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ABSTRACT

RESUMO

Descritores: Microcauterização térmica, enxaqueca, neuromodulação.

ORIGINAL ARTICLE

Application of thermal microcautery in migraine

management

Aplicação da microcauterização térmica no manejo da

migrânea

Eleni Papageorgiou

Konstantine Kovas

Camillus Power

Nikolaos Kostopoulos

Dept. of Neurology, General Hospital of

Athens, G. Gennimatas, Greece.

Dept. of Pain Medicine, Tallaght University

Hospital, Dublin, Ireland.

Holistic Health Centre, Athens, Greece

*Correspondence

Eleni Papageorgiou

E-mail: helenmorou@yahoo.gr

Received: December 5, 2019.

Accepted: December 26, 2019.

Thermal microcautery is a novel minimally invasive intervention for migraine.

We present a case series of twenty-one patients who underwent this technique.

Nineteen patients reported improvement in migraine management. Of these

four patients went on to complete remission and a further eleven patients

reported over 50% improvement. In addition, the majority of patients noted

reductions in intensity and duration of headache with a better response to

medication. The efcacy of thermal microcautery generates a new hypothesis

that attempts to explain how a neuromodulation technique may be helpful in

the management of migraine.

Keywords: Thermal microcautery; Migraine; Neuromodulation.

A microcauterização térmica é uma nova intervenção minimamente invasiva

para enxaqueca. Apresentamos uma série de casos de vinte e um pacientes

submetidos a essa técnica. Dezenove pacientes relataram melhora no

tratamento da enxaqueca. Desses quatro pacientes, a remissão foi concluída

e outros onze relataram mais de 50% de melhora. Além disso, a maioria dos

pacientes observou reduções na intensidade e duração da dor de cabeça com

uma melhor resposta à medicação aguda. A ecácia da microcauterização

térmica gera uma nova hipótese que tenta explicar como uma técnica de

neuromodulação pode ser útil no tratamento da enxaqueca.

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INTRODUCTION

Migraine is a highly disabling disease, with high

nancial and social impact (1). Migraine treatment can

be both acute and preventive, several pharmacological

classes can be effective, as also may non-pharmacological

therapies (2,3). Nerve blocks, botulinum toxin type A,

and neuromodulation may play an important role in the

management of migraine (4)

A number of studies have come to light, showing

that external stimulation of certain parts of the head,

may contribute to the management of pain (5,6,7,8)

Thermal microcautery have been used for the treatment

of pain disorders, but limited information is available

about its role in migraine treatment (9). We aimed in

this study to present our experience in a case series of

patients treated with thermal microcautery.

METHODS

Sample

Patients were selected from the Neurological

Headache outpatient clinic of G.N.A. ‘’G. Gennimatas’’,

from November 2017 up to March 2019.

Inclusion / exclusion criteria

The inclusion criteria were as follows –

1. Diagnosis of chronic migraine with or without

aura and/or Medication Overuse Headache

(MOH).

2. The failure of at least one preventive treatment.

3. Patients were not allowed to undergo

Botox injections (10,11) Acupuncture and

Transcutaneous Electrical Nerve Stimulation for

at least 3 months.

Technique description

In this technique we applied instantly intense heat

(600° C) to an area of localized pain (2) identied by

clinical examination before the procedure. The heat

was applied by a low temperature cautery disposable

ne tip pen, Fiab Disposable electrocautery pensF7255

(28 mm) which is routinely used in dermatology for

microsurgery.

Thermal microcautery was performed on bilateral

cervical, occipital, supraorbital and temporal areas, (12)

depending on what patients referred to as the most

painful points during the attack of migraine and also

between acute attacks.

Post procedure a cooling cream was applied (1gr.,

Pistacia Lentiscus, Shorea robusta)

It was planned that each patient would undergo 4

sessions, every 7-10 days. Each patient had a recording

of the frequency, duration, intensity of episodes of

headache, medication use and response. We recorded

the VAS pain score in each session.

The protocol of the study had been submitted

to the Hospital’s Ethical Committee and had been

approved. All patients were fully informed about the

aim of the study, the procedure and the complications

and had lled out a consent form.

RESULTS

Twenty-one patients have completed the study over

a two-month period with follow-up on all patients for six

months (twenty female patients – one male). The age

ranged from 37 to 68 years old (average 51.1 years old).

All of them had received at least one preventive therapy:

six patients used propranolol, twelve topiramate, three

valproic acid, ve unarizine, four amitriptyline, thirteen

SSRIs-SNRIs, ve botulinum-A. Additional, ve patients

had undergone Acupuncture and two used cannabis

oil on a daily basis. None of them had undergone any

invasive therapy or used anti-CGRP antibodies.

Fourteen patients used triptans at the acute phase

of the episode, all of them paracetamol and/or NSAIDs

and two Cephaly.

Fifteen of twenty-one patients had a combined

diagnosis of migraine and MOH.

Nineteen of twenty-one patients reported overall

improvement of their symptoms.

Four patients reported complete remission of their

migraine which has persisted for six months.

Eleven patients reported over 50% improvement

(reduction in the frequency, intensity and/or duration

of headaches) and four patients reported a 30%

improvement.

15 patients out 19 who reported improvement,

recorded a reduction in the frequency of episodes, 16 a

reduction in the intensity of the pain, 9 a reduction in the

duration of each episode.

15 patients noted a better response to the drugs

administered at the acute phase of pain,

Five patients were able to stop their preventive

treatment in six months.

Patients tolerated the procedure well including

application of the cooling cream. Five patients

Figure 1. Pie graph of evaluation of Migraine symptoms at the

end of the study (21 patients)

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experienced relief of migraine immediately following the

procedure.

The mild burn after the application of cauterization

was healed in 2-3 days, leaving no aesthetic marks. No

skin reactions appeared.

DISCUSSION

The present study shows promising results with

thermal microcautery in migraine preventive treatment,

due to its efcacy and tolerability (13).

Explanations for our ndings may include the

theory of the distorted communication within the

trigeminocervical complex. A possible pathophysiological

mechanism of action is the modication of the perception

of pain through peripheral stimulation (1,14) in the regions

of distribution of trigeminal and occipital nerves (12,15)

Through the anatomical and functional convergence of

these nerve endings, a wider distribution of the stimulus

is supposed to trigger centrifugal pathways that regulate

pain (16). It is known that stimulation of the occipital

nerves regulates the activity of sensory neurons in

the trigeminocervical complex; so, stimulation of the

trigeminal nerve as well, is supposed to have the same

effect. Its branches in the trigeminal divisions and C1 and

C2 dermatomes (9) converge with sensory bers of the

dura mater and share the same receptive eld. Thus, it is

possible that an extracranial stimulation such as thermal

microcautery can also modify the activity of the sensory

bers of the dura.

Migraine originates in a distorted communication

within a complex neural network which leads to the well

described neuro-vascular cascade of events (17). We

hypothesize that a thermal microcautery stimulus resets

this network restoring its natural homeostasis.

The study has several limitations, rst it is not

controlled by a sham procedure or other treatment as

a comparator. A baseline phase before the treatment

performed has not been performed, so a possible recall

bias may affect our results.

Conclusion

Thermal microcautery is a promising therapy

for migraine, further randomized clinical studies are

necessary to conrm its efcacy

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