"The Queen's Migraine" by Kinga Britschgi.

 

    (After this article appeared on my blog, Costco and Amazon removed the product from their sites.)

    Cefaly's promotional materials characterize this little battery-powered device as "innovative" and "highly effective." But if you dig up its clinical-trial data, you will find that it produced a "therapeutic gain" of just 26 percent. If your doctor prescribes Cefaly, he probably won't provide you with this information. He probably won't know anything except for what the sales rep told him ("It's a miracle!"). And he may very well not know that the FDA acknowledges "mild to moderate risk" to users of Cefaly, a "novel invention" which "is not substantially equivalent to any already legally marketed device."  Are you feeling reassured?

 

     Migraines affect nearly 30 million Americans, according to the National Headache Foundation. "Each migraine can last from four hours to three days. Occasionally, it will last longer," WebMD says.

    "I am concerned about the safety of allowing brain stimulation devices loose on the public, without prior efficacy or safety limits," said Mark George, director of the Medical University of South Carolina's Brain Stimulation Laboratory. "We need to proceed cautiously."

     Something is obviously amiss for a medical device that requires a prescription, and was only approved in the U.S. a few days ago, to have been available without a prescription through U.S. retailers since 2011. The "Cefaly® Anti-migraine Device," offered by Amazon and distributed by Lynda Medical Shop, makes claims that go well beyond the FDA approval. The product "provides a prevention treatment program to increase the production of endorphins and raise the trigger threshold of the pain for a result of less frequent migraines...It blocks pain & provides relief during a migraine."  None of the italicized statements has been authorized by the FDA, and in fact the device is not supposed to be used during a migraine. It has received one 5-star review, one 2-star and one 1-star on the Amazon site. The same photo is used by Amazon for the "Cefaly set: Anti-Migraine and Anti-stress" product. This one cleverly omits the trademark sign. Its descriptive material says: 

 

• Frequent headaches, anxiety and stress? Cefaly can change your life
• With its pleasant stimulative effect, it inhibits pain, arrests headaches, calms anxiety and soothes stress.
• A few sessions a week are all that's needed to restore your well-being, clear your head and alleviate stress.

   To quote Ricky Riccardo: "Somebody's got some 'splaining to do."    

    That simply is not true true.  In fact, it's such a blatant and easily contradicted statement that I can't believe Cefaly made it. As I wrote in this post (http://kronstantinople.blogspot.com/2013/09/our-future-everything-in-modulation.html), researchers around the world are developing and have developed external neurostimulation devices to treat a wide range of conditions, including depression, tinnitus, insomnia, anxiety, pain, and several others.  I'll review these efforts at the end of this article. Here is just one of them, by California-based Neurosigma:

The concept is the same as Cefaly but uses a different design.

External trigeminal nerve stimulation.

    It is a fascinating field of study, filled with promise and peril, but it was going strong long before Cefaly got into the picture. In fact, Cefaly's TENS technology was first used in migraine research in 1980.

 

THE PROOF IS IN THE NOGGIN 

 

 

 CEFALY IS NOT "THE FIRST" EXTERNAL NEUROSTIMULATION DEVICE

    There are many external neurostimulators that precede the Cefaly product. For example, at the push of a button, the device shown below gives out two fleeting bursts of electricity, which short-circuit the "electrical storm" in the brain that causes the splitting pain, flashing lights and blurred vision associated with migraines, according to the manufacturer. 

    It has been approved in Britain by The National Institute for Health and Care Excellence, or NICE, according to media reports two months ago. "Single pulse trans-cranial magnetic stimulation is a wonderful example of clinical and laboratory research delivering a real improvement in migraine treatment that is both effective and extremely well tolerated," Professor Peter Goadsby, chair of the British Association for the Study of Headache, and director of the National Headache Centre at King's College Hospital in London, says.

    In a November, 2013 article, "Jumper Cables for the Mind," New York Times reporter Dan Hurley describes undergoing transcranial direct-current stimulation, or tDCS, an experimental technique for delivering extremely low dose electrical stimulation to the brain. (http://www.nytimes.com/2013/11/03/magazine/jumper-cables-for-the-mind.html?hpw).  

    This is another technology that preceded Cefaly's "first" external neurostimulation device.

