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Transauricular vagus nerve stimulation in an elderly patient with chronic-resistant migraine – A case report
*Corresponding author: Namrata Kahlon, Department of Physiology, ESIC Medical College and Hospital, Faridabad, India. kahlonnamrata@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Rana S, Kahlon N, Pandey AK, Deepak KK. Transauricular vagus nerve stimulation in an elderly patient with chronic-resistant migraine – A case report. Indian J Physiol Pharmacol. doi: 10.25259/IJPP_722_2025
Abstract
Migraine is a disabling neurological disorder that may progress to chronic or resistant forms, which are especially challenging to manage in elderly patients. Transauricular non-invasive vagus nerve stimulation (ta-nVNS) has recently gained recognition as a safe supplementary treatment for migraines in adults; however, there is limited data available for individuals over the age of 65. We report the case of a 67-year-old male with chronic resistant migraine refractory to three pharmacological prophylactic classes. The patient participated in biweekly ta-nVNS sessions for a period of 6 weeks, which led to a marked decrease in both the frequency and intensity of headaches, alongside improvements in headache impact test scores and heart rate variability indices. When symptoms reappeared after several weeks, they were effectively managed with a second course of ta-nVNS, administered once a week. ta-nVNS appears to be an effective, non-invasive adjunct therapy for chronic resistant migraine in elderly individuals, showing beneficial modulation of autonomic function and migraine burden.
Keywords
Elderly
Heart rate variability
Migraine
Neuromodulation
Resistant migraine
Vagus nerve stimulation
INTRODUCTION
Migraine is a common and debilitating primary headache disorder characterised by recurrent unilateral, pulsatile headaches often accompanied by nausea, vomiting and sensory sensitivities.[1] In India, about 26.3% of the population is estimated to suffer from migraine, and women are affected more often than men.[2] A portion of this population converts to chronic migraine, which is defined as per the International Classification of Headache Disorders (ICHD-3) criteria as headaches on ≥15 days/month with at least eight migraine days, representing a severe disease burden.
Patients who do not respond to at least three different classes of preventive medications are classified as having resistant migraine, which presents additional therapeutic challenges.[3] Age-related neurochemical changes and polypharmacy make management particularly complex in elderly patients, as pharmacologic options carry increased risks of adverse effects and limited efficacy. Current treatment options are a mixed bag and offer limited, short-term relief and often cause side effects such as medication overuse, headaches and gastric ulcers.[4] Therefore, there is growing interest in non-invasive neuromodulation techniques, such as transauricular non-invasive vagus nerve stimulation (ta-nVNS), as a therapeutic tool in the management of migraine.[5] Nonetheless, there is limited evidence to support the use of (transauricular vagus nerve stimulation) in older patients suffering from chronic migraines that do not respond to treatment.[6]
The following case demonstrates successful management of chronic-resistant migraine in an elderly patient using ta-nVNS, in a tertiary care hospital in the Delhi National Capital Region (NCR). This study is one of the first research literatures that highlight the use of ta-nVNS in Indian population and that too in an elderly patient with chronic migraine. This case may represent one of the first reports from the Indian subcontinent describing the use of tanVNS in an elderly patient with chronic migraine, thereby contributing preliminary evidence from a previously under-reported population.
CASE REPORT
Patient information
A 67-year-old male physician working in a tertiary care centre in Delhi-NCR, with a known case of chronic migraine without aura for the past 20 years, presented to neurology with a history of 8–12 migraine headaches occurring per month, accompanied by nausea and vomiting. The severity of headaches was rated as 7/10 on the Visual Analogue Scale (VAS). He had no family history of migraine. He was also a known case of Hypertension on diltiazem 90 mg daily for the past 15 years.
Previous medication history included propranolol (40 mg daily for 4 years), amitriptyline (25 mg daily for 4 months) and topiramate (50 mg daily for 6 months), all with inadequate relief. Acute attacks were managed with paracetamol, naproxen and zolmitriptan nasal spray. Due to failure to achieve relief despite the trial of 3 classes of pharmaceutical drugs, he was diagnosed with chronic-resistant migraine.
Clinical findings
On examination, vital signs and neurological findings were within normal limits
Pedal oedema with pitting was present. Blood pressure was normal on regular medication
Heart rate variability (HRV) was recorded to assess autonomic function and was within normal limits
The headache impact test (HIT-6) score was 62, indicating severe impact.
Diagnostic assessment
Diagnosis was based on the ICHD-3 criteria for chronic migraine (1.3) without aura. No neuroimaging abnormalities were found. The diagnosis of resistant migraine was confirmed after failure of three prophylactic drug classes. Baseline HRV and HIT-6 were used to assess autonomic tone and quality of life, respectively [Figure 1].
Therapeutic intervention
The patient received electrical stimulation over the auricular branch of the vagus through electrodes placed on the tragus of the left ear at the listed parameters [Figure 2] using the portable Soterix Medical vagus nerve stimulator device. TanVNS sessions were administered on parameters derived from available literature[7] and device standardisation protocols from our work.
Follow-up sessions were given twice a week for 6 weeks. All parameters were assessed after 6 weeks, along with repeat HRV and HIT-6 recordings. The patient’s headache intensity and frequency were extracted from his headache diary. Events during the intervention timeline are depicted in Figure 3.
