Neuromodulation for Migraine: A Guide for Primary Care Physicians 

By Leah Small

Approaches to migraine treatment often assume that a patient has access to a neurologist or headache specialist. In truth, primary care physicians are responsible for the majority of migraine care in the United States. 

According to the Observational Survey of the Epidemiology, Treatment and Care of Migraine (OVERCOME), 70.3% of patients predominantly use primary care for migraine consultation and management compared to 23.1% for a neurologist and 15.6% by a headache specialist. In addition, a majority (73.5%) of migraine patients principally treated by their primary care providers are not referred to a neurologist, but rather remain in primary care.

These statistics are not surprising, as many Americans (particularly those in less densely populated areas) simply do not have access to a local headache specialist or neurology practice. A survey published in The Journal of Headache and Pain highlights a critical access issue: Approximately one-third of patients decline referrals to neurology or headache specialists due to prolonged wait times in their area. In some regions, patients may face delays of up to 14 months before establishing care with a neurologist or headache subspecialist.

The authors of the OVERCOME study concluded that “Primary care providers are well-positioned to manage migraine and recommendations encourage that primary care clinicians manage migraine, especially episodic migraine… however, primary care providers face time limitations and competing demands across diseases during a visit and this makes it challenging to prioritize migraine management.” This dynamic places considerable pressure on PCPs to diagnose and initiate treatment for migraine within brief encounters, which may lead to suboptimal care. Supporting this concern, findings from the Chronic Migraine Epidemiology and Outcomes (CaMEO) study revealed that only 11.5% of individuals with migraine successfully accessed a healthcare provider, received an accurate diagnosis, and obtained appropriate treatment. 

In the context of widespread medication overuse and polypharmacy, emerging therapies like neuromodulation offer primary care providers a valuable nonpharmacologic option for managing migraine—particularly at the frontlines of care where patients most frequently present. This article reviews the current approach to migraine treatment, outlines the role of neuromodulation in primary care, and provides an overview of FDA-cleared neuromodulation devices available for treating migraine.

Evolving treatment protocols for migraine in primary care

The therapeutic landscape for migraine management has expanded significantly in recent years. Over the past decade, several novel, migraine-specific pharmacologic agents have emerged, including 5-hydroxytryptamine 1F (5-HT1F) receptor agonists, calcitonin gene–related peptide (CGRP) monoclonal antibodies, and CGRP receptor antagonists. In February 2025, the American College of Physicians released updated clinical guidelines outlining evidence-based recommendations for primary care providers on the preferred strategies for pharmacologic migraine prevention.

Importantly, recent guidelines have concentrated primarily on pharmaceutical strategies for migraine management, without addressing nonpharmacologic interventions such as neuromodulation. Non-invasive neuromodulation encompasses a range of FDA-cleared devices with distinct mechanisms of action and targeted stimulation pathways designed for migraine treatment. As an emerging and rapidly evolving area within headache medicine, neuromodulation is increasingly recognized for its role in personalized migraine care.

Observational data suggest that many patients prefer to minimize or avoid pharmacologic therapy when possible, highlighting the value of alternative options. Moreover, primary care and specialty providers frequently encounter challenges related to medication overuse and systemic side effects—issues that are gaining attention not only in clinical practice but also in broader ethical and public health discussions.

Given its utility as both an acute and preventive treatment, its compatibility as monotherapy or adjunctive therapy, and its favorable safety profile due to the absence of systemic exposure, neuromodulation represents a compelling addition to the migraine treatment armamentarium in primary care settings.

Clinicians increasingly recognize the effectiveness of a multimodal approach to migraine management. As outlined by the American Headache Society in its clinical guidance, “Comprehensive migraine therapy typically includes management of healthy lifestyle modifications, avoiding triggers, prophylactic/acute medications, status migrainosus action plan, non-pharmacologic therapies and/or devices, and migraine self-management strategies.”

While each of these components has a role in optimizing patient outcomes, non-invasive neuromodulation devices are emerging as particularly effective tools—especially within the primary care setting—due to their safety profile, ease of use, and ability to complement or reduce reliance on pharmacologic therapies.

