Migraine Headache Prevention with TENS (Cefaly Effectiveness Study)

Migraine prevention with a supraorbital transcutaneous stimulator: a randomized controlled trial. Neurology. 2013 Feb 19;80(8):697-704. Schoenen J, Vandersmissen B, Jeangette S, Herroelen L, Vandenheede M, Gérard P, Magis D.

Abstract OBJECTIVE: To assess efficacy and safety of trigeminal neurostimulation with a supraorbital transcutaneous stimulator (Cefaly, STX-Med., Herstal, Belgium) in migraine prevention. METHODS: This was a double-blinded, randomized, sham-controlled trial conducted at 5 Belgian tertiary headache clinics. After a 1-month run-in, patients with at least 2 migraine attacks/month were randomized 1:1 to verum or sham stimulation, and applied the stimulator daily for 20 minutes during 3 months. Primary outcome measures were change in monthly migraine days and 50% responder rate. RESULTS: Sixty-seven patients were randomized and included in the intention-to-treat analysis. Between run-in and third month of treatment, the mean number of migraine days decreased significantly in the verum (6.94 vs 4.88; p = 0.023), but not in the sham group (6.54 vs 6.22; p = 0.608). The 50% responder rate was significantly greater (p = 0.023) in the verum (38.1%) than in the sham group (12.1%). Monthly migraine attacks (p = 0.044), monthly headache days (p = 0.041), and monthly acute antimigraine drug intake (p = 0.007) were also significantly reduced in the verum but not in the sham group. There were no adverse events in either group. CONCLUSIONS: Supraorbital transcutaneous stimulation with the device used in this trial is effective and safe as a preventive therapy for migraine. The therapeutic gain (26%) is within the range of those reported for other preventive drug and nondrug antimigraine treatments. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that treatment with a supraorbital transcutaneous stimulator is effective and safe as a preventive therapy for migraine.

My comments:

This is an interesting paper; this combined with peripheral nerve stimulation studies has changed my current protocol for migraine, cervicogenic and tension headache treatment.  These authors were reading and relating their treatment to the same peripheral nerve stimulation studies I was. Like me, they think that research is applicable to transcutaneous stimulation, which avoids the expense and complication of surgery.  It’s also interesting where we differ: my initial approach is acute reduction/elimination of headache pain during an attack with 12 minutes of treatment, while they looked at prevention secondary to a daily 20 minute treatment.  They use the Cefaly headband device which was shown to be safe in over 2300 patients and was the subject of my last blog. They used parameters of up to 16 mA, at 250 uS, at 60 Hz.  While the other paper discussed their findings regarding safety and satisfication, I think this one is more interesting as it gave harder numbers with regards to effectiveness.

How effective was it?  At least moderately so for prevention of headaches.  Both the TENS and placebo group had a decrease in monthly migraine headaches of about 20% after the first month but in the 2nd and 3rd month of treatment the sham group headaches started increasing more towards baseline while the TENS group continued to improve.  At 3 months, total headache days had decreased 32% in the TENS group compared to 3% in the placebo group.  Headache severity decreased 8% in the TENS group compared to 3% in the placebo group, and acute drug intake decreased 37% in the TENS group compared to increasing 1% in the placebo group.

Results were not as good as that shown with the surgically- implanted electrode studies. However, surgery was avoided and unlike the surgically-implanted stimulators complications were essentially nil.  I still think they are missing something by doing only supraorbital (forehead) stimulation without also hitting the suboccipital (back of the neck) region. It’s still a great paper though, and based on my results with TENS/EMS for headaches the findings are certainly believable.  I’ll be doing a follow-up blog comparing acute outcomes of the combined supraorbital and occipital stimulation to what I got with occipital nerve stimulation alone after I collect data on another 15 patients.  So far, the results appear favorable.

Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember Spinal Flow Yoga for you or someone you know in the future.

Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

18 thoughts on “Migraine Headache Prevention with TENS (Cefaly Effectiveness Study)”

  1. I have just started to use Cefaly.

    Cefaly also have a product for tens on the occipital region (Arnold
    kit), but they say that this is only for those who have diagnosed
    Occipital Neuralgia, it wont help for those normal migraine patients –
    even if it feels like the pain comes from that region.

    So I’m interested to hear your comments on that, since you had such
    good results with treating headache only from the occipital region
    with all kind of patients, not only Occipital Neuralgia patients.

    Also I would like to start EMS training of the neck and shoulder
    region since i think it might help to relieve headache. Do you have
    any information for beginners on that? ie. electrode placement,
    preferred device etc.? or maybe a book recommendation.


    • Hi Rikard,

      That is interesting information about the Arnold Kit for occipital stimulation with the Cefaly. I googled it and was able to get a look at it, but I’m unsure how it works. I saw that there was no research on it as of yet, but that they were recruiting patients for a study which sounds like it’s underway, so it will be interesting to see what they come up with. When I wrote this blog last year they had not come out with it yet, so if you try it, I would be interested to hear your feedback.

      This paper (page 7) shows that they were placing the electrodes to combine supraorbital nerve stimulation (just above the eyes) and occipital nerve stimulation at the base of the the skull. The paper talks about surgically implanted electrodes (called percutaneous), but all the nerves they were targeting are very close to the skin, so they can likely be effectively stimulated with transcutaneous electrodes. Looking at the picture now, I place my electrodes ~3.5” (~10 cm) rubber carbon electrodes a little lower on the occipital region, such that the bottom half of the electrode is on the neck and the top half on the base of the skull. I have been having a little trouble with the photo editing and wordpress theme on my blog, but if I get it straightened out I’ll try and post diagrams of exactly where I put my pads.

      I’m not sure why they said it only treats occipital neuralgia, and not posterior head migraine pain. In the percutaneous studies they found occipital stimulation decreased migraine pain ~40% of the time, with the percent of effectiveness increased on average to 93% when they added the stimulation over the eyes, so it wasn’t an “either-or”, but rather a “both” being better scenario. Perhaps because, as noted in the blog which discussed the above paper, migraine headaches tend to be more frontal. As I noted above, I think one of the reasons the Cefaly effectiveness isn’t as effective as the percutaneous stimulation was that they didn’t have the occipital stimulation, so it’s good to see they are adding that. I did finish my data collection on the combination of ONS and SONS stimulation with my own TENS/EMS machines and the combined stimulation worked better. My “study” would better be termed a case series, however, as I don’t have a control group and there was no blinding. Still, I think it works great, so I’ll have to organize that data and do a blog on it. Most of my patients that did really well had episodic headaches, 1-2 a week, and the EMS would more often than not eliminate the pain either immediately after a 10 or 12 minute treatment, or within 5 minutes of stopping and the pain was gone for days at least. In patients with chronic migraines (for which I treated only 3) who had headaches on most days of the week, the EMS was more hit or miss. Sometimes it worked, or worked partially, and the pain didn’t stay gone as long. Two out of those three patients still thought it helped enough to purchase a TENS/EMS machine for home.

      I started out using an EV-906 combination EMS/TENS machine, and now I’m using a Globus Genesy 300. Both are overkill for headaches (I use them for low back pain and increasing muscle strength after surgery), both are considerably more powerful than the specialized Cefaly machine, and both are ultimately programmable, so that if any new research comes out regarding different treatment protocols for headaches or most anything else, they can be quickly and easily adapted. It was only after reading the Cefaly safety study and recreating their parameters on my machines that I felt comfortable putting EMS/TENS on the head.

