S2 E10: Devices

A National Migraine Centre Heads Up Podcast transcript


Series 2, episode 10

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Speaker 1 [00:00:00] Did you know one device to help migraine uses magnetic pulses. There are many ways to help your migraine. Welcome to the Head’s Up podcast brought to you by the National Migraine Centre, the only UK charity treating migraine and headache.


Dr Jessica Briscoe [00:00:22] Hello and welcome to this fortnight’s Heads Up podcast. I’m joined by Dr. Katy Munro.


Dr Katy Munro [00:00:29] Hello.


Dr Jessica Briscoe [00:00:30] I don’t know why I introduced you first. I’m Dr. Jessica Briscoe.


Dr Katy Munro [00:00:33] Oh, yes. I remember you.


Dr Jessica Briscoe [00:00:36] So again, we’re doing our podcast virtually again because we’re still in lockdown. But we’re working hard to keep bringing you your episodes. Today’s episode is on the devices that can be used for prevention and management in acute phase of migraine. So a lot of people probably don’t know as much about the devices, and that’s why we thought it would be quite important to do this episode, because we talk a lot about different medications, but some people don’t get on with the medications or don’t want to take medications. So we thought it was important to show that there are different options and there are quite a lot aren’t there, Katy.


Dr Katy Munro [00:01:15] There are actually and often when I’ve mentioned them to patients, they’ve never heard of any of them. So I think it’s really quite important to know which ones are available, how you get them and which ones are coming soon, because there’s quite a lot of exciting developments for migraine. And also there’s one that is available for cluster headache and we’ll come on to that at the end of the episode.


Dr Jessica Briscoe [00:01:34] Absolutely.


Dr Katy Munro [00:01:35] So the first one we’re going to talk about is called Trans Magnetic Stimulation. And this is the sTMS device by eNeura, which we’ve had in the clinic for a long time. When I was first working in the clinic, it was an enormous, heavy device. But they’ve streamlined it and changed it from handles to buttons. And this one works by disrupting the cortical spreading depression, by sending a magnetic pulse through the brain. You hold it at the back of your head with both hands because it’s quite heavy, isn’t it? And then you press the buttons and it puts a pulse, which patients have described to me as a jolt, not unpleasant.


Dr Jessica Briscoe [00:02:16] People can’t feel it actually, some people can’t really feel very much. It’s quite interesting. Some people feel a bit of a jolt, some people don’t notice very much at all. It’s quite variable.


Dr Katy Munro [00:02:25] Yeah, it doesn’t seem to be unpleasant and it’s very, very safe, isn’t it? I’ve even had a teenager who had it prescribed to him and he got on quite well with it but mostly it’s adults.


Dr Jessica Briscoe [00:02:36] Me too. I’ve used it in a teenager as well. The company have actually done some research to display the safety because I was a little bit nervous about prescribing it for someone who was under 18 just because we try as much as possible- we’ve talked about this before, about use of medications and things like that in children and adolescents. And we try and go with evidence based medicine where possible. And they have actually done some study data which showed that it can be very effective in children and it’s safe. That’s the most important thing. It’s like with anything, it’s about whether or not people who are younger will use it as often as people who are older and motivated to use it as much. But I think that’s like with any device or medication to be honest.


Dr Katy Munro [00:03:20] You can use this as a preventor or you can use it in an acute attack, can’t you? And the guidance is that you build up to using a maximum of four pulses in the morning and four pulses in the evening as a preventor. So you do have to commit to doing that on a regular daily basis. But then if you get an acute attack in between, you can use a maximum of three pulses, three times in an acute attack. Have you come across anybody who’s used it that way?


Dr Jessica Briscoe [00:03:47]  Not really. Most people that I found have used it as a preventative. I’ve always suggested it as an acute intervention. But I haven’t particularly found that people have found that helpful.


Dr Katy Munro [00:04:03] Yeah, well it’s been one of those things. The trouble is with some of the devices, is that they’re very tricky to get on the NHS even though they’re approved by NICE and we have the ability to prescribe it through the clinic and people can have a free trial for three months, can’t they? But  if they do like it and it’s working for them and a lot of things have to be used in migraine for at least three months to really judge whether they’re working and then people have to rent the licence to keep using it. And that’s about £158 a month, which is not an inconsiderable amount of money. But you know, at least people can have a think about it and have a look at it, you know, on the eNeura website, and see what it looks like.


Dr Jessica Briscoe [00:04:49] Yeah, absolutely. I think also sometimes if you’re in an acute attack, actually picking something up or putting something on can feel a bit more troublesome, actually. So I sometimes wonder if that’s why people don’t use it as an acute intervention quite so much. But that’s supposition. There’s no evidence to back that up.


Dr Katy Munro [00:05:15] People also are often quite concerned about putting something, you know, they feel a bit freaked out about ‘oh it’s going to put something into my brain’. But actually it’s incredibly safe and the people have used it have really well tolerated it. And, of course, you’re talking later to Dr. Andreou, who’s done a lot of studies with this. So she’s going to go into a bit more detail what experience they’ve had at Guys and St Thomas’s headache clinic and that will be very interesting. Anybody who’s interested in whether they might try it have a listen to Dr. Andreou and Jessica speaking later in the podcast. Very few side effects with sTMS.


