FDA Approves Wearable Device for Migraine Prevention

By Pat Anson, PNN Editor

A wearable neuromodulation device has been approved by the Food and Drug Administration as a preventative treatment for migraine. In a recent study, the Nerivio device significantly reduced the number of migraine days per month in patients with episodic and chronic migraine.

Nerivio is worn on the upper arm and controlled by a smartphone app. It uses mild electrical pulses to disrupt pain signals in the brain without the use of drugs. The device has previously received clearance from the FDA as an acute treatment for migraine in adults and children over age 12.

"Nerivio already has a well-established efficacy and safety profile in acute migraine treatment," said Andrew Blumenfeld, MD, Director of the Los Angeles Headache Center and co-author of the study published in the journal Headache. "Effective preventive treatment is key to managing migraine, but it is often underutilized.”

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The randomized, placebo-controlled trial involved 248 migraine sufferers who used either Nerivio or a placebo device for 45 minutes every other day. Those who used Nerivio experienced a mean reduction of 4 migraine days per month, compared to a reduction of 1.3 days in the placebo group. Participants also experienced statistically significant reductions in the number of days they required acute migraine medication.

“The trial data demonstrates Nerivio can now cover the full treatment spectrum and provide access to migraine prevention and relief, especially for the adolescent population, who have a strong preference for clinically effective, drug-free treatment solutions. With FDA clearance of the device, its availability and potential use for preventive and acute treatment is welcome news for both physicians and patients," Blumenfeld said in a statement.

Like most new migraine treatments, Nerivio can be expensive, with the wholesale price currently listed at $599 for a 12-treatment unit. Out of pocket costs will be less if the device is covered by insurance or if patients enroll in Nerivio’s Patient Savings Program. A prescription is required.

With Nerivio’s new dual-use indication, patients may use the device more often to proactively prevent migraines. To better support existing and new users, the number of treatments per unit is being expanded from 12 to 18 treatments.

The Nerivio app allows patients to customize their treatment, receive reminders for preventive treatment, track their migraine patterns, and share migraine data with their doctor. The app can also leads users through a Guided Intervention of Education and Relaxation, using techniques such as diaphragmatic breathing, muscle relaxation and guided imagery.

Nerivio is made by Theranica, a medical technology company based in Israel, which estimates the device has over 40,000 users in the United States. The company is investigating whether the device may help treat other chronic pain conditions besides migraine.

Thinking Outside the Pill Box: Another Approach to Pain Management

By Alon Ironi, CEO, Theranica Bio-Electronics

Well into my adulthood, I struggled with chronic back pain. I took medication after medication, finding myself getting sucked into the habit of popping painkillers and wondering why my pain wasn’t healing. I eventually discovered the psychological and mental elements inherent in chronic pain, and shifted my approach to pain management, which rapidly cured my back pain.  

The holistic approach to healing pain has historically been ridiculed in the medical community, preventing many physicians from recognizing the legitimacy of alternative treatments. The time has come to evolve beyond just popping pills to treat pain, towards a biopsychosocial perspective.  

The discovery and introduction of penicillin in 1928, marked the very beginning of medication popularization in the West. The development of new medications – for a wide range of uses - has extended life span and improved quality of life.  Unfortunately, the benefits associated with medication have encouraged its frequent use for disorders it simply is not meant for, such as certain types of chronic pain.  

Medication overuse headache is one example where drugs intended to treat migraine and headache can, with excessive use, lead to the deterioration of the exact condition they are supposed to be treating. Medication is an incredible tool when used properly, but it’s not the only tool, and it can be seriously harmful when misapplied.

What is Pain and How Do We Treat It? 

Pain is a unique bodily experience that, unlike other disorders, indicates an underlying issue in one’s physiology. Pain is an alarm system. It tells us that something is wrong, and if we mask it without treating its underlying cause, we might cause a great disservice to our bodies.  

The use of medication to treat short-term acute pain, while a person simultaneously heals from the cause of that pain, like a pulled muscle or a tear in a tissue, makes sense. However, the use of medication in instances of chronic pain - pain that persists longer than three months - is problematic.  

Chronic pain is a debilitating condition that impacts an individual’s everyday life. From migraine to chronic knee pain to chronic back pain, the routine of normal life is disrupted. Often, this chronic pain had an initial cause, such as a surgery, fall or injury that has since healed, but the pain persists long after its source has disappeared. This type of pain, as Haider Warraich, a physician and clinical researcher at Harvard, so aptly puts it, is like “an overlearned traumatic memory that keeps ricocheting around in our brains, often long after the injury it rehearses has fully healed.” 