    "Using less than 1 percent of the electrical energy necessary for electroconvulsive therapy, powered by an ordinary nine-volt battery, tDCS has been shown in hundreds of studies to enhance an astonishing, seemingly implausible variety of intellectual, emotional and movement-related brain functions," he writes. 

    J. León Morales-Quezada, senior research associate at Harvard’s Laboratory of Neuromodulation, is conducting experiments on the ability of this therapy to improve the speed and accuracy with which people perform attention-switching tasks. It is showing promise in several areas of brain function, and has the advantage of not requiring implantation.

 

THE NEW "FOCUS" ON STYLE AND MIND

    Electric neurostimulators have been used for years in therapy and as an adjunct to exercise, but a new device from Focus Labs claims to “increase the plasticity of your brain,” using transcranial Direct Current Stimulation (tDCS). 

 

 

Another stimulator with a definite "coolness" aspect.

 

    The $250 headset, which is not FDA-approved because it is not marketed as a medical device, sends anywhere from 0.8 to 2.0 milliamps of electrical current to your prefrontal cortex for 10 to 40 minutes. It went on the market last May.  It does have physiological effects, which range from mild tingling to headaches and mood changes.  

    And I wrote about off-the-shelf technology that you can use on your own brain to do who-knows-what? Just mess with yourself!(http://kronstantinople.blogspot.com/2014/08/shock-treatments-can-off-shelf-brain.html)

 

THIS THING'S GOT GAME

    "It’s mostly geared toward video gamers who want to improve their hand-eye coordination and get an edge on opponents, but if the system really does improve individual performance, perhaps one day we’ll see it used by clinical specialists like surgeons and trauma docs during procedures to improve focus and prevent mistakes. It’s controlled via Bluetooth through an iOS device like an iPad or iPhone, and you can set the strength of the current and duration for your particular needs," the Focus site explains. 

 

Saline solution on sponges helps prevent burning of the skin.

     Amit Etkin, an assistant professor of psychiatry and behavior sciences at Stanford University, says the safety of tDCS has not been verified.

    "It's true that tDCS has been used in studies and even shown substantial positive effects on patients," said Etkin, whose clinic specializes in transcranial magnetic stimulation, a depression treatment that is highly regulated and poses a slight risk of seizure. But, he noted, "The worst-case scenario is that a bunch of users who don't have specific instructions will use it in a variety of different ways and alter their brains in ways that they don't anticipate and we don't anticipate." 

GENTLY LIBERATING NEUROTRANSMITTERS 

    Then there is the Fisher Wallace Cranial Stimulator, which is aggressively marketed to treat depression, anxiety and insomnia. This device has been FDA cleared since 1991 for the treatment of insomnia, anxiety and depression, according to its web site. It works by "gently stimulating the brain's production of serotonin, beta-endorphin and other neurochemicals required for healthy mood and sleep."  Like the Cefaly product, it involves external neurostimulation.

    "Multiple published studies demonstrate the safety and effectiveness of the technology, which is typically used by patients for 20 minutes, twice a day (once in the morning and once before bed)," the web site says.  

    Research suggests that the electrical current from the Fisher Wallace device targets the limbic system, which contains brain structures linked to the experiencing of emotions, and that it stimulates the release of the feel-good neurotransmitters dopamine and serotonin. the site claims.

    Chip Fisher bought the patent three years ago and now manufactures the device at his own laboratory. He said he believes that his device might be beneficial for disorders as varied as obsessive-compulsive disorder, drug addictions, attention deficit hyperactivity disorder, post-traumatic stress disorder—and, in fact, "anybody with a brain."

 

"Migraine" mosaic by Boehringer Ingelheim.

 

AND HERE WE GO AGAIN WITH THE VAGUS NERVE

     Cyberonics, whose invasive, problematic VNS system has undoubtedly deterred many potential customers -- has seen the light, and has developed an alliance with CerboMed, a private company based in Erlangen, Germany. Its NEMOS t-VNS system, which includes an earplug-like device, is designed to stimulate a branch of the vagus nerve in the outer ear by sending a pulse through the skin. 

Isn't this a bit nicer than having a wire wrapped deep inside your neck?