Dr Jessica Briscoe [00:05:55] Yeah, absolutely.


Dr Katy Munro [00:05:58] Tingling.


Dr Jessica Briscoe [00:05:58] Yes. Tingling. As I said, most people don’t find the jolt particularly unpleasant but I have to say I haven’t really come across any.


Dr Katy Munro [00:06:05] Light headed and tinitus are on the list I’ve seen.


Dr Jessica Briscoe [00:06:08] I haven’t had anyone who’s actually- I mean, I’ve had one person who thought it made their migraines worse. But to be honest, I don’t think it was the device. It was a natural pattern of their migraine.


Dr Katy Munro [00:06:19] Yeah. Migraine fluctuates anyway, doesn’t it.


Dr Jessica Briscoe [00:06:22] Exactly. I haven’t really had many people say that they’ve had any adverse effects to it, to be honest. Shall we move on to the next one.


Dr Katy Munro [00:06:31] Yes.


Dr Jessica Briscoe [00:06:32] So we should probably talk about Cefaly next, that’s the one that we prescribe most- well, we prescribe that and sTMS probably most because they’re the ones that have been around for the longest. So the Cefaly device is an electrical stimulation device. It’s sort of based a bit on the tens machine. Again, I talk about it a bit with Anna later on, but if anyone’s sort of had any experiences of back pain or pain elsewhere, sometimes people get tens machines prescribed on the NHS sort of as a neuromodulation therapy and this is a bit like a tens machine essentially, but it’s placed on the fore head, so it’s put in a slightly different place to the sTMS. And actually again, it can be used for either in the acute phase of the attacks, so as an intervention in a migraine attack or it can be used as a preventative. What do you tend to find, Katy? Do you find that people find it more helpful for acute or preventative?


Dr Katy Munro [00:07:37] I’ve got some patients who really love this actually and they find that they put it on, it’s quite relaxing and soothing. I’ve got one patient who actually goes off to sleep wearing it. As a preventor, you have to use it for 20 minutes a day regularly. You have to keep going, keep going with it. And I always warn people that I think of it as a bit Star Trek-y because you stick it in the middle of your forehead, don’t you, and it’s a little diamond shaped thing. It used to have two arms that went over your forehead and made it even more Star Trek-y. But, what I find people don’t like, you have to press the little buttons as it’s stuck. There’s an electrode that goes onto your forehead in the middle, and as the pulse increases, as the sort of stimulation increases, some people find that unpleasant, or they find they have to get used to it. It stimulates a branch of the trigeminal nerve, which we know is very commonly involved in migraine generation of pain. And there are two little nerves coming off from that called the supratrochlear and supraorbital nerves, either side of your eyebrows. And that’s sometimes where we put the Botox injections, isn’t it? And sometimes people have nerve blocks in those.


Dr Jessica Briscoe [00:08:52] Yeah, absolutely.


Dr Katy Munro [00:08:54] So, the theory is very good in that this disrupts those messages that are going in to cause migraine. If you want to use it in an acute attack, you need to sit there for an hour. So it’s not something you wear around Tescos or the supermarket.


Dr Jessica Briscoe [00:09:11] No, that’s what I was going to say, actually. If you’re out and about, you can’t really put it on. I mean, you can, but you might get some slightly strange looks.


Dr Katy Munro [00:09:17] Might have to sit in the car park in your car for a while.


Dr Jessica Briscoe [00:09:21] Yeah.


Dr Katy Munro [00:09:22] Not ideal but yeah, I mean, the beauty of these two devices we’ve talked about is that they are so safe. And so if you, you know, people have got side effects from medication or they’re not keen to look into injection preventors, which we’ve covered in other podcast episodes, then I think Neuromodulation Devices for migraine are a very exciting and a very lovely safe option.


Dr Jessica Briscoe [00:09:51] Absolutely.


Dr Katy Munro [00:09:52] Of course, you can buy the Cefaly Dual, can’t you?


Dr Jessica Briscoe [00:09:54] Yeah, you can buy the Cefaly dual over the internet.


Dr Katy Munro [00:09:59] Yes.


Dr Jessica Briscoe [00:09:59] Or we do sometimes prescribe it, but I don’t think it makes much of a difference.


Dr Katy Munro [00:10:03] I think the price is the same isn’t it, really.


Dr Jessica Briscoe [00:10:05] Exactly exactly.


Dr Katy Munro [00:10:07] The nice thing about the- you can buy it for £336 at the moment, at the time of recording, and you can try it for two months. Shame it’s not three. I think three would have been better. But, two months you can try it and if you don’t like it or it’s not working, you can get a refund of £280 from the manufacturer. So I sort of say to people, you know it’s a £50/£60 gamble. And some people do really like it and then they carry on and they buy themselves- you do have to replenish the electrode sticky tabs.


