Non-Medication Treatments for Chronic and Episodic Migraine: A Systematic Review and Meta-analysis

Abstract

INTRODUCTION: Treatments for refractory and intractable migraine have been of growing interest, particularly given the diversity and utility of novel treatments. Neuromodulators, nerve blocks, botulinum toxin A (BT-A), and surgery for migraine headache all offer new avenues for patients who do not sufficiently respond to conventional therapies or tolerate the side effects of medications. However, no studies have compared outcomes for these treatments. Furthermore, although headache frequency is an important factor that is often analyzed, headache intensity and duration are essential aspects of migraine treatment inherent to quality of life improvement but are often underreported.[1-4] Thus, this study is the most rigorous analysis and the first to compare the effectiveness of these contemporary treatments for migraine based on changes in the frequency, duration, and severity of migraines in adults. METHODS: Pubmed, Embase, and Cochrane Library databases were searched to identify randomized placebo-controlled trials that compared BT-A, nerve block, neurostimulation, or migraine surgery to placebo for preventive migraine treatment. Data on changes from baseline to follow-up in headache frequency, severity, duration, and quality of life were analyzed. RESULTS: After exclusion, there were four studies with 137 patients for nerve block, ten studies with 1857 patients for BT-A, ten studies with 416 patients for nerve stimulator, and four studies with 185 patients who underwent surgical treatment. There was a significant decrease in headache frequency of 5.69 days in patients who underwent nerve block (95% CI: 0.37, 11.01; p=0.04). p=0.04) and 4.58 days in surgery (95% CI: 2.26, 6.90; p<0.001). Headache severity (VAS score 1-3) was significantly decreased in all four treatments. Duration of headaches was significantly reduced for the BT-A cohort by 4.58 days (95% CI: 2.26, 6.90; p<0.001) and the surgery cohort by 0.44 days (95% CI: 0.13, 0.74; p=0.01). Quality of life as demonstrated by MIDAS score was improved significantly for patients who underwent treatment with BT-A (95% CI: 0.31, 0.52; p<0.001). Adverse events were significantly higher in the BT-A group only (95% 0.32, 0.88; p<0.001). CONCLUSION: Of these treatments, only migraine surgery and BT-A significantly improved migraine severity and duration, the first study to do so. Migraine surgery is a cost-effective treatment to reduce headache frequency, severity, and duration without significant risk of complications compared to placebo. BT-A is also effective in reducing severity and duration with improved migraine burden, but is associated with significantly more adverse events and greater lifetime cost. REFERENCES: 1. Moisset X, Pereira B, Ciampi de Andrade D, et al., Neuromodulation techniques for acute and preventive migraine treatment: a systematic review and meta-analysis of randomized controlled trials. J Headache Pain. 2020; 21(1): p. 142. 2. Nagori SA, Jose A, and Roychoudhury A, Surgical Management of Migraine Headaches: A Systematic Review and Meta-analysis. Ann Plast Surg. 2019; 83(2): p. 232-240. 3. Shauly O, Gould DJ, Sahai-Srivastava S, and Patel KM, Greater Occipital Nerve Block for the Treatment of Chronic Migraine Headaches: A Systematic Review and Meta-Analysis. Plast Reconstr Surg. 2019; 144(4): p. 943-952. 4. Bruloy E, Sinna R, Grolleau JL, et al., Botulinum Toxin versus Placebo: A Meta-Analysis of Prophylactic Treatment for Migraine. Plast Reconstr Surg. 2019; 143(1): p. 239-250.