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How to address patient concerns about neuromodulation in migraine
Neuromodulation is a possible alternative to medications for treatment of migraine, but many patients are reluctant to try it. At EHF 2020, Dr Marco Lisicki of the Conci Carpinella Institute, Córdoba, Argentina, presented his approach for prescribing neuromodulation in the clinic.
The aim of neuromodulation is to reverse the pathophysiological changes that are seen in the brain of patients with migraine. External or implanted devices are used to stimulate specific nerves or regions.
Neuromodulation is a possible alternative to medication for either preventive or acute treatment of migraine. It could also be considered as a strategy for patients with medication overuse headache or refractory migraine.
Patients are concerned about side effects
Neuromodulation strategies are generally well tolerated1,2, with fewer treatment-limiting adverse events than some frequently used medications.3 The proportion of patients experiencing these events was similar to nutraceuticals4 and antibodies targeting calcitonin gene-related peptide (CGRP) receptors.5
Patients worry more about side effects than whether a treatment will work
This is a key benefit of neuromodulation over some other options. Patients worry more about the side effects they might experience than whether the treatment will work.
In a study of patient attitudes, clinicians explained to patients the expected side effects of different migraine medications and asked them if they would be willing to take them at different levels of expected efficacy. Even when patients were told their headaches would stop completely, only about 20% to 60% were willing to take the medication.6
Most patients are not willing to tolerate side effects even if a treatment works completely
One of the most frequent reasons for discontinuing preventive treatment of episodic and chronic migraine is side effects. This reason was as common as lack of efficacy, and much more common than discontinuation because the treatment was unsuccessful.7
Communication is key
Some clinicians and patients are not comfortable with the idea of treatment with a medical device rather than a medication. How can their concerns be addressed?
It is important to talk to the patient. Explaining that there is an evidence base for neuromodulation and it is generally well tolerated empowers the patient. It gives them the information they need to make an informed choice.
You may want to try before you buy
Dr Lisicki suggested an approach they use at their center when they prescribe neuromodulation. Instead of telling the patient to buy a device immediately, they offer the opportunity to test the device for tolerability at one session at the center.
Address patients’ worries through conversation and a trial period
The majority of patients want to continue, so they are then allowed to rent the device for a couple of months. After this, the patient can choose to buy the device, rent it again, or discontinue.
This process ensures patients who are skeptical or uncomfortable with the concept of neuromodulation have a chance to try the treatment without committing to it straight away.
Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.
References
1. Magis D, et al. J Headache Pain 2013;14(1):95
2. Diener HC, et al. Cephalalgia 2019;39(12):1475-87
3. Diener HC, et al. J Neurol 2004;251(8):943-50
4. Schoenen J, et al. Neurology 1998;50(2):466-70
5. Goadsby PJ, et al. N Engl J Med 2017;377(22);2123-32
6. Turner DP, et al. Pain 2016;157(10):2226-34
7. Blumenfeld AM, et al. Headache 2013;53(4):644-55