How to Recommend a Neuromodulation Device to your Patient

Learn about the four neuromodulation devices approved for migraine treatment and when to recommend them

While acute migraine medications are available and effective, there are a variety of reasons that the available prescription and over-the-counter options may not be sufficient. Patients might not get enough relief, might be unable to take certain medications because of comorbidities or might experience unwanted side effects. Neuromodulation devices are a new option for migraine treatment with few side effects.

We spoke to Laura Xanders, FNP-BC, about neuromodulation devices and how to decide which one to recommend to your patients.

What are the available neuromodulation devices?

There are four neuromodulation devices currently available:

• E-TNS– an external trigeminal nerve stimulator (Cefaly)
• nVNS – a noninvasive vagal nerve stimulator (Gammacore)
• sTMS– a single-pulse transcranial magnetic stimulator (sTMS mini)
• REN – a remote electrical neuromodulator (Nerivio)

Each device works in a different way, although they all act on nerves to disrupt pain signals. “Each device is slightly different, but all are designed to either prevent or acutely treat migraine episodes,” Dr. Xanders says, “This is a relatively new branch of treatment options for patients within the last few years.”

You can learn more about how each device works and how patients use them in our guide.

Who is a good candidate for neuromodulation devices?

These devices can be great options for patients who are sensitive to side effects, says Dr. Xanders. “There’s a lot of benefit in using a device and especially if you’re somebody who is really prone to side effects,” says Dr. Xanders. “We do have a lot of patients where side effects are the limiting factor for using certain medications, so that’s really one of the bigger benefits is just how well they’re tolerated.”

Dr. Xanders says they’re also another helpful tool for migraine patients to have access to. “It gives more options for the patients, so that they’re not strictly using oral medications,” she says.” That’s especially important because some oral medications come with the risk of medication overuse headache.

These devices can be a good option for people who are worried about drug interactions. “For some patients, I think that the appealing part of these devices is simply the fact that they don’t have to take a medication,” Dr. Xanders says.

It’s important to note that having an implant is a contraindication for using this device as can be a tendency to have skin reactions to things. Cefaly, for example, is contraindicated in patients that have a cardiac pacemaker. You can learn more about specific contraindications for each device in our guide.

How to decide which device to recommend?

Dr. Xanders says she usually presents all the devices a patient is not contraindicated for to see which one a patient is interested in trying. Each device works in a slightly different way and is used by the patient in a different way. For example, the E-TNS device (Cefaly) uses an electrode that a patient applies to their forehead while the REN device is applied to the upper arm.

Her clinic has sample devices so patients can look at each device and see how they work. This can also be accomplished by watching videos on the companies’ websites.

How do patients obtain a device?

Dr. Xanders says the biggest roadblock for these devices is actually getting them in the hands of patients. A primary care provider’s role at this point is writing prescriptions and filling out forms on the device’s website to assist patients. One device, the Cefaly, is available without a prescription on the manufacturer’s website.

Providers can also counsel patients on their payment options since they will have to pay for these devices out of pocket. Patients can generally use funds from a health savings account, and most manufacturers offer payment plans.

How to educate your patients about these devices

Because the devices are so new, Dr. Xanders says the companies provide good educational information for patients on how to use the devices. She also has patients bring the device in so she can watch them use it. “They can tell you that they’re using it, but maybe they’re using it incorrectly,” she says. “It’s good to watch them do it to ensure visually that everybody’s on the same page.”

How to follow up with your patients

Dr. Xanders says you should follow up with your patients in a similar manner to any treatment. She also says to encourage your patients to use the device for at least a month or two to see how the device works for different types of headaches. “I always call it different flavors of headache and seeing which one it seems to be most effective for so they can kind of try to fine-tune their approach,” she says.

Primary care practitioners are essential to identifying and treating headache disorders. The American Headache Society’sFirst Contact – Headache in Primary Care program provides educational resources to empower healthcare professionals and improve headache and migraine care. Learn more about the program here.