Check the report in Neurology Reviews March 2015, which is a summary of presentations at the Eighth Annual Winter Conference of the Headache Cooperative of Pacific.

Cefaly is a transcutaneous supraorbital neurostimulator device, indicated in the United States for prevention of migraine. With a physician’s prescription, it can be purchased for around $300. It clips onto the forehead, is battery-powered, and delivers a series of electrical pulses and should be used 20 minutes a day. Almost 40% of patients had a reduction in migraine days per month of at least 50%. About half of the patients were dissatisfied, either because of lack of effect or uncomfortable paraesthesias from the stimulation. It may be increasingly effective with continuous use over months.

Transcranial magnetic stimulation has been approved by the FDA since May 2014 but is not available for general use yet. It has been tested as a preventative device and also to treat each headache. It seems to work only in patients who have migraine with aura. It is a handheld wand-like device and placed close to the skull and patients activate it with 2 pulses within 1 hour of the onset of the visual aura. Data are mostly but not consistently positive in clinical trials.

Vagal nerve stimulation is a new noninvasive technique for cluster headache. It is a device held over the vagal nerve in the left side of the neck. Stimulating that nerve has been shown to be effective in patients with intractable epilepsy. In that disorder, the device is implanted, but with cluster, it is noninvasive. It is designed to treat each attack, rather than as a preventative. One in 4 patients seems to respond and thus would not need injectable sumatriptan or oxygen. The device is approved in Europe and Canada, not in the US at this time.

Occipital nerve stimulation has been used for years. It is well established that occipital nerve blocks with local anesthetics can block cluster headaches, and these injections can be given every several days until the standard oral medications start to work. There is also an implantable occipital nerve stimulator that gives continuous pulses to the occipital nerves, presumably blocking their activation. This technique is unlikely to be widely used because there are problems with electrode migration, cable discomfort, muscle spasms, infection, battery depletion.

Deep brain stimulation consists of various techniques, targeted at different disorders, mainly Parkinson’s. It is also used to treat intractable cluster headaches, with stimulation targeted at the hypothalamus. It seems effective but should be considered a “last resort,” as there are significant risks, including cerebral hemorrhage and stroke.

Jack Florin, MD

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