Follow-up and outcomes
Significant reductions in headache frequency, intensity and rescue medication use were observed after the first intervention. HIT-6 score improved from 62 to 48. HRV parameters showed enhanced parasympathetic activity, reflected by improved lowfrequency/high-frequency ratios. At the point of enrolment patient had just stopped topiramate and baseline HRV may be influenced by its hyperpolarising effects.[8]
The patient was monitored during the follow-up period. The patient experienced a migraine-free period after tanVNS intervention wherein he was on no pharmacological prophylaxis. First relapse occurred at 14 weeks from the point of recruitment; however, it was mild in intensity (3/10 on VAS) [Figure 1] and resolved on its own. The relapsing headaches worsened over time, and at 20 weeks, the patient reported headaches of intensity 10/10, 2–3 times a week. This warranted a second intervention phase (once weekly for 4 sessions) with no pharmacologic prophylaxis. The effect of ta-nVNS on headaches this time was attenuated, and after 4 weeks of the second tanVNS intervention, topiramate had to be started which provided complete relief to the patient. Summarised outcomes of therapy are shown in Table 1.
| Parameters | At the point of enrolment | After the first intervention (12 sessions over 6 weeks) | 20-week follow-up (prophylaxis*) | After the second intervention (4 sessions over 4 weeks) | Inference |
|---|---|---|---|---|---|
| Parameters of headache | |||||
| HIT-6 score | 62 | 48 | 68 | 51 | Clinically meaningful improvement in headache-related quality of life |
| VAS | 7 | 5 | 7 | 5 | Subsequent reduction in migraine intensity |
| Migraine attacks/month | 8 | 3 | 5 | 4 | Subsequent reduction in attack frequency |
| Parameters of HRV: Frequency domain | |||||
| LF (nu) | 43.32 | 41.38 | 48.89 | 48.78 | Relative reduction following initial intervention; increase during follow-up suggests sympathetic reactivation |
| HF (nu) | 59.68 | 56.97 | 50.39 | 52.07 | Relative increase after intervention indicating parasympathetic modulation |
| LF/HF ratio | 0.726 | 0.7264 | 0.97 | 0.9368 | Shift toward autonomic balance with parasympathetic predominance following stimulation |
HF (nu): High frequency in normal units, HIT-6: Headache impact test, HRV: Heart rate variability, LF (nu): Low frequency in normal units, VAS: Visual Analogue Scale. *Patient stopped all pharmacological prophylaxis after completion of the first ta-nVNS intervention. Episodes of migraine during follow-up were managed with rescue medication
DISCUSSION
This case demonstrates that ta-nVNS can provide meaningful clinical improvement in resistant migraine, even in an elderly patient population. The reduction in headache burden and enhanced parasympathetic tone corroborate the proposed mechanism of vagal modulation in pain pathways.[9]
Although the therapeutic response waned over time, reinitiation of ta-nVNS restored clinical benefit. However, the clinical benefit appeared attenuated, which may be attributable to a reduced frequency of ta-nVNS administration during this phase (four sessions over 4 weeks), compared with the initial treatment period, during which clinical improvement was observed following twelve sessions delivered over 6 weeks. This temporal association suggests a possible dose–response relationship, wherein the therapeutic efficacy of ta-nVNS may be proportional to the frequency of stimulation. The observed improvement in HRV indices indicates parasympathetic augmentation, consistent with prior literature linking vagal stimulation with autonomic stabilisation.[10]
The efficacy of ta-nVNS appeared greater when used alongside pharmacological prophylaxis, suggesting a synergistic effect. These findings support ta-nVNS as a safe, well-tolerated and effective adjunct for chronic migraine refractory to medication.
Patient perspective
The patient expressed satisfaction with the therapy, noting substantial relief after long-term refractory migraine. He particularly appreciated the non-invasive nature of ta-nVNS and the absence of adverse drug effects.
Informed consent
Informed consent was obtained from the patient for participation in the study and for publication of this case report.
CONCLUSION
The case above demonstrates the use of transcutaneous auricular vagus nerve stimulation (ta-nVNS) as a unique therapeutic intervention for the treatment of chronic, treatment-resistant migraine in an elderly patient. It highlights ta-nVNS as a safe and effective non-invasive adjunct therapy in older individuals, with potential benefits in reducing migraine burden and modulating autonomic nervous system function.
Acknowledgements:
The authors acknowledge the multidisciplinary research unit of our institute, funded by the Department of Health Research, Ministry of Health and Family Welfare, Government of India, for providing the transauricular non-invasive vagus nerve stimulation device used in this study.
Author contributions:
SR: Conception, design, data acquisition, analysis and manuscript preparation; NK: Conception, design, manuscript preparation, reviewed and approved the final version; AKP: Helped in grant acquisition, reviewed and approved the final version; KKD: Reviewed and approved the final version. All authors contributed equally to the conception, design, data acquisition, analysis and manuscript preparation. All have reviewed and approved the final version.
Ethical approval:
The research/study was approved by the Institutional Review Board at IEC, ESIC Medical College and Hospital, Faridabad, approval number 134/X/11/13/2024-IEC/DHR/16, dated 10th April 2024.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for their images and other clinical information to be reported in the journal. The patient understands that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: The vagus nerve stimulator device was funded by MRU, under DHR, GOI Grant no: LRAC Dated 25.03.2025.
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