Neuromodulation in Migraine: The Effective Non-Pharmacological Option

Pharmacological options do not suit everyone, and this is especially true in chronic conditions such as migraine. While it is true that significant advances in migraine management have come from newer and safer medications such as CGRP-targeting medications, there remains a significant need for non-pharmacological options. This need arises either due to medication intolerance and side effects, or due to personal beliefs about avoiding daily or routine medications.

Thankfully, neuromodulation has evolved to bridge this gap.

What Is Neuromodulation?

Neuromodulation is the use of controlled electrical or magnetic stimulation to modify the function of certain nerve pathways, with the goal of achieving positive effects such as pain relief.

This technique is not entirely new—its history dates back to the late 1800s, shortly after electricity could be generated and stored. At first, neuromodulation was explained by the “gate control theory of pain”: the idea that stimulating non-painful nerves can “close the gate” to painful signals (similar to why rubbing a cut can reduce its pain).

Today, research has shown that neuromodulation works through more complex mechanisms, including:

• Modifying neurotransmitter release.

• Altering nerve excitability.

• Changing how pain pathways in the spinal cord and brain process signals.

Benefits of Neuromodulation for Migraine

Neuromodulation offers several unique advantages that make it an appealing treatment option:

1. Non-pharmacological: While no treatment is completely free of side effects, neuromodulation provides relief without the need for pills—ideal for patients with medication intolerance or multiple health conditions.

2. Self-administered: Most neuromodulation devices can be used by patients at home, maximizing convenience and autonomy.

3. Rescue and preventive therapy: These devices can be used acutely to abort migraine attacks or regularly to reduce their frequency.

4. Safe and well-tolerated: Neuromodulation devices generally have minimal safety concerns, and long-term use has not been linked to serious adverse effects.

Common Neuromodulation Devices for Migraine

Several neuromodulation devices are currently FDA-approved or cleared for migraine management. We will review each of these devices in future articles, and discuss how they work and their specific use. These include:

1. Transcutaneous Supraorbital Neurostimulator (Cefaly®)

• Targets the supraorbital nerves located above the eyes.

• Can be used daily for prevention or during acute attacks as a rescue therapy.

• FDA-cleared and available without prescription.

• Not recommended for patients under 18 or those with metallic implants (e.g., pacemakers).

2. Transcranial Magnetic Stimulation (TMS, eNeura®)

• Uses a magnetic coil to interrupt abnormal brain activity associated with migraine.

• FDA-approved for both prevention and acute treatment.

• Prescription required; coverage may be available through insurance.

3. Non-invasive Vagus Nerve Stimulator (gammaCore®)

• Applied externally to the vagus nerve in the neck.

• Helps deactivate the “fight or flight” response and counteracts migraine-related physiological changes.

• FDA-cleared for both acute and preventive treatment.

• Covered by some insurance plans, including VA benefits.

4. Remote Electrical Neuromodulation (REN, Nerivio®)

• A wearable device placed on the upper arm, controlled via a smartphone app.

• Stimulates pain-sensitive fibers in the arm to reduce migraine pain through central pain modulation.

• FDA-cleared for acute migraine treatment.

Who Should Consider Neuromodulation?

Neuromodulation may be especially beneficial for:

• Patients who cannot tolerate or do not respond to migraine medications.

• Individuals seeking drug-free treatment options.

• Those who prefer flexible, on-demand therapy that can be used at home.

Summary

Neuromodulation is a safe, non-pharmacological, and effective option for migraine treatment. With multiple FDA-cleared devices—including Cefaly®, eNeura®, gammaCore®, and Nerivio®—patients now have more choices than ever before to manage migraine both preventively and acutely.

By offering drug-free pain relief, neuromodulation provides hope and flexibility for those who struggle with traditional migraine medications.