A couple of posts ago I discussed plastic surgery for migraine treatment, the pros and cons. I want to discuss (again) a new wave of procedures for migraine prevention that, while holding great promise, must be discussed honestly.
I also want to give a disclaimer about these news items that I post here. We have a very busy schedule and while I read constantly about headache research, these posts are not meant to be scholarly. I report here as a journalist. While I try to keep my facts straight, I will not be quoting statistics giving precise dates and references like I do when I write an article for a journal. I don’t have time to do that here. You will see typos now and then because I have to type like a mad-man between patients. I have no time even to even proof read what I’ve written. But I feel this information is important to get out to the public.
First of all, chronic headaches have four avenues of treatment; 1) avoiding triggers, 2) hands-on physical treatments, 3) nutritional and 4) medications. The procedure I will discuss comes under number 2 as one of the hands-on physical treatments for headache.
I think it was about 5-6 years ago that I was sitting in the American Headache Society’s Scientific meeting in LA. I saw a presentation of the four point electrical stimulator for intractable chronic migraine patients. These 12+ patients were extremely intractable. They had been to good headache centers and had the best care, yet they still suffered from headaches daily.
My jaw almost literally dropped when I saw the results. There was about an 80% improvement in these very difficult patients, a couple experience complete headache freedom. I knew that we were on to something . . . something very big!
I’ve worked in headache care for 30 years and throughout this time, even while working at some of the best headache treatment centers in the world, there were that small group of patients who just didn’t respond. These were very nice people who did everything that we asked them to do, yet without response. We needed hope for these nice people, and this was a glimmer of that hope.
Since there there have been several studies, some nationwide, including the PRISM (NCT002860785) studies. In some only the occipital nerves were stimulated and in some four point (above the eye and the occipital nerves) were stimulated. We have a fair amount of data now. The implantable occipital nerve stimulator has been approved for chronic migraine treatment by the European Union ( I think). I am very happy for this advancement and I hope this is just the threshold of good things to come, such as an external stimulator (that doesn’t require surgery).
We just had our first patient approved by their insurance company since opening the Pacific Rim Headache Center. I have had a couple of patients in the past that I had the stimulator implanted (they were in the PRISM study). But I do have some concerns to keep our perspective in balance.
All patients want a one-step fix and that is understandable. I would too. When each new treatment (like Botox) there is renewed hope. But there is no panacea for headache treatment. Anyone who tries to tell you that they have a 100% success rate is lying. I’ve had patients fail the stimulator in they same way they failed Botox and medications (plus every CAM therapy you can imagine). The surgery isn’t simple and complications (lead placement movement, infections or wire breakage) is far too common.
The other concerning part of this equation is that money is corrupting. If you search the web you will find many slick ads for headache cures. Some are magic supplements. Some are rub on lotions, diets, books promising cures, dental procedures using fancy alignment machines and the list goes on and on. There are now clinics devoted to doing these electrical stimulator implants for intractable migraine. I’m glad they are there. We always need the “next step” and I wouldn’t hesitate sending one of my patients there . . . if they had failed all conventional treatments . . . and have realistic expectations.
The problem is, in our bizarre world of health care economics, procedures are paid by insurance companies at a very high rate. This skews treatment towards procedures. For example, if a surgeon implants a electrode under the skin and near these nerves they will be paid about $5,000/ hour by the insurance company. I hate to put it this way but it isn’t that complicated. Anyone who does surgery would tell you that (vs deep brain stimulation, which is quite complicated). On the other hand, if I spend 2 hours with a patient, discussing the whole spectrum of treatments, lifestyle, stress, nutrition, medications and etc, the same insurance company will eventually pay us about $80 for that hour (our overhead is about $120/hour).
So when providers see the large $$ they can earn, they tend to over-sell their treatments. Some of the ads I’ve seen for electrical stimulation of nerves for chronic migraine and de-compressive surgery are a bit like infomercials . . . not a scientific endeavor. It is a little scary.
Now, to be very candid, I’ve sat in meetings, lunches and receptions in my long career when I’ve heard (or “over heard”) the conversation among headache specialists of how to make money by doing things like this. For example, when you do Botox the way we do, a patient now and then, carefully selected, we make no money on it. Indeed, in 2012 we lost about $5,000 on doing Botox because it was not always reimbursed by insurance companies and we had to pay $1200 for the drug up front. We do it to serve our patients.
But if your goal is to make a lot of money, you can design a system where you do Botox on every patient that comes in the door, then set up a program where the provider goes from patient to patient doing Botox injections like a humming bird does from flower to flower (with a nurse doing most of the work) and then billing $300 per patient for your time (which really was about 10 minutes), and actually make a lot of money. I’ve heard headache specialists bragging about this plan. It wasn’t about who was the best patient for Botox but how to get as many patients as they could to do Botox to make more money.
But this is not just a problem with so-called western medicine. I’ve seen plenty of patients whom their chiropractor told them that they didn’t have the right curvature of their spine and they needed to come in and be treated twice a week for six months to fix it. Yet they were no better at any point along the way. The “free exam” is also a gimmick where they sign people up to come back again and again. It is wonderful when a patient seeks a chiropractor and is better. That’s not what I’m talking about. When the chiropractor makes them better I want to send them flowers and sing their praises.
I also saw a headache clinic (western medicine) start to do “group appointments.” Now, while they might sell it as good for the patient, however, these providers told me personally that their main goal was to make more money by seeing 10 patients at once and billing all 10 for an hour thus multiplying their money times 10. So it isn’t altruistic at all.
So here is where my concern lies. I am happy that the electrical stimulation of nerves is working for some and I hope that over time it is refined and made better and better. But we should be cautious because patients living well is our highest priority and fads can be harmful if not kept in perspective.
As I watched some of the interviews with the companies that do the electrical stimulator I was troubled by some of the language I heard. We know how electrical stimulation works ( won’t go into it here ) and it is virtually the exact same way that preventative medications work but in a more focused approach (delivering the inhibitory stimulus directly to the nerve endings and possibly brain-stem). However, the company representatives suggested that they treat the underlying disease while medications only cover it up. I hate to be so harsh but I must say, that is total BS. That is not what preventative medications do at all and every time I hear someone say that I know they have been scammed Narcotics cover up the underlying disease, but good, preventative medications treat the heart of the disease, an over-active headache alarm system by calming down the over-active nerves. That is the root of the problem and those good preventative medications are the best solution for many. That is exactly what the stimulators do as well. But when language like that is used “drugs just cover up the symptoms, we treat the real disease” it is the same language that other people use, who are trying to sell the patient some goods . . . from people who don’t have a clue as to the real cause of headaches. It is the language of a used car salesman (from the 50s. I heard they, used-car salesmen, are much better now). Buyer’s beware!
I’m glad that I never went into the medicine to make money. I don’t have never had that drive. My stress is trying not to go bankrupt (because we give away so much of our care for free) so we can continue to exist to serve patients.
So that is the good, the bad and the ugly of the electrical stimulators for headaches.