vs 23.00 (21.00-25.00), P < .05] of the study group were higher than those of the control group. There were no significant adverse reactions during the treatment of both groups.

CONCLUSIONS

Compared with oral escitalopram alone, repeated transcranial magnetic stimulation in the treatment of middle-aged and elderly patients with major depressive disorder can further improve the efficacy, and can more effectively improve the BDNF level and cognitive function, with ideal safety.

Repetitive transcranial magnetic stimulation for cerebellar ataxia: a systematic review and meta-analysis

Background

Repetitive transcranial magnetic stimulation, a non-invasive brain stimulation technique, can manage cerebellar ataxia (CA) by suppressing cerebral cortical excitability. Hence, this study aimed to summarize the efficacy and safety of rTMS for CA patients by meta-analysis.

Methods

The PubMed, Embase, Web of Science, and Cochrane Library databases were searched for eligible studies published till 20 May 2023. Weighted mean difference (MD) and 95% confidence intervals (CIs) were used to assess the effect of rTMS treatment. Additionally, the quality of the included studies and the risk of bias were evaluated using the Physiotherapy Evidence Database (PEDro) scale.

Results

Overall, eight studies involving 278 CA patients were included in this meta-analysis. rTMS could significantly improve the Scale for the Assessment and Rating of Ataxia (SARA) (MD: -2.00; 95% CI: -3.97 to -0.02, p = 0.05), International Cooperative Ataxia Rating Scale (ICARS) (MD: -3.96; 95% CI: -5.51 to -2.40, p < 0.00001), Timed Up-and-Go test (TUG) (MD: -1.54; 95% CI: -2.24 to -0.84, p < 0.0001), 10-m walk test (10 MWT) (MD10-m steps: -2.44; 95% CI: -4.14 to -0.73, p = 0.005), and Berg Balance Scale (BBS) (MD: 2.59; 95% CI: 1.15-4.03, p = 0.0004) as compared to sham stimulation. Active rTMS was not significantly different from sham rTMS in changing the duration (MD10-m time: -1.29; 95% CI: -7.98 to 5.41, p = 0.71). No severe adverse events were observed in both sham stimulation and active rTMS groups.

Conclusion

This meta-analysis provides limited evidence that rTMS may be beneficial in treating CA patients. However, these findings should be treated with caution due to the limitations of the smaller sample size and the inconsistent approach and target of rTMS treatment. Therefore, more large-scale RCTs are required to further validate our analytical findings.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=295726, identifier: CRD42022295726.

Repetitive Transcranial Magnetic Stimulation for Neuropathic Pain and Neuropsychiatric Symptoms in Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Neuropathic pain and neuropsychiatric symptoms are common complications reported by the traumatic brain injury (TBI) population. Although a growing body of research has indicated the effectiveness of repetitive transcranial magnetic stimulation (rTMS) for the management of neurological and psychiatric disorders, little evidence has been presented to support the effects of rTMS on neuropathic pain and neuropsychiatric symptoms in patients with TBI in all age groups. In addition, a better understanding of the potential factors that might influence the therapeutic effect of rTMS is necessary. The objective of this preregistered systematic review and meta-analysis was to quantify the effects of rTMS on physical and psychological symptoms in individuals with TBI. We systematically searched six databases for randomized controlled trials (RCTs) of rTMS in TBI patients reporting pain and neuropsychiatric outcomes published until March 20, 2022. The mean difference (MD) with 95% confidence intervals (CIs) was estimated separately for outcomes to understand the mean effect size. Twelve RCTs with 276 TBI patients were ultimately selected from 1605 records for systematic review, and 11 of the studies were included in the meta-analysis. Overall, five of the included studies showed a low risk of bias. The effects of rTMS on neuropathic pain were statistically significant ( $\text{MD}=-1.00$ , 95% CI -1.76 to -0.25, $P=0.009$ ), with high heterogeneity ( $I^2=76\%$ ). A significant advantage of 1 Hz rTMS over the right dorsolateral prefrontal cortex (DLPFC) in improving depression ( $\text{MD}=-6.52$ , 95% CI -11.58 to -1.46, $P=0.01$ ) was shown, and a significant improvement was noted in the Rivermead Post-Concussion Symptoms Questionnaire-13 (RPQ-13) scores of mild TBI patients after rTMS ( $\text{MD}=-5.87$ , 95% CI -10.63 to -1.11, $P=0.02$ ). However, no significance was found in cognition measurement. No major adverse events related to rTMS were reported. Moderate evidence suggests that rTMS can effectively and safely improve neuropathic pain, while its effectiveness on depression, postconcussion symptoms, and cognition is limited. More trials with a larger number of participants are needed to draw firm conclusions. This trial is registered with PROSPERO (PROSPERO registration number: CRD42021242364.