This perception of chronic pain has its roots in quite a controversial physician -the late Jon Sarno, MD, a professor of rehabilitation medicine in the 1980’s and 90’s. His theories, while not rigorously proven in formal clinical studies, were built upon anecdotal data from thousands of patients he treated during his lifetime and are still being explored today. They have jumpstarted a revolution in our understanding of pain.  

The biopsychosocial model focuses on illness as a complex interaction of chemical and electrical reactions that are induced by biological, psychological and social factors. Contemporary pain researchers, like Lorimer Mosely, a clinical scientist, have applied this model to pain, recognizing that pain is comprised of both physical sensation and emotional stimulus, such as the fear of pain itself.  

Pain is no longer perceived as entirely “physical” in nature. It is now understood to be exacerbated by the fear of tissue damage and the aversion to previously experienced pain. As clinical research develops and shifts its focus to a more biopsychosocial approach to illness and pain, doctors must re-evaluate their first-line treatment suggestions. 

Drug-Free Pain Management 

Based on this new perception of pain, several nonpharmacological treatment methods for pain management have been developed. One approach is a purely psychological treatment called cognitive behavioral therapy, a form of talk therapy that discourages negative thoughts associated with pain and trains people to adhere to thoughts that stimulate the body’s natural pain relief system. Another example of nonpharmacological pain treatment is massage therapy,  which addresses pain by releasing muscle tension.  

Neuromodulation is highly effective in treating certain pain disorders through the use of electrical stimulation to modulate pain pathways in the neural system.  Several forms of neuromodulation treatment exist today, with different mechanisms of action and efficacy.  

Spinal cord stimulation, for example, is used to treat back pain and leg pain. But it is highly invasive, with electrodes surgically placed near the spinal cord to send electrical currents to the spine.

Deep brain stimulation is being studied for the relief of chronic pain, but it is also quite invasive, as it involves implanting electrodes into the brain.  

Nerivio is a non-invasive, wearable neuromodulation device made by my company that is FDA-approved for the treatment of acute migraine. Nerivio is self-applied to the upper arm, where it uses remote electrical neuromodulation (REN) to stimulate analgesic neurotransmitters in the pain pathways of migraine. In clinical trials, Nerivio and other REN devices have been shown to be just as effective as pharmacological treatments.  

To be clear, medication is a necessary and beneficial tool for treating infections, reducing fever, managing sickness and much more. However, its use in chronic pain management is sometimes misplaced, especially at a time when newer non-drug therapies are emerging.  

The holistic approach to pain management is the future. It considers the balance and context of a patient’s life and combines multiple modalities for their treatment. People are multifaceted and their treatment should be multifaceted as well. It is my hope and vision that this field of research will continue to develop and will soon be widely embraced by most medical professionals.  

Having experienced the benefits of drug-free pain management first-hand, I truly hope that health care systems will support patients in accessing these much-needed alternative treatments to improve quality of care and life.  

Alon Ironi is the CEO and co-founder of Theranica Bio-Electronics, the developer of Nerivio.

Alon received a Master of Science in Electrical Engineering from Santa Clara University, and a Bachelor’s of Science in Electrical Engineering from the Technion- Israel Institute of Technology.

Neuromodulation Device Effective for Most Migraine Sufferers

By Pat Anson, PNN Editor

A wearable neuromodulation device significantly reduced headache pain in nearly two-thirds of migraine sufferers, according to a new study. About one in four participants (22.6%) who used the device had no migraine pain after two hours.

The study findings, published in the journal Frontiers in Pain Research, are based on an analysis of over 23,000 remote electrical neuromodulation (REN) treatments with Nerivio, a device worn on the upper arm that uses mild electrical pulses to disrupt pain signals.

It’s important to note the study was designed and funded by Theranica Bio-Electronics, Nerivio’s manufacturer. Three of the five co-authors are Theranica employees.

“The current analysis of a very large group of patients, over a long period of time and multiple treatments, reinforces that REN provides a safe, efficacious and stable treatment option for acute treatment of migraine, both as a standalone and as an adjunct therapy. This is a very important component in the migraine therapy toolbox," lead author Jessica Ailani, MD, Director of the MedStar Georgetown Headache Center and Professor of Clinical Neurology, said in a press release.

Nerivio is controlled by a smartphone app that allows patients to set the intensity of their 45-minute treatments at the onset of a migraine. The app also has a migraine diary that allows patients and their doctors to track the effectiveness of REN.

