NON- DRUG MIGRAINE TREATMENT & PREVENTION WITH CEFALY- A GUIDE FOR GPS & PHYSIOHERAPISTS INTRODUCTION Dr Len Rose - Pain Physician Melbourne Pain Clinic, MB BS, Dip M Health -Clin Hip, Dip Medical law Fellow of Aust College of Medical Law and author of 4 Books Hi I'm Dr. Len Rose. I've been a general practitioner for fifty years with a special interest in pain management and headache management for the past thirty five years. 1. NON-PHARMACOLOGICAL OPTIONS FOR THE TREATMENT & PREVENTION OF

MIGRAINE Over the past thirty five years I've come to use and take an interest in the use of a variety of techniques for the treatment of migraine and other headaches. These range from the psychological and therefore my interest in hypnosis became very important in the treatment of these headaches. I developed an interest in the use of transcutaneous electrical nerve stimulation nearly forty years ago and over the years I've seen that develop through bulky cigarette box sized devices through to far more exciting microelectronic devices which provide similar but probably more efficient uses for specific treatment of pain conditions and particularly of headaches. I've also had the opportunity to use hypnosis and other forms of relaxation and to work with other professionals, other healthcare professionals. For many years I worked with psychologists and psychiatrists, social workers and physiotherapists in a multi-disciplinary pain management clinic. We've had the opportunities to use a wide range of treatments which are far fortunately very, very commonly available nowadays. 2. CEFLAY – WHY IS AVAILABLE & WHAT PATIENS CAN BENEFIT

With my long term interest in the treatment of headaches I was very excited a couple of years ago when I was first approached with a very simple but very sophisticated device for the treatment of headache which was the sort of endpoint of the development of transcutaneous electrical nerve stimulation. This device was Cefaly, which is a simple headband device with one button that provides three different programs and allows us to treat possibly for the first time many patients who are resistant to the treatment of the headaches by medication or where medication has actually caused an increase in the headaches that so-called chronic daily headaches which is often related to an over usage of analgesics particularly paracetamol and aspirin. The Cefaly allows us to provide the patient with a simple device that they can use by themselves which has only one functional button, which fits on the forward like a pair of spectacles, and provides treatment which has been shown in a number of studies now to be far more effective than in particular, but also far more effective in some cases than the anti-epileptic medications which are also available for the treatment of headache and with far less side effects. 3. CEFALY – MODE OF ACTION

Like all transcutaneous electrical nerve stimulators and related devices, the Cefaly produces an electric current which is transmitted through the skin by self-adhesive electrodes, a single electrode

NON- DRUG MIGRAINE TREATMENT & PREVENTION WITH CEFALY- A GUIDE FOR GPS & PHYSIOHERAPISTS in this case. Which stimulates to the major branches of the fifth cranial nerves the trigeminal nerve. It stimulates the supratrochlear and the supraorbital branches of the trigeminal nerve which causes a major nerve coming directly from the brain. The impulses from the Cefaly electrode are then transmitted through the branches of the trigeminal nerve and produce an area of numbness, change sensation all the way up to the crown of the head so that this sensation is associated also with depletion of the various neurotransmitters that are said to be associated with the production of migraine, muscle contraction headache, and in some cases cluster headaches as well. What we've found is that in some of these patients with very resistant headaches or problems with major side effects associated with medication that within five to ten minutes in many cases the patient will experience a decrease in the severity of their migraine. In some cases they will be associated with or a feeling of marked relaxation and sometimes drowsiness so that the patient can get that rest that they require while they're having the treatment. And in other cases what we can do is interrupt the cycle of the headaches by reducing the frequency duration and severity of those particular headaches all in a very very simple device that can be worn like a pair of spectacles. 4. CEFALY – EFFICACY & SAFETY Just speaking now about the efficacy and safety of the Cefaly. The Cefaly from my experience has been an extremely effective mode of treatment of severe and chronic headache in a wide range of patients. Patients who've had in some cases headaches that have been daily headaches for up to ten years, patients who've had migraine headaches up to three to four migraines a week in some cases, and patients who've had incapacitating migraines that have had no answer as far as their medication or their treatments are concerned. What we found is that the Cefaly has a predictable efficacy in treating these headaches which is mirrored in the documentation the various papers that have now been published on Cefaly and which can be found by looking up Google Scholar. Anybody who's interested in in headache and particularly the interaction of headache and Cefaly can look this up very very easily online.

