What is Thermal Microcautery (TMC) ?

Thermal microcautery (TMC) is a form of peripheral nerve field stimulation (PNFS). It is a new method of neuromodulation. There is activation of the A(touch), Aδ and c (fast and slow pain) nerve fibers possibly working by the mechanism of the Gate theory of pain (2). There is facilitation of the descending noxious inhibitory pathway, which is well known to be activated by noxious stimuli.

Additionally, it may be a new direct brain mechanism involving neuromatrix theory, offset analgesia mechanisms and modulation of learning pathways.

Thermal Microcautery (TMC) and Migraine

  • TMC is a minimally invasive intervention. It is an extremely efficient method that opens new avenues in the understanding of the pathogenesis and treatment of migraine. The hypothesis of its efficacy is based on the theory of the distorted communication within the trigeminocervical complex.
  • A possible pathophysiological mechanism of action is the modification 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 (5) 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 fibers of the dura mater and share the same receptive field. Thus, it is possible that an extracranial stimulation such as thermal microcautery (TMC) can also modify the activity of the sensory fibers of the dura.
  • Migraine (4) originates in a distorted communication within a complex neural network which leads to the well-described neuro-vascular cascade of events (4,17). We hypothesize that a thermal microcautery (TMC) stimulus resets this network restoring its natural homeostasis and can be a promising treatment for migraine.
  • The technique for the thermal microcautery (TMC) consists of applying a heated electrode of a device (Fig1) on specific areas on points chosen very precisely following a protocol that takes into consideration many factors.
Thermal Microcautery Unit (Fig1)
Thermal Microcautery Unit (Fig1)

Factors

Thermal Microcautery - Factor
  • Individual characteristics of the patient
  • Duration of the migraine and impact on daily life
  • Age and general health of the patient
  • Psychological state of the patient
  • History of treatments and patient’s response to these
  • Location of pain
  • Intensity of pain according to V.A.S. (visual analogue scale)
  • Initial response to TMC if it is a follow-up case

Parameters

  • Temperature of the electrode
  • Length of time of the heat application by the TMC electrode
  • Depth of the application of thermal microcautery on the skin
  • Number of treated points
  • Frequency of follow up of TMC treatment
  • After the treatment, there is the very important step of herbal cream application that allows the heated area to feel totally comfortable and to heal quickly
  • Patient should be guided to keep a migraine diary which will determine the follow-up treatment
  • The frequency of the TMC sessions depends on the initial response to the treatment and the speed of relief
Thermal Microcautery - Parametar

Outcome

Thermal Microcautery - Outcome
  • Our observations indicate that 50% of patients show total recovery.
  • These patients have attracted our attention to TMC because theoretically MIGRAINE IS NOT CURABLE.
  • How is it possible that the brain’s hyperexcitability is reversed?
  • How can the initial brain switch that triggers the migraine be neutralized?
  • A lot of experts are researching this phenomenon that might lead us to a better understanding of the migraine pathophysiology.
  • 30% of patients reduce their medication significantly and recover their lifestyle with much fewer migraine attacks, improved parameters like the intensity of the attack, frequency, impact on daily life and show faster response to milder medications.
  • 20% of patients however are not responding to the treatment for reasons that we are analyzing in case we find other ways to help them.