Dr Jessica Briscoe [00:10:41] And also make sure that you prep your head in the right way so that the electrodes will last for long enough. There are all sorts of hints and tips that people have come up with to try and get the most out of the electrodes, to be honest. So we’ve got some other, sort of, newer devices as well that are coming onto the market. I always hate calling it that. There’s the Nerivio, which is quite exciting because it’s very new. This has only been around- I’ve only been aware of it for probably a bit less than a year now. So I think I only heard about it last summer or autumn. And this is actually interesting because it’s not used around the head or neck at all. You actually apply the electrodes in a completely different place. It’s your arm, I think, isn’t it, Katy?


Dr Katy Munro [00:11:31] Yes. It’s your upper arm. Yes.


Dr Jessica Briscoe [00:11:32] Yeah. And it’s actually a peripheral device.


Dr Katy Munro [00:11:36] Yes. So peripheral electrical stimulation.


Dr Jessica Briscoe [00:11:40] Yeah. Or PES.


Dr Katy Munro [00:11:44] I was quite interested because I saw one of these first in September in Dublin, but it has been out in the United States since May 2019. So, you know, they’ve been using it. And then we did have a patient who came to the centre who had moved over from America and she’d been using one. So I got to have a look at it and speak to her about it. And she quite liked it I have to say. It’s a very easy little device to strap on your arm, it’s flat. We haven’t got it available in the UK and I don’t know when we will.


Dr Jessica Briscoe [00:12:14] It’s quite interesting because it’s, again, used in an acute attack isn’t it. It’s not a preventative but it’s supposed to give relief during an attack. And I was discussing it with one of my colleagues who works in a completely different area of medicine, she does a lot of dermatology surgery. And I was saying, I think it’s really interesting how it works when you don’t apply it to the head. And she said, well, we do the same thing in surgery. You stimulate nerves in a different part of the body and then we operate and it works quite well, people don’t feel pain. And I thought that was really interesting, actually. I mean migraines are famous for borrowing things from other areas of medicine. But it is nice when you sort of think of something that will not cause any harm, that won’t give too many side effects that could be used as an alternative for people who don’t tolerate medications or can’t use them. I think actually the application of these devices is really exciting and I’m hoping it comes across here soon, to be honest, so that people can try it.


Dr Katy Munro [00:13:14] It’s not that expensive either in the States they’re selling them for about $99, if my research is correct, that certainly was what they were marketing them for. And it also uses your smartphone to control it, doesn’t it?


Dr Jessica Briscoe [00:13:29] Oh really? That’s cool.


Dr Katy Munro [00:13:29] Yes, this is the way that things are going, aren’t they?


Dr Jessica Briscoe [00:13:30] I think you know more about it than I do, Katy.


Dr Katy Munro [00:13:33] Well, I just was fascinated because, like many people, I immediately thought, well, how can putting something on your arm help your brain? But of course, we do send signals up from peripheral parts of our body and that’s the way that they’ve gone with the research on this one, which is very exciting. I think, you know, hopefully Theranica who make this device will be looking to bring it out in Europe or in the UK sometime in the near future, but we don’t have any dates on that yet. There are a couple of other kind of rarer things which I literally don’t know anything about other than the names of them. So they’re called caloric vestibular stimulation and percutaneous mastoid electrical stimulation which are in development. I don’t think they’re being used anywhere. But have you come across those?


Dr Jessica Briscoe [00:14:25] No, I think I had heard of the mastoid stimulation device, but I hadn’t heard of the caloric vestibular stimulation.


Dr Katy Munro [00:14:34] I think the message is basically that people are looking into all sorts of ways of treating migraine with electrical or other impulses rather than people having to take medication which is great news.


Dr Jessica Briscoe [00:14:48] Yeah. And it would be nice to hear- I mean, I presume with the caloric vestibular stimulation they are looking at people who get vestibular type symptoms a little bit, which would be wonderful because we’re always saying, you know, that tends to be a bit of a forgotten group of patients, people with vestibular migraine. Again, probably because it takes a while to diagnose them so they’re further through the disease process. So if we could find something that would be a bit more targeted to them, that would be exciting. But I suppose it’s a watch this space situation.


Dr Katy Munro [00:15:20] Oh just a word more about the Nerivio, which I forgot to say earlier, apparently because it’s an electrical stimulation, you can’t use it in people with heart failure or cardiovascular disease. So that’s a bit of a shame in a way. But also, of course, anybody who’s also got implanted medical devices like pacemakers or hearing aid implants. So we’ll have to be a bit careful if that is available to pick and choose the right patients to have that. But in general, if you’re a fit and healthy person but you have horrible migraine, acute migraine, episodic migraine, this one is for, then the Nerivio might be something to think about.


Dr Jessica Briscoe [00:16:00] Yeah, I think the last thing we wanted to talk about was the vagus nerve, because it’s one of those nerves that we’re always quite interested in, isn’t it, Katy? We talk about it a fair amount.


