Abstract
BackgroundThe debilitating nature of migraine and challenges associated with treatment-refractory migraine have a profound impact on patients. With the need for alternatives to pharmacologic agents, vagus nerve stimulation has demonstrated efficacy in treatment-refractory primary headache disorders. We investigated the use of cervical non-invasive vagus nerve stimulation (nVNS) for the acute treatment and prevention of migraine attacks in treatment-refractory episodic and chronic migraine (EM and CM) and evaluated the impact of nVNS on migraine-associated sleep disturbance, disability, and depressive symptoms.MethodsTwenty patients with treatment-refractory migraine were enrolled in this 3-month, open-label, prospective observational study. Patients administered nVNS prophylactically twice daily at prespecified times and acutely as adjunctive therapy for migraine attacks. The following parameters were evaluated: pain intensity (visual analogue scale [VAS]); number of headache days per month and number of migraine attacks per month; number of acutely treated attacks; sleep quality (Pittsburgh Sleep Quality Index [PSQI]); migraine disability assessment (MIDAS); depressive symptoms (Beck Depression Inventory® [BDI]); and adverse events (AEs).ResultsOf the 20 enrolled patients, 10 patients each had been diagnosed with EM and CM. Prophylaxis with nVNS was associated with significant overall reductions in patient-perceived pain intensity; median (interquartile range) VAS scores at baseline versus 3 months were 8.0 (7.5, 8.0) versus 4.0 (3.5, 5.0) points (p < 0.001). Baseline versus 3-month values (mean ± standard error of the mean) were 14.7 ± 0.9 versus 8.9 ± 0.8 (p < 0.001) for the number of headache days per month and 7.3 ± 0.9 versus 4.5 ± 0.6 (p < 0.001) for the number of attacks per month. Significant improvements were also noted in MIDAS (p < 0.001), BDI (p < 0.001), and PSQI global (p < 0.001) scores. No severe or serious AEs occurred.ConclusionIn this study, treatment with nVNS was safe and provided clinically meaningful decreases in the frequency and intensity of migraine attacks in patients with treatment-refractory migraine. Improvements in migraine-associated disability, depression, and sleep quality were also noted.
Highlights
The debilitating nature of migraine and challenges associated with treatment-refractory migraine have a profound impact on patients
Data suggest that attenuation of pain by vagus nerve stimulation (VNS) occurs via inhibition of signalling through afferent vagus nerve fibres to the trigeminal nucleus caudalis (TNC) [19] and via modulation of inhibitory neurotransmitter release, resulting in decreased glutamate levels in the TNC [20, 21]
All patients were classified as migraine disability assessment (MIDAS) grade III/IV, with most having clinical signs of sleep disturbance and depressive symptoms (Table 2)
Summary
The debilitating nature of migraine and challenges associated with treatment-refractory migraine have a profound impact on patients. With the need for alternatives to pharmacologic agents, vagus nerve stimulation has demonstrated efficacy in treatment-refractory primary headache disorders. We investigated the use of cervical non-invasive vagus nerve stimulation (nVNS) for the acute treatment and prevention of migraine attacks in treatment-refractory episodic and chronic migraine (EM and CM) and evaluated the impact of nVNS on migraineassociated sleep disturbance, disability, and depressive symptoms. Along with premonitory (i.e. aura) and attack-associated symptoms (i.e. phonophobia, photophobia, nausea, and vomiting) [2], patients with migraine are likely to experience sleep disturbances [6, 7] and other comorbidities such as depression and anxiety [8, 9]. Individuals with treatment-refractory migraine require alternatives to standard pharmacologic therapies. Data suggest that attenuation of pain by VNS occurs via inhibition of signalling through afferent vagus nerve fibres to the trigeminal nucleus caudalis (TNC) [19] and via modulation of inhibitory neurotransmitter release, resulting in decreased glutamate levels in the TNC [20, 21]
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