References

  1. Ellens, D. J., & Levy, R. M. (2011). Peripheral neuromodulation for migraine headache. In Peripheral Nerve Stimulation (Vol. 24, pp. 109-117). Karger Publishers. DOI: 10.1159/isbn.978-3- 8055-9489-9
  2. Melzack, R., & Wall, P. D. (1965). Pain mechanisms: a new theory. Science, 150(3699), 971-979. DOI: 10.1126/ science.150.3699.971
  3. Lovati, C., D’Amico, D., & Bertora, P. (2009). Allodynia in migraine: frequent random association or unavoidable consequence?. Expert review of neurotherapeutics, 9(3), 395- 408. https://doi.org/10.1586/14737175.9.3.395
  4. Goadsby, P. J., Holland, P. R., Martins-Oliveira, M., Hoffmann, J., Schankin, C., & Akerman, S. (2017). Pathophysiology of migraine: a disorder of sensory processing. Physiological reviews, 97(2), 553-622. DOI: 10.1152/physrev.00034.2015
  5. Lipton R, Goadsby PJ, Cady R, Aurora SK, Grosberg BM, F., & F G, et al. (2009). PO47 PRISM study: occipital nerve stimulation for treatment-refractory migraine. Cephalalgia, 29(Suppl 1), 30. Retrieved from http://journals.sagepub. com/doi/pdf/10.1111/J.1468- 2982.2009.01960.X
  6. Nayak, R., & Banik, R. K. (2018). Current Innovations in Peripheral Nerve Stimulation. Pain Research and Treatment. Hindawi Limited. https://doi.org/10.1155/2018/9091216
  7. Lauritsen, C. G., & Silberstein, S. D. (2019, May 1). Rationale for electrical parameter determination in external trigeminal nerve stimulation (eTNS) for migraine: A narrative review. Cephalalgia. SAGE Publications Ltd. https://doi. org/10.1177/0333102418796781
  8. Rapoport, A. M., Lin, T., & Tepper, S. J. (2020). Remote Electrical Neuromodulation (REN) for the Acute Treatment of Migraine. Headache: The Journal of Head and Face Pain.
  9. Ishiyama, S., Shibata, Y., Ayuzawa, S., Matsushita, A., & Matsumura, A. (2018). Clinical Effect of C2 Peripheral Nerve Field Stimulation Using Electroacupuncture for Primary Headache. Neuromodulation, 21(8), 793–796. https://doi. org/10.1111/ner.12772
  10. Loeb, L. M., Amorim, R. P., Mazzacoratti, M. da G. N., Scorza, F. A., & Peres, M. F. P. (2018). Botulinum toxin a (BT-A) versus low-level laser therapy (LLLT) in chronic migraine treatment: A comparison. Arquivos de Neuro- Psiquiatria, 76(10), 663–667. https://doi.org/10.1590/0004- 282×20180109
  11. Zidan, A., Roe, C., Burke, D., & Mejico, L. (2019). OnabotulinumtoxinA wear-off in chronic migraine, observational cohort study. Journal of Clinical Neuroscience, 69, 237-240. DOI: 10.1016/j.jocn.2019.07.043
  12. Popeney, C. A., & Aló, K. M. (2003). Peripheral neurostimulation for the treatment of chronic, disabling transformed migraine. Headache, 43(4), 369–375. https:// doi.org/10.1046/j.1526-4610.2003.03072.x
  13. Fishman, M. A., Antony, A., Esposito, M., Deer, T., & Levy, R. (2019). The Evolution of Neuromodulation in the Treatment of Chronic Pain: Forward-Looking Perspectives. Pain Medicine (Malden, Mass.), 20(1), S58–S68. https://doi. org/10.1093/pm/pnz074
  14. Popeney, C. A., & Aló, K. M. (2003). Peripheral neurostimulation for the treatment of chronic, disabling transformed migraine. Headache: The Journal of Head and Face Pain, 43(4), 369-375. https://doi.org/10.1046/j.1526- 4610.2003.03072.x
  15. Slavin, K. V., Nersesyan, H., & Wess, C. (2006). Peripheral neurostimulation for treatment of intractable occipital neuralgia. Neurosurgery, 58(1), 112–118. https://doi. org/10.1227/01.NEU.0000192163.55428.62
  16. Landy, S., Rice, K., & Lobo, B. (2004). Central sensitisation and cutaneous allodynia in migraine. CNS drugs, 18(6), 337- 342. https://doi.org/10.2165/00023210-200418060-00001
  17. D’Andrea, G., D’Arrigo, A., Dalle Carbonare, M., & Leon, A. (2012). Pathogenesis of migraine: role of neuromodulators. Headache: The Journal of Head and Face Pain, 52(7), 1155- 1163. https://doi.org/10.1111/j.1526-4610.2012.02168.x