Optimising Migraine Treatment Through Non-invasive Brain Stimulation: A Systematic Review of NIBS Applications and Pharmaceuticals

Migraine is a common disabling disorder, and the need for effective prophylactic treatment is unmet, with low efficacy, tolerability, and accessibility. Current preventive pharmaceuticals often result in poor adherence due to intolerable side effects and high costs. Neuromodulation has recently emerged as an alternative, but its efficacy has not been assessed against pharmaceuticals. This review comparatively assessed the efficacy of pharmaceuticals and neuromodulation in migraine prophylaxis. Randomised controlled trials between 2020-2025 were searched on PubMed, Scopus, Embase, Web of Science, and Cochrane Library. After quality and risk of bias assessment, a random-effects meta-analysis was conducted for pooled effect sizes on migraine frequency (MMD), severity, intensity, acute medication days (AMD), and adverse events (AEs). 35 trials were included, and all interventions significantly reduced MMD. Transcranial direct current stimulation (tDCS) had consistently high reductions in all parameters, particularly multifocal tDCS across MMD and AMD. Within pharmaceuticals, CGRP-mAbs had the highest consistent efficacy with milder AEs. The first-line treatment topiramate had similar or lower efficacy compared to CGRP-mAbs and neuromodulation. The findings suggest that neuromodulation is as effective, or sometimes more effective, than pharmaceuticals in migraine prophylaxis with fewer AEs. Protocol standardisation, long-term outcomes and larger sample sizes are recommended for future research.