    CerboMed’s device has received clearance for marketing in Europe for patients with epilepsy, depression, and pain, but is not yet approved in the U.S. In September 2013, Cyberonics said it had made an initial investment of about $2.6 million in Cerbomed and gained an exclusive option to market the NEMOS device worldwide as an epilepsy treatment.

   In a clinical trial in Germany, "Five of the seven patients who applied t-VNS for nine months showed a reduction in seizure frequency." This information is obviously not adequate to enable a prospective patient to make an informed decision. How much reduction? How severe was the disease in those studied?

   The transcutaneous therapy is also being tested in migraine patients. 

 

"Fragmentation" by Frederic Durville

   Cyberonics’ VNS system already dominates the market in devices for epilepsy. Some 100,000 people worldwide have received its relatively primitive and permanent implant. Think how they must feel, knowing that the wire that is gripping a nerve deep in their necks is unnecessary? 

ANOTHER NONINVASIVE APPROACH FOR DEPRESSION AND EPILEPSY

      Another intriguing, nonsurgical option: Los Angeles-based NeuroSigma received EU certification last year for an external trigeminal nerve stimulation (eTNS) system for the adjunctive treatment of epilepsy and major depressive disorder for adults and children aged nine years and older, according to Medscape.

    The device has been evaluated in clinical trials conducted at the University of California, Los Angeles (UCLA) and the University of Southern California. It consists of an external pulse generator and disposable electric patches placed on the forehead that are replaced daily and must be worn for 12 hours a day.

    But in the clinical trials, the improvement rates "did not achieve significance," according to a 2013 Medscape article. Only 30 percent of patients responded to the treatment.

    The study, the first randomized, active controlled trial of external trigeminal nerve stimulation in drug-resistant partial seizures, was published in the February 26 issue of Neurology. The lead investigator was the vice president of NeuroSigma.

    Commenting on the results for Medscape Medical News, Gregory Bergey, MD, from Johns Hopkins Epilepsy Center, said, "These things need more study." 

 

Portrayal of epilepsy by Hieronymous Bosch.

    An accompaning editorial stated: "The beneficial effect demonstrated by DeGiorgio et al. was modest but is sufficient to encourage design of a more definitive study." 

    "As a non-invasive neuromodulation therapy, trigeminal nerve stimulation may represent a paradigm shift in the way we treat major depression and offers the potential to significantly improve the lives of millions of people without the side-effects common to medication treatment," said UCLA's Ian A. Cook, MD, who led clinical and human mechanism of action studies of the device in depression. 

 

A TREATMENT WITH REAL MAGNETISM

    Yet another contestant in this race to the pot of gold is Neuronetics' Neurostar mechanism, which uses a highly focused pulsed magnetic field, similar in type and strength to those produced by a magnetic resonance imaging (MRI) machine, to stimulate cortical neurons.

 

    Another promising example of external neuromodulation comes from New Jersey-based ElectroCore, maker of the handheld gammaCore device. The firm conducted clinical trials on the use of vagus nerve stimulation to treat migraine headaches. The attractive little invention  also holds promise for such disparate conditions as coma, irritable bowel syndrome, asthma and obesity, according to Scientific American.

ElectroCore's device treats migraines and is being tested for tinnitus.

     The results of ElectroCore's trial, which involved only 21 volunteers, were presented in July month at the International Headache Congress in Boston. Eighteen of the test subjects reported a reduction in the severity and frequency of their headaches, rating them, on average, 50 per cent less painful after using the device daily and whenever they felt a headache coming on.

    The device also appears to stimulate the release of inhibitory neurotransmitters, which counter the effects of glutamate, Scientific American added. This is a neurotransmitter, which is pertinent to the treatment of depression.

 

IN CONCLUSION:

    You're not still reading this, are you? God, let's get up and give our cardiovascular systems a little workout, why don't we? I don't know about you, but my butt is totally numb. Take David Bowie's advice:

    The moonlight needs to be serious these days. Everybody with any power is screwing everything up. Poor moon. She used to be radiantly cheerful.

    To wrap things up, I'll just say that research in the field of neuromodulation is exciting and promising on one hand, and profoundly troubling on the other. This is dangerous territory -- playing around with our brain circuitry -- and we need regulators who are committed to ensuring our health and safety. We don't have them. We have bureaucrats who are some combination of overworked, complacent and morally compromised.

    Patient: Beware.