Dr Katy Munro [00:16:08] Yeah, it gets a lot of publicity the vagus nerve lately. I seem to find it everywhere I look.


Dr Jessica Briscoe [00:16:14] Well it’s a really important nerve that’s why. It’s sort of got its fingers in all the pies I always think.


Dr Katy Munro [00:16:20] And it’s called the vagus nerve because, Jessica…


Dr Jessica Briscoe [00:16:25] Well, it’s the wandering nerve. I love telling people this. It’s the wandering nerve, it goes all the way through the body. So it’s one of the cranial nerves, it starts in the brain. And wanders all the way through the body actually we were talking about it earlier. What a surprise. We were talking about it earlier, Katy, weren’t we? And how it actually wraps around the ear as well. And sometimes some of the treatments that people use might be related to the vagus nerve. And it goes all the way down the neck through the body. It’s one of those nerves where, in any disease process, you hear about it and someone will say, oh, the vagus nerve and you think, of course it’s involved. Of course it’s involved. But it’s very important in migraine isn’t it.


Dr Katy Munro [00:17:05] It is. I mean one of the reasons I’m commonly talking to patients about the vagus nerve is because of the gastric statis and of course we know that everybody with migraine gets a certain degree of gastric statis, which inhibits the emptying of the stomach and that slows down the absorption of painkillers. So feel free to listen to one of our earlier podcasts, in which we describe why it’s useful to use one of the pro kinetic antiemetics with your painkilling medication, because that can be very helpful. And that’s all to do with the vagus nerve. So the migraine affects the vagus nerve. So people have looked into stimulating the vagus nerve and see if that helps migraine or also cluster headache.


Dr Jessica Briscoe [00:17:49] Cluster headache, yes. It’s the gammaCore isn’t it, that tends to be used for vagal nerve stimulation. It’s again, an electrical stimulation device which you hold up to the neck because that’s quite an easy place to access the vagus nerve. Because also you have to be a bit careful. I mean, Anna does talk about this in a quite a lot more detail, actually. But, you know, it’s one of those nerves that’s meant to be quite hard to access, actually, to get stimulation from. So the neck seems to be where they’ve got access to it. You hold it up to the neck and then you deliver- I can’t remember how many pulses you deliver?


Dr Katy Munro [00:18:29] Oh, it’s more of a time thing rather than a pulse thing.


Dr Jessica Briscoe [00:18:32] And you just hold it down, don’t you.


Dr Katy Munro [00:18:33] Yes. And if you see it being demonstrated, first of all, you have to find the carotid pulse. And then when you set it and you increase the electrical current going through it, when it’s working, it causes the side of your lip to twitch down. It looks quite funny, feels a bit weird first of all, but if it’s in the right place, then it gives people this kind of twitchy face. It’s not unpleasant. And I have had patients who’ve used this both for migraine and for cluster headache. We used to try it for migraine, there’s not a lot of good evidence. It’s not approved by NICE for migraine or chronic migraine or episodic migraine.


Dr Jessica Briscoe [00:19:15] I don’t tend to suggest it for migraine.


Dr Katy Munro [00:19:16] One of the other things that it did seem to help when a few migraine sufferers at my clinic were using it was, it did seem to help the sort of gastric IBS type symptoms of their migraine. But it’s not brilliant for the headache part. But for cluster headache that’s a different story.


Dr Jessica Briscoe [00:19:33] Absolutely. Yeah. And it can be very useful for- we talk about it a little bit more actually in our Cluster Headache podcast, if you have a little listen back, if you’re really interested in that, it can be very helpful for cluster headache management.


Dr Katy Munro [00:19:47] So there are other ways to affect the vagus nerve. And one of the ones that I sometimes speak to people about is to calm the anxiety that goes with migraine as well, because we know the vagus nerve is involved with parasympathetic nervous system. And one of the ways that you can switch that system on is by slow exhaling, relaxing breathing.


Dr Jessica Briscoe [00:20:11] Do you think that’s why mindfulness is helpful? One of the reasons that mindfulness helps.


Dr Katy Munro [00:20:18] One of the ways it works? Probably, yes. But certainly just by exhaling five slow breaths, that starts to switch on the parasympathetic system and calms people down. So it’s definitely adding that in as well. If you’re starting to get a migraine, people do often say, don’t they, ‘if I go and sit quietly in a dark room and slowly breathe in and out quietly’. What you don’t want to do is breathe in deeply and keep panting and hyperventilating because that makes everything worse.


Dr Jessica Briscoe [00:20:48] You get your carbon dioxide levels up and then you could have all sorts of horrible symptoms. So please don’t do that.


Dr Katy Munro [00:20:57] Yeah. So think about your vagus nerve is the message.


Dr Jessica Briscoe [00:21:02] Great. I think that’s all of the ones that we wanted to talk about. Please keep tuned, because I will be talking to Dr. Anna Andreou, who works for St Thomas’ Headache Centre and also lectures for King’s College, because we’ll be talking a little bit more about clinical applications of these devices.