      Right now, my current go to protocol for headaches is an EMS current with a 1-2 second ramp, 5 seconds on 10 seconds off, telling my patients to increase intensity as tolerated. So far, none of them have exceeded the levels of current produced by the Cefaly machine over the supraorbital region (the forehead is pretty sensitive). Over the occipital region, people generally tolerate more current, but there haven’t been any transcutaneous safety studies performed for occipital stimulation. I haven’t seen any side effects, but that doesn’t mean you won’t. I use rubber carbon electrodes held in place with elastic straps which get through the hair just fine without sticking as well as for these reasons. There is minimal research on the safety of occipital region EMS/TENS which might be why Cefaly is being cautious with their recommendations. However, if I had one I’d certainly try it.

      If you decide to, I would love to hear your experience (but since this is medicine related, I’M NOT TELLING YOU TO TRY IT). If you try the Arnold kit, I would love to know if the occipital electrodes hook into another type of TENS machine, or if they run off of batteries and have the same parameters as the headband. The max settings of the Cefaly headband feels strong to me on the forehead, but I expect might not be strong enough to be optimally effective over the neck/occipital region.

      As for the book recommendation, there really isn’t a good how-to guide and most professional books are written in such a way as to be unintelligible and even still, I think the authors don’t have a good grasp on what works or not. As such, I’m currently writing my own book on the subject, which I hope will be a concise practical guide. In the meantime, a lot of that material has been going into my blogs on TENS and EMS, so feel free to browse and ask questions.

  2. About the Cefaly Occipital kit: I think it just connects to the Cefaly device instead of the normal forehead electrodes which have special connectors to connect to main unit. So it would take a little bit of fiddling to connect the occipital kit to other devices. I haven’t seen the thing myself so I’m not 100% sure. Also, the occipital headband needs to be applied with gel (messy in the hair..).

    My thinking now is to try to replace the Cefaly with a normal TENS unit, since all the parameters is provided. In this way I can do simultaneous supraorbital and occipital stimulation + neck EMS training with the same unit. And I can get rubber carbon electrodes instead of the sticky and expensive Cefaly electrodes. It would make it easier to use, and cheaper… but dangerous if accidentally setting wrong parameters.
    I would be doing it on my own initiative, I know there is no recommendation from you. But do you have any comments?

    Here is someone who have measured the parameters on an actual Cefaly unit. Interestingly, his measurements differs from the official parameters by Cefaly.

    You say that you use EMS for occipital stimulation. Do you also use EMS on the forehead? What current do you use?

    There is always a warning in the manual of these devices, not to use on certain parts of the body. The head and sides of neck included. On the head I can understand the danger to send electricity into the brain, but on the side of the neck.. whats the danger? I would like to use it there since its a problematic area for me, connected to the headache.

    Thank you very much for sharing your knowledge in this. I find it hard to get quality information in this field.

    • Yeah, I’ve got comments, haha!

      If the Arnold Kit just plugs into the Cefaly headband and gives occipital stimulation instead of supraorbital stimulation, it will likely be hit or miss as to how well it works. Plus the Cefaly machine only puts out 16 milliamps (mA) at 250 microseconds (uS), which might not be strong enough to be that effective on the occipital region. With my first data collection study for headaches, my patients were getting to an average stimulation of 36 mA with a pulse width of 300 uS.

      It’s the combination of mA times uS that gives you the “charge” expressed in coulombs delivered, which is the best indication of dose. Charge = Current (amps) x Time (seconds) so if the Cefaly maxes out at 16 mA (.016 A) with a pulse width of 250 uS (0.00025 seconds) for a max delivered dose of 0.0000004 coulombs, which if my math is correct works out to a dose of 4.0 uC (microcoulombs) while the average dose occipital (for which a good portion of my electrodes are on the posterior neck region) is (.036 M) X (.0003 S) =.00108 C or 10.8 uC. I was delivering more than double the charge with my machine than the Cefaly is reportedly able to deliver. The math isn’t that hard, but there are a lot of zeros to keep track of and people often get confused with terminology that doesn’t sound that different, for example “milli” (1/1000 or one in a thousand) and “micro” 1/1000000 or 1 in a million). The majority of TENS studies I have seen looking at other types of pain (