It is from this app that study data was collected from 12,151 U.S. patients from 2019 to 2021. Most had been prescribed REN by headache specialists, indicating their migraines were difficult to treat with pain medication alone. During the study, about two-thirds of patients only used REN, with the remainder continuing to use over-the-counter or prescription medications.

"To the best of our knowledge, this study is the largest prospective real-world evidence analysis of a migraine device to date," said Alon Ironi, CEO of Theranica.

Migraine affects more than 37 million people in the United States, according to the American Migraine Foundation. In addition to headache pain, migraine can cause nausea, visual disturbances, and sensitivity to light and sound. Women are three times more likely to suffer from migraines than men.

Although migraine sufferers have many new treatments available, such as CBD oil and calcitonin gene-related peptide (CGRP) inhibitors, many find them too expensive or ineffective. Theranica hopes Nerivio can help fill the treatment gap, either as a standalone replacement for medication or as an adjunct.

"While some people with migraine get relief from prescribed or even over-the-counter medications, others do not respond to medications, or cannot tolerate their side effects. There are also people who cannot use medications due to contraindications or being at risk of drug-drug interactions or medication overuse headache,” Ailani said.

The FDA approved Nerivio as a treatment for acute migraine in adults in 2019. Last year the label was expanded to include children over the age of 12 with episodic or chronic migraine. Over 25,000 people in the U.S. have used the device, according to Theranica.

Nerivio is only available by prescription. When purchased wholesale, the listed price is $599 for a twelve-treatment unit, although buyers can save money by enrolling in a patient savings program, depending on their insurance coverage.  

A New Option for Young Migraine Sufferers

By Pat Anson, PNN Editor

Migraines can have a devastating impact on children and adolescents. In addition to causing head pain, upset stomachs and visual disturbances, migraine attacks can disrupt school and social activities at a sensitive time in a young person’s life.

Although pediatric migraines are common, affecting about 10% of school-age children and one in five teenagers, treatment options are very limited compared to adults. There are no FDA approved pharmaceutical migraine treatments for kids under the age of 12. That leaves doctors to prescribe migraine medication to children off-label, including a new class of migraine drugs called CGRP inhibitors, which have not yet been approved or studied in young children. 

A small new study suggests there may be a safer and more effective option for young migraineurs: neuromodulation. Research recently published in the journal of Pain Medicine found that Nerivio, a neuromodulation device worn on the upper arm, was more effective in treating acute migraine in adolescents than triptans and over-the-counter pain relievers. Nerivio uses smartphone-controlled electrical pulses to stimulate nerves and disrupt pain signals.

“To my knowledge, this is the first study that directly compared remote electrical neuromodulation and standard-care treatment options in adolescents,” says lead author Andrew Hershey, MD, co-director of the Headache Center at Cincinnati Children’s Hospital Medical Center.

“Migraine in adolescents is associated with poorer performance and absence from school and social activities during a particularly formative time in life. Providing teens with more effective and engaging treatments for migraine can have far-reaching positive effects over the course of their lives.”

Nerivio was developed by Theranica, an Israeli medical technology company that sponsored the study. The FDA approved the device as a treatment for acute migraine in adults in 2019 and recently expanded the label to include children over the age of 12 with episodic or chronic migraine.

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Thirty-five adolescent migraine patients aged 12 to 17 took part in the two-month comparison study. Over-the-counter drugs and oral triptans were used by patients during the medication month, and Nerivio during the Remote Electrical Neuromodulation (REN) month.

Two hours after treatment, over a third (37%) of patients achieved complete pain freedom during the REN phase of the study, compared to just 8.6% in the medication phase. Some degree of pain relief was reported by 80% of patients in the REN phase, as opposed to 57% in the medication phase.

“This study provides evidence that Nerivio may be considered as a first-line acute treatment, especially for adolescents with medication restricting comorbidities or a preference for a non-medication-based treatment,” said co-author Samantha Irwin, MD, a pediatric neurologist at the UCSF Benioff Children Hospital in San Francisco. “The importance of having a non-pharmacologic, discrete, easy-to-use and effective acute treatment in the adolescent armamentarium cannot be overstated.”

Long-Term Effects of Childhood Migraine

Early treatment of childhood migraine is important because there is emerging evidence that repeated headache attacks in children reduce the formation of “gray matter” in parts of the brain that process pain signals, leading to more frequent and severe migraines in adults.   

“We’ve done studies here independent of any pharmaceutical company where we’ve show that the earlier we can intervene with effective therapy and education of patients, the better their long-term outcome,” Hershey told PNN. “So we really have this opportunity to intervene with a child or adolescent that can affect them for their life.