Dr Katy Munro [00:21:23] What we’re not covering in this episode are the invasive neuromodulation treatments, which are available through specialist headache clinics for people who have a really, really hard to treat chronic migraine and that involve surgical operations and implants, which is not something we get involved with much.


Dr Jessica Briscoe [00:21:40] Not really. No.


Dr Katy Munro [00:21:42] Not really. Not our thing. But it is important to know that those kind of treatments are available. So don’t lose hope. There’s almost invariably something else that we can suggest or point you in the right direction of finding a specialist headache clinic that can talk to you about those. Just at this point, we’d like to say thank you so much to all of those people who have kindly donated to our appeal. As a charity we do rely on your donations. And the lockdown has really hit us financially quite badly. So to enable us to keep going with the podcast and more importantly probably, to keep going, seeing our patients, we would be very, very grateful if you could donate something on the link, which is in the blurb. Thanks very much.


Dr Jessica Briscoe [00:22:34] Hello and it’s Dr. Jessica Briscoe. Today I’m joined by Dr. Anna Andreou, who is the headache research director at the Headache Centre at Guy’s and St Thomas’ and senior lecturer at King’s College.


Dr Anna Andreou [00:22:45] Good morning.


Dr Jessica Briscoe [00:22:47] Good morning. So we’ve been trying to do this episode for a little while and we’re talking about devices. We’re doing it remotely because of the coronavirus pandemic restrictions. So apologies if you hear any sort of extra noise in the background, but we’ll try and get through it.


Dr Anna Andreou [00:23:03] We’ll try our best. I hope it’s going to work.


Dr Jessica Briscoe [00:23:06] Yes, fingers crossed. And maybe if we can start off by just a little bit of an introduction so that people can know who you are and a little bit about what you do.


Dr Anna Andreou [00:23:16] Of course. So my background is actually in biology and then training in neurophysiology. And ever since I finished my PHD, I work in the headache research field. I’ve been trained at Queen’s Square, then moved to the US at the University of San Francisco, then back to UK, Imperial College, and now within King’s College and the Headache Centre at Guy’s and St Thomas’. My main research focus is on the mechanisms of migraine in terms of the biological reasons of why we get a migraine, but also the mechanisms of action of neurotreatments, and especially when it comes to neurotreatments I have a special interest in what we call the non-invasive neuromodulation techniques.


Dr Jessica Briscoe [00:24:08] Great. And that’s really what we wanted to talk about today, because I think people are really aware of some of the more sort of medical or injection or oral treatments that people can take. But I think there’s a bit less awareness of some of the devices that are actually available.


Dr Anna Andreou [00:24:24] That’s correct. And I think it’s important to raise awareness about these treatments that are available, especially because usually they don’t have the side effects that patients may experience with the oral treatment or the unpleasant effect of receiving an injection.


Dr Jessica Briscoe [00:24:42] Absolutely. I mean, we speak to a lot of people in clinic who seem to be quite sensitive to side effects. And a lot of the medications do for some people have quite a lot of side effects, so it’s good to have other options. So what devices are there available at the moment for migraine?


Dr Anna Andreou [00:24:59] So I’m going to just speak about the non-invasive ones. We mentioned that there are also invasive techniques by invasive, we mean that some sort of procedure needs to take place in order to implant a stimulating device on any part of the neuro system that is involved in migraine. However, today we’re going to focus on the non-invasive techniques that involve devices that the patients can actually take with them at home. They can self-treat their attacks, but also use them on a daily basis for prevention. So these techniques involve the transcranial magnetic stimulation. This is a single pulse transcranial magnetic stimulation or Spring sTMS, as it’s called. Also, we have the vagus nerve stimulator from electroCore. We then have the Cefaly device that some people may have purchased from the Internet, apparently it’s available on the Internet and they can puchase it.


Dr Jessica Briscoe [00:26:05] Yeah. It is available on the internet.


Dr Anna Andreou [00:26:09] It is a transcutaneous electrical stimulation technique. And most recently there was another device approved but is not available in the UK yet. And that’s the Theranica Nerivio machine, which is just an electrical stimulation, essentially on the forearm. So it doesn’t really stimulate directly the nerves that are related directly to the migraine pathophysiology, but it’s meant to interfere with some brain pathways that are responsible for the pain.


Dr Jessica Briscoe [00:26:50] Yeah, that one I found quite interesting because all of the other ones, where they’re placed, you can see why they’d be beneficial. So the Cefaly sort of on the forehead, the sTMS at the back of the head, the gammacore at the neck. So it sort of seems a bit counterintuitive to have a nerve stimulator that doesn’t seem to be anywhere near where the pain is or the symptoms are.


Dr Anna Andreou [00:27:11] I do agree with you. The background of it or the principle of why they think it’s working. Although I have to admit, studies have been very limited. We’ve only seen a single publication and a presentation at a conference. Anyway, their rationale is that by stimulating some nerves in the periphery, on the arm in this case, you confuse the pain system in the brain. So the brain focuses on the stimulation that receives on the arm and not on the pain that comes from the trigeminal system, which is the system involved in migraine.


