This treatment is serendipitous, so I’ll add some background information on how I came to it. As shown by my other blogs, in the last year I’ve been especially interested in electric muscle stimulation (EMS) to help recovery by accelerating strength gains better than exercise alone. A number of my knee and back pain patients commented that the EMS helped with pain better than my earlier use of transcutaneous electrical nerve stimulation (TENS), which is basically the same thing as EMS but with shorter pulses and/or lesser intensity. The intention of TENS being to control pain rather than restore muscle. I had a patient with low back pain that had a near full recovery of strength, but had a persistent 1/10 pain which was reduced but not eliminated when using TENS. I mentioned he might want an electric stim machine for home; I had just started using it for core strength and thought it might help him strengthen since his pain level plateaued. After using EMS for 12 minutes to his abdominal muscles as well as low back, he said he was pain free for the first time. Soon after I read a study using EMS for low back pain that used similar pad placement and parameters for patients with low back pain. I have been successfully using that method as part of my treatment for my low back pain patients ever since. Around the same time, I had a patient come in who had just suffered a stroke, and had severe neuralgia in one of her legs, confining her to a wheelchair. She wasn’t able to tolerate any exercise with that leg because it was hypersensitive to pressure, so I figured I would try EMS on it and she would either like it or hate it. Turns out she loved it; it immediately and substantially decreased her pain, she was walking later that hour, and had full recovery of leg strength, endurance, and gait in about a month. She asked me if it would work for headaches. I said I would do some research and this is the first paper I came up with:
Abstract
A headache is a common neurological disorder, and large numbers of patients suffer from intractable headaches including migraine, tension headache and cluster headache, etc., with no clear therapeutic options. Despite the advances made in the treatment of headaches over the last few decades, subsets of patients either do not achieve adequate pain relief or cannot tolerate the side effects of typical migraine medications. An electrical stimulation of the peripheral nerves via an implantable pulse generator appears to be good alternative option for patients with treatment-refractory headaches. A number of clinical trials show considerable evidence supporting the use of peripheral nerve stimulator (PNS) for headaches not responding to conservative therapies. However, the mechanism by which PNS improves headaches or predicts who will benefit from PNS remains uncertain. The decision to use PNS should be individualized based on patient suffering and disability. Hence, further work is imperative. Here, we discuss the mechanism, indication, efficacy, implant technique, and complications of PNS.
The data from the paper sounded good, with the following taken from the outcomes:
“Since 1999 a number of studies have shown the efficacy of effective treatment of intractable headaches using PNS. Weinert and Reed showed 80% success in a group of 62 patients with intractable occipital headache [55]. For occipital neuralgia Slavin et all., determined that 70% of patients experienced pain relief [42] while Melvin et al., reported that 91% of patients experienced a reduction of medication need [43].”
“Propency and Alo reported significant improvement in headache frequency, severity, and disability (migraine disability assessment score [MIDAS]) in 25 patients with chronic disabling transforming migraine with ONS [54]. The average improvement in the MIDAS score at the 18 month follow up was 88.7%.”
“Magis et al., presented a prospective pilot study on occipital nerve stimulation for drug-resistant cluster headaches. In their study two patients (n=8) were pain free after a follow up at 16 and 22 months, and three patients experienced a 90% reduction in attack frequency. The intensity of attacks improved by 50%, and all but one patient was able to substantially reduce their preventative drug treatment [57].”
With results that good, it makes you wonder why everyone suffering with severe headaches wasn’t having PNS. The problem is that the PNS electric stimulators were surgically implanted with wire leads placed alongside the occipital nerve at the base of the skull. There were a number of serious complications including infection and lead migration (when the wire planted alongside the nerve shifts). Plus, the surgically implanted battery pack only has a 3-5 year life span, and the rechargeable version has a 10 year span. So while the PNS treatment seems very effective, I can’t imagine many headache sufferers would be willing to go that route.
I figured the occipital nerve is very superficial and should be easy to stimulate with my EMS unit by placing the electrodes high on the posterior aspect of the cervical spine. I was already using large rubber carbon electrodes rather than sticky gel electrodes so there was no interference with the patients’ hair, and they are effectively held in place by a snug but not tight 4” wide elastic strap around the neck. I used my favorite EMS settings that worked for me better than TENS with the low back pain and neuropathic hypersensitivity. At worst I figured I would increase the strength of the suboccipital muscles and posterior cervical extensors, which would be better than nothing. I had a knee patient come in complaining of a 10/10 headache saying she didn’t think she would be able to do her exercises. I suggested we try EMS and 12 minutes later her pain was gone and did not return. A few days later another patient being treated for low back pain had an 8/10 headache, I stimmed her suboccipital region and 12 minutes later it was a 2/10 and later resolved. So I started offering a free EMS treatment to anyone with a current headache. I have been keeping and recording the results in a spreadsheet. This is my result thus far:
[table id=5 /]
So far, nobody has reported increased pain and only one patient had no immediate improvement (we later found via MRI that this patient’s headaches were due to severe multi-level cervical stenosis). Twelve of the 21 had complete relief of headaches immediately following the treatment. Most patients comment that the EMS is comfortable and removes the aura associated with migraines as well as the headache. Some have said when they stim while first experiencing an aura it stops the migraine from coming on. Some have tried the EMS with lower intensity stimulation with modest effect and tried it again later with increased intensity to have their pain fully resolved. Pain reduction or elimination has ranged from relief lasting several hours, to several days, to headache pain not returning at all.
Since then I have modified my treatment parameters to see if they improve results. I have been reading more papers, including some from back in the 80s when they were doing traditional TENS for headaches and were finding positive results as well, though that research seems to have been forgotten. I’ll do some blogs on them to talk about what can be learned, good or bad, from prior and upcoming research as well as updates from my data collection. So far I’ve been collecting data with reference to immediate reductions in pain once the headache is there, but going forward I’ll also be looking at more at specific parameters in the older TENS and current PNS studies and combining that with my surface EMS to see if that affects frequency and intensity of future headaches.
In the meantime if anyone local to my office has a current headache and wants to be part of my study and see if EMS works for them please call the office and we’ll try to get you in for an immediate and free appointment to try it out. In the future I’ll likely be adding a placebo/control group to control for the power of suggestion, but at this point I’m collecting preliminary data you’re sure to get what I think works best.
Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.
Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.
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