“A device can be as effective as a drug. What I tell patients is that it gives them their own locus of control. Instead of taking a medication and hoping it works, they’re actually controlling the device with their smartphone, and so they can really take control of their headaches, which is ultimately what we want them to do.”    

Nerivio is only available by prescription and is eligible for insurance. When purchased wholesale, the listed price is $599 for a twelve-treatment unit, although buyers can save money by enrolling in a patient savings program, depending on their insurance coverage.  

Theranica is currently recruiting patients for a placebo-controlled study to see if Nerivio may be effective in preventing migraines. The company is also investigating whether the device may help treat other chronic pain conditions besides migraine.

Migraine affects more than 37 million people in the United States, according to the American Migraine Foundation. In addition to headache pain, migraine can cause nausea, blurriness or visual disturbances, and sensitivity to light and sound. Women are three times more likely to suffer from migraines than men.

Nerivio: What’s All the Buzz About?

By Mia Maysack, PNN Columnist

If you have migraines and are open to more holistic approaches to treating them, I’d like to share my experience with Nerivio. It’s the first smartphone-controlled neuromodulation device for the treatment of migraine, with or without aura. I was provided one of the devices, which is worn on the arm, at no cost by the manufacturer, Theranica Bio-Electronics.

Nerivio requires a prescription from a doctor. I was able to be seen via telemedicine through Cove for my appointment, which was convenient. A script was written for 12 treatments, which are thought to be most beneficial within the first 30 minutes of experiencing aura or the onset of pain.

Given that my head hurts 24/7/365, I was hesitant to even try Nerivio, but ultimately decided it was worthwhile due to the low risk of side effects. I've tried different types of neuromodulation devices before, without success, and went into this with an open mind and minimal expectations.

Nerivio didn't take any of my discomfort away, but it did cultivate a decent enough distraction. Despite my blaring head pain, I love loud music. I realize that could seem odd, but I figure since it hurts anyway, turn it up! Anything to switch up the frequency of this migraine that's stuck on repeat. 

I view Nerivio similarly. You have to chill out for the treatments, which are 45 minutes in length. Though it is possible to go about daily activities during treatments, I found it more comfortable not to. I'd take deep breaths and visualize the armband just like music, disrupting the head pain and transmitting restorative waves.   

Much like the beloved 12" subwoofer in Ophelia (my car), I controlled the volume, using my smartphone to dictate the intensity of Nerivio.

When it’s on, Nerivio delivers small electric impulses into the upper arm that disrupt pain signals in the brain. I first compared the feeling of neuromodulation to that of a tingle or itch, but after becoming more familiar, I'd label it as vibrational. It doesn't hurt, and the sensation is a welcome change of pace for anyone experiencing head pain 

It's important to remember there is a weak current of electricity, so fingers shouldn't be directly placed on the device when it's on, nor should it be used in any place other than your arm. 

The device costs about $100. That can be a significant amount of money, especially for those of us unable to maintain any sense of normalcy regarding employment or income. But I’ve paid out of pocket far more than that, regularly, for co-pays and uncovered treatments, not to mention pills that demanded Benjamin Franklin’s face for not even a week’s worth of treatment.   

What I appreciate about Nerivio is that it’s something I can do on my own. I altered the arms I used it on and always incorporated relaxation with my experiences to whatever extent I could.  It worked nicely in conjunction with mindfulness breaks, as well as first thing upon waking up or last thing before bed. 

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It’s also relieving to literally be holding the “power” in the palm of my hands. If there’s a need to halt a session, there is a pause button. Although I didn’t get around to utilizing it, Nerivio also has a feature that assists in promoting guided imagery and meditation as a further enhancement.   

For each treatment, all that’s necessary is to hit the power button on the armband and ensure it has synced up to your device. Within the first few moments when starting, a questionnaire pops up on the screen asking how you’re feeling. This acts similarly to a virtual diary to track symptoms and hopefully improvement. This step isn’t necessary, although never a bad idea to monitor or check in as to where you’re at.

All in all, I’d have to say if you’re curious enough and able to, go ahead and give Nerivio a try.  I believe it could be beneficial for other migraine conditions not as complex as mine.  

I haven’t been paid or endorsed at all for this review and offer these words solely as a resource for those who are considering it.  Feel free to follow up with questions, as I’m honored to help navigate the Nerivio process with you in any way I am able.

Mia Maysack lives with chronic migraine, cluster headache and fibromyalgia. Mia is the founder of Keepin’ Our Heads Up, a Facebook advocacy and support group, and Peace & Love, a wellness and life coaching practice for the chronically ill.