Dr Jessica Briscoe [00:27:51] Yeah, it’s an interesting one. We’ll have to see how that one goes.


Dr Anna Andreou [00:27:57] Exactly. Still early days for that one. So we have to be a bit cautious.


Dr Jessica Briscoe [00:27:59] Absolutely. So where did these devices come from? Why did they decide to start using these sort of neuromodulators- non-invasive modulators? Do you know what the history was behind it, at all?


Dr Anna Andreou [00:28:15] Well, you have to imagine that this type of Neuromodulation techniques have been around for many, many years. For example, TMS has been around for over 30 years. The stimulation of the vagus nerve has been used in many, many other disorders before being trialled in migraine. And essentially the Cefaly device is no more than a tens machine as we use it. Some people may be aware of a tens machine, a transcutaneous electrical stimulation machine, if they had, for example, any back pain and they use some, you know, small leads with some plasters on the back just to stimulate the muscles and feel some relief. So all of the techniques have been around for many, many years and trialled in many other disorders. So I think it was a matter of time before someone tries them in the migraine field. Of course, it has to do with the rationale of why we use them. So the Cefaly device is meant to apply peripheral stimulation on a branch of the trigeminal nerve- the supraorbital nerve, which is thought to be activated during a migraine attack. Then the electrical machine, the vagus nerve stimulation machine is meant to stimulate the vagus nerve. So the vagus nerve it’s a bit tricky to understand because the nerve projecting from the brain down to the body, to the heart, the digestive system, the immune system.


Dr Jessica Briscoe [00:29:52] It’s the wandering nerve, isn’t it, it kind of goes everywhere.


Dr Anna Andreou [00:29:55] It’s an autonomic nerve. It’s involved in many, many different processes. When you speak with experts of the vagus nerve, they are going to tell you that it’s very, very difficult to stimulate it peripherally actually. The earlier vagus nerve stimulation devices were actually invasive ones, especially when they were first used in epilepsy and they were quite successful in epilepsy. But the idea behind it is that the vagus nerve in the brain can indirectly interact with migraine related centres and it can then modulate the activity of the pain system that is involved in migraine. Now the TMS machine, the Spring TMS is a completely different it has a completely different mode of action because it’s the only machine that actually stimulates the outer part of the brain, what we call the cortex, and more specifically at the back of the head. So we call this the occipital cortex. And what we know about the occipital cortex is that it’s an area that becomes hyperactive in migraine patients, so it’s quite hyperactive in chronic migraine patients, but also becomes hyperactive during migraine attack. So the idea behind it is that this technique will lower that hyperactivity. And over time, it seems that it can modulate it to a more natural level let’s say.


Dr Jessica Briscoe [00:31:33] Yeah, it’s interesting. Because you’ve done a fair amount of research into the sTMS, haven’t you? So I think that’s probably what we were going to focus on a little bit.


Dr Anna Andreou [00:31:43] Yes. We’ve done a lot of research with sTMS.


Dr Jessica Briscoe [00:31:49] Because one of the questions that people often ask us is, well, how will you know whether it’s going to be helpful for you, are there some patients or some patient groups that it seems to work better in? So is it better for episodic migraine or chronic migraine or does it not particularly matter?


Dr Anna Andreou [00:32:07] Well, in our clinic, we have tried or we have patients who have tried all three different techniques. So having said that, we have to mention that the patients we usually see at the headache centre are very difficult to treat patients, usually they have tried many other treatments and they fail to respond to the treatments. So they have a more complex biology. Their migraine biology is more complex. So in these patients, we haven’t actually had any good success with the Cefaly device. And Cefaly, as I said, it may be a bit of an expensive machine on the net, but it’s the same as a tens machine. So you could actually get a much cheaper transcutaneous electrical stimulation machine and try the same way. And again, we didn’t see any good response to it. The electrical device with the vagus nerve stimulator, again, we didn’t have any good experience with it, but it could be beneficial in less complex patients. Maybe it’s just the population of the patients we tested it on.


Dr Jessica Briscoe [00:33:24] Potentially. I mean, we haven’t particularly got numbers, actually, cause we haven’t correlated them yet. But I’ve definitely spoken to a handful of patients that find the Cefaly quite useful. But they do tend to be the less refractory patients so the ones that haven’t tried lots of different medications and found no success with them. So yeah, I think I can completely understand that for more complex biology-


Dr Anna Andreou [00:33:48] And I think this is one of the points we have to make. It is worth trying these devices earlier in the treatment pathway, a lot of them can be quite cheaper actually than other treatments. Like Botox, for example. So maybe introducing them earlier in the treatment pathway of a patient.


Dr Jessica Briscoe [00:34:09] Yeah. Rather than as a last resort, which is what I think people are sometimes doing.


Dr Anna Andreou [00:34:13] Exactly. And also, they don’t have the side effects that other treatments have. So some patients actually may prefer to try these treatments rather than trying just another oral tablet or going through an invasive procedure that involves injections, you know, either multiple injections or injections with side effects within the CGRP antibodies.