NON- DRUG MIGRAINE TREATMENT & PREVENTION WITH CEFALY- A GUIDE FOR GPS & PHYSIOHERAPISTS What we found is that patients have had remarkable results. Patients with daily headaches have had complete cessation of the headaches after one, two, sometimes a few more treatments. In my experience these patients have had similar benefits to Botox without the toxicity of Botox. Botox is another topic of conversation obviously for another day, but Cefaly is safe. The worst thing that can happen with Cefaly is a possible interaction between the electrode and the skin as with all transcutaneous electrical nerve stimulators. Very occasionally patients have related the changes in sensation that are experienced as a result of the stimulation to be more uncomfortable than they are prepared to put up with, but in most cases patients will persevere with the treatment and will experience quite significant results very quickly. As far as relaxation is concerned, there is a program which is aimed at relaxation. Most patients have found that that's very effective and we're very fortunate in Australia because in some parts of the world the Cefaly devices don't have that program built into them. We now have the full gamut of treatments in Australia. As far as accessibility, these devices are very accessible. All you have to do is go to the Cefaly website. www.cefaly.com.au

In Australia a patient can obtain one of these Cefalys through rental for up to three months or more if that's what they want, or they can buy the machine outright for around about four hundred dollars. The device is a simple to use although most patients might benefit from referral to a health care professional or to the GP themselves because ideally it should be a doctor who's showing the patient the treatment and if not it should be a physiotherapist who knows how to use the Cefaly and to explain to the patient the benefits and potential risks associated with it although those risks are minimal. 5. CEFALY – AVAILABILITY & FURTHER INFORMATION Another benefit of Cefaly is that because it's a transcutaneous electrical nerve device, stimulator device, many health funds will help you to fund the device for the patient. You can also often receive support from third party insurers.

NON- DRUG MIGRAINE TREATMENT & PREVENTION WITH CEFALY- A GUIDE FOR GPS & PHYSIOHERAPISTS

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The Transport Accident insurers workers' compensation insurance companies who have been supporting the provision of tense devices for many many years should have no difficulty in supporting patients who have headaches as a result of either a work related injury or a transport accident related injury and it's certainly worthwhile having a look at that for that financial support. 6. CEFALY – WHERE CAN MY PATIENTS OBTAINED IT.? When asked how do I provide my patient with a Cefaly? It's really quite simple. Go to the website, look at the literature that's available out there, that's provided through organizations such as Headache Australia and the Brain Foundation and the patient can make direct contact with the company (SciGen) through their own website www.cefaly.com.au. You don't need a prescription. Patients are able to access either rental options or purchase options very very simply and it should again place a degree of control in the patients’ hands because they can start the whole process off.

NON- DRUG MIGRAINE TREATMENT & PREVENTION WITH CEFALY- A GUIDE FOR GPS & PHYSIOHERAPISTS 7. CEFALY – SUMMARY To summarize:

• the Cefaly presents the end point of the development of transcutaneous electrical nerve devices, stimulator devices and has its final application in the treatment of headache and the assistance of patients becoming more relaxed.

• The device has two main roles. It acts as a headache preventative and a headache modulator and

• it also provides an interesting device to assist patients with relaxation. • They're very simple to use, one button, three programs, easy to obtain through the website,

they’re very economical, they can be either rented or purchased and most importantly they're very effective with almost no side effects whatsoever.

There's a range of websites and resources that are available. There is a constant Twitter feed on migraine and headaches. There is Google Scholar and the web resources on headache and migraine are vast and so are some of the resources now available on Cefaly. CEFALY RESOURCES – www.cefaly.com.au