A brief overview of neuromodulation for migraine for primary care providers 

Noninvasive neuromodulation is an increasingly utilized, evidence-based treatment modality for migraine. These FDA-cleared devices modulate peripheral and central pain pathways through targeted electrical or magnetic stimulation, leading to reductions in migraine frequency and intensity and, in some cases, improvement of associated symptoms—all while minimizing exposure to systemic side effects and medication-related risks.

Backed by over two decades of clinical research, noninvasive neuromodulation has demonstrated a strong safety and efficacy profile as both a stand-alone and adjunctive therapy. For primary care providers, these devices offer a valuable, patient-centered option within the broader migraine management toolkit, particularly for individuals seeking to limit or avoid pharmacologic treatments.

FDA-cleared neuromodulation devices for migraine

Five neuromodulation devices currently hold FDA clearance for the acute and/or preventive treatment of migraine, each supported by peer-reviewed clinical studies:

1. External Trigeminal Nerve Stimulation (eTNS): CEFALY^Ⓡ

• Mechanism: Microcurrent stimulation of the supraorbital and supratrochlear branches of the trigeminal nerve.
  
• Indication: Acute and preventive treatment of migraine in adults (18+).
  
• Access: Over-the-counter or prescription.
  

2. External Concurrent Occipital and Trigeminal Neurostimulation (eCOT-NS): Relivion^Ⓡ

• Mechanism: Simultaneous stimulation of the occipital and trigeminal nerves.
  
• Indication: Acute treatment of migraine in adults (18+).
  
• Access: Prescription only.
  

3. Remote Electrical Neuromodulation (REN): Nerivio^Ⓡ

• Mechanism: Electrical stimulation of peripheral nerves in the upper arm to induce conditioned pain modulation.
  
• Indication: Acute and preventive treatment of migraine in patients aged 8 and older.
  
• Access: Prescription only.
  

4. Transcutaneous Vagus Nerve Stimulation (tVNS): gammaCore™

• Mechanism: External vagus nerve stimulation via electrodes placed on the neck.
  
• Indication: Acute and preventive treatment of migraine and cluster headache in adults.
  
• Access: Prescription only.
  

5. Transcranial Magnetic Stimulation (TMS): SAVI Dual™

• Mechanism: Disruption of cortical spreading depolarization, a key mechanism in migraine with aura.
  
• Indication: Acute and preventive treatment of episodic migraine in patients aged 12 and older.
  
• Access: Prescription only.
  

When should primary care providers consider neuromodulation for migraine?

Neuromodulation represents a valuable treatment option that should be considered at various points in a patient’s migraine care pathway—particularly when pharmacologic therapies are ineffective, contraindicated, or poorly tolerated. Specific clinical scenarios where neuromodulation may offer unique benefits include:

• Patients who prefer to avoid pharmaceuticals or seek to reduce overall medication intake due to personal preference or prior negative experiences.
  
• Individuals with medication overuse headache (MOH), a common contributor to the chronification of migraine, where reducing acute medication reliance is critical.
  
• Patients with contraindications to standard migraine medications (e.g., cardiovascular disease, pregnancy) or at risk for drug-drug interactions.
  
• Incomplete or absent response to current pharmacologic treatments, where neuromodulation may serve as an adjunct or alternative approach.
  
• Patients unable to tolerate pharmaceutical treatments due to systemic side effects or poor tolerability profiles.
  

Given their non-invasive nature, favorable safety profile, and ability to be used as either acute or preventive therapy, neuromodulation devices are particularly well-suited for primary care integration—either as first-line alternatives or as part of a stepped-care model.

Primary care providers play a pivotal role in early migraine diagnosis and management. Incorporating neuromodulation into treatment discussions empowers providers to offer evidence-based, non-pharmacologic options tailored to patient needs and preferences—particularly for those at risk of medication overuse or systemic side effects. Given the expanding landscape of neuromodulation devices and their accessibility, they represent a practical and patient-centered addition to the primary care migraine toolkit.