Dr Jessica Briscoe [00:34:33] Yeah, absolutely. How long do people need to try them for before they can decide whether they’re effective?


Dr Anna Andreou [00:34:43] Well the consensus is that the patients have to try it for three months before we can actually conclude that the treatment is effective or not. And it does make sense because we’re trying to change the way the neurosystem involved in migraine has been behaving, and this neurosystem has been behaving in such a way for a long period of time. So patients need to understand that it does take time to actually reverse that hyperactivity of the neurosystem in migraine. So usually a three month period is what it takes to actually see an effect. And what we always tell our patients is that they have to be persistent. They have to keep using the device, and eventually they will see the benefit of it if they are good candidates. You did mention earlier and you asked me, how do you know if it’s going to work? Well, it’s very difficult. Usually we don’t know if it’s going to work. So, for example, the TMS device, which is the one that we found to be the most effective in the patient population, we’ve trialled it. We have success between 50 to 60% of the patients will actually find it effective and they will be willing to keep using it. We have patients that have been using it for over two years now and they’re doing quite well on it. Yes.


Dr Jessica Briscoe [00:36:08] Those are quite good numbers actually. 50 to 60% for any migraine treatment is actually very very good.


Dr Anna Andreou [00:36:13] I think it is, I mean, if you think about it, it’s about to compete with, you know, Botox and even the new CGRP antibodies, isn’t it? Yeah. So essentially the way we try to prescribe it to patients is that if a patient has a migraine with aura, but also if they are hypersensitive to light, I mean, most patients are but if they have more light sensitivity than the average migraine patient, usually we will prescribe the TMS device. Also, we found that a subset of migraine patients with what is called vestibular migraine also benefit from this treatment.


Dr Jessica Briscoe [00:36:53] That’s interesting as well because we’ve done an episode on vestibular migraine and they can be- and I’m not sure if it’s also because it traditionally takes a bit longer to diagnose vestibular migraine, but actually they can be a group that don’t always respond to treatments quite as quickly. So it’s quite nice to have another option for that group of patients.


Dr Anna Andreou [00:37:13] That’s true. And usually they do come with more, you know, they experience more side effects. So we found that the TMS device actually has a very good effect in this group of migraine patients.


Dr Jessica Briscoe [00:37:28] That’s really interesting. Are any of these available on the NHS?


Dr Anna Andreou [00:37:32] Well, yes and no. So the Cefaly device, my understanding is, is that it’s not available on the NHS, but patients can purchase the device through the internet and obviously they can follow this treatment with the guidance of their doctor. I don’t think any doctor will have any problem with their patient using or trialling the device and they can advise on its use. The electrical device is available for migraine patients, but usually it involves the doctor doing what is called an individual funding request. So unfortunately, although these devices are approved by NICE, they didn’t come with funding. So the doctors usually have to request for an individual funding in order to prescribe this device to their patients. The eNeura TMS device, on the other hand, also didn’t come with funding during the NICE approval. However, in our headache centre and I believe we are the only headache centre that manages to get commissioners to fund the treatment and that made it very easy for us to actually provide it as an NHS free of charge treatment to a big number of patients.


Dr Jessica Briscoe [00:38:51] So, we talked a little bit about the past, the history of non-invasive stimulation and a bit about what’s around at the moment. How about the future? Are there any more potential targets or things that could potentially be coming out that could be helpful for migraine that you’re aware of?


Dr Anna Andreou [00:39:10] That’s a very good question. I’m not aware of actual active trials at the moment. But essentially, I think the future will come or may come with modifications of the current available non-invasive techniques. For example, one of the disadvantages, if you want to say that, for the TMS, is that the actual stimulation is always the same. So we cannot adjust the stimulation to the patient. So with these devices in the future may come with an individual stimulating parameters for each patient. So we can individualise the treatment. And actually these days in depression, they’re trialling the TMS device with a different type of stimulating paradigm, this called the theta-burst stimulation, and they found it quite attractive. So maybe the migraine field will be the next one to try this type of treatment with the vagus nerve stimulation. One of the arguments that is around the field is that the stimulation is not enough to actually stimulate the vagus nerve. So it’s very, as I said earlier, it’s very difficult to stimulate the vagus nerve peripherally. And when you speak with experts, experts will tell you, ‘oh, actually the patients don’t lose weight during the vagus nerve stimulation then it means that you’re not really stimulating’. And in our patients, we’ve never seen any patients losing weight because of the electrical. So potentially changes will happen again to achieve a better stimulation of the vagus nerve.


Dr Jessica Briscoe [00:41:01] So a few things I was actually thinking as well the sTMS, one of the disadvantages I’ve seen with it is it’s quite heavy actually to hold so I know with the Cefaly they’ve actually changed the shape of it slightly as the years have gone by. I’m sure they’ll be all sorts of design changes over the years, too.


Dr Anna Andreou [00:41:21] Oh, yes. You know what, changes have already happened three times already. And the device became a bit slimmer, a bit lighter, a bit more fancy in its design. But yes, I agree with you. I think as technology moves on and especially you have to imagine that these are engineering devices and the engineering field is progressing massively with new batteries, small batteries, mini batteries. So I think we will see, you know, an easier to use devices in the future as well.


Dr Jessica Briscoe [00:41:56] Great. Well, thank you so much for speaking to me about this today. I think people find it really interesting to learn a bit more about the non-invasive devices that are available.


Dr Anna Andreou [00:42:06] Oh it’s been a pleasure.


Dr Jessica Briscoe [00:42:09] Thank you.


Charlotte Burr [00:42:13] Hi, Nicola. So you’ve been using the Cefaly device. How long have you been using it for?


Nicola [00:42:17] Six months.


Charlotte Burr [00:42:18] Six months. And does it work for you?


Nicola [00:42:22] When I first put it on for the 20 minute cycle, I actually thought i can’t stand this it’s too uncomfortable. And I did it once a day for about two weeks, and then I got used to it.


Charlotte Burr [00:42:34] Okay.


Nicola [00:42:35] So I use it twice a day for 20 minutes as a preventor and during a migraine attack it’s a different programme. It’s an hour and it massages your head and for that hour, you actually don’t think you’ve got a migraine. It’s absolute bliss. And then when it finishes, you really think has it gone? Sometimes it’s not quite as severe at the end as it was at the beginning, or sometimes it’s the same. But you’ve had an hour where you might have dropped to sleep or something like that because it’s very soothing.


Charlotte Burr [00:43:04] So how much do you think it’s sort of reduced- is it more the severity or can it sort of prevent attacks as well?


Nicola [00:43:11] I think it might prevent attacks. It depends what other sort of things you’ve got going on as well. Obviously I’m menopausal so I might be having more attacks because of that. But it’s definitely- for my anxiety if I think I’ve got a headache, will it go into a migraine- which is part of what I have to struggle with as I’m sure other people do. It’s sort of when I’ve used the 20 minute programme sometimes it just resets your brain and it has actually gone then and you think, Oh, it wasn’t a migraine.


Charlotte Burr [00:43:42] That’s fantastic. And it’s quite small now, isn’t it, the device? Do you take it round with you?


Nicola [00:43:48] No, I don’t actually. Some of the pictures you see people sitting up with it on. I have to lie down I’m afraid, it sort of makes me feel a bit funny if I sit up.


Charlotte Burr [00:43:57] Yes. And then you wouldn’t want to let put it on on the tube or the bus.


Nicola [00:43:59] And it actually says don’t drive the car with it on. How would you drive a car with it on?


Charlotte Burr [00:44:05] Yeah. It’s probably very distracting I think.


Nicola [00:44:07] And i think brain does get used to it.


Swati Raina [00:44:10] Is it because of the vibrations?


Nicola [00:44:13] And apparently where they pointer part is is one of the acupressure- because I’m having acupuncture now as well, and that’s one of the points where they would use probably one of the needles. So that’s where it’s massaging in the middle of your forehead. So i tend to- the electrodes that you have to buy they last about ten days, 20 uses because I use it twice a day. It’s part of my routine now. All i can say is it’s definitely worth a try because the initial outlay might seem expensive, but you have it on a 60 day trial. So if it’s not successful, all you would lose was £50 and the Dr was saying to me, well, it’s worth a try.


Charlotte Burr [00:44:57] And it’s worked so…


Nicola [00:44:58] Yeah, I’m trying to promote it to people at work who have migraine as well.


Charlotte Burr [00:45:02] That’s fantastic. Well, thank you for letting us know.


Nicola [00:45:05] People hadn’t sort of heard of it. Funnily enough, when I told my acupuncturist about it, she went away and did some research and someone was told off because she was using it all day long, she loved it that much.


Charlotte Burr [00:45:19] Oh, well, that’s great. And it’s nice to know because obviously some things work for some people and some don’t. So it’s nice to have the options out there. And something that’s not always medicine.


Nicola [00:45:28] And it’s not a painkiller.


Charlotte Burr [00:45:30] Yeah exactly.


Nicola [00:45:30] Because i’m trying to cut down how many painkillers I take. And so therefore, I think, well, I won’t take the aspirin this time. I’ll try it with that first. So rather than just panicking and- not panicking, but you get very anxious.


Charlotte Burr [00:45:42] Well, that’s fantastic. Well, thank you very much for sharing your experience with us.


Nicola [00:45:47] You’re very welcome.


Dr Katy Munro [00:45:50] So thanks for listening to this episode about devices. We hope you found it useful and interesting. We’re going to take a short break from the podcast, but we are planning series three already and will be back later in the summer with some more topics. If you have any ideas on what you’d like us to cover, we’d love to hear from you. Just email info@NationalMigraineCentre.org.uk And keep safe everyone. Bye.


[00:46:19] You’ve been listening to the Heads Up podcast. If you want more information or have any comments, email us on info@NationalMigraineCentre.org.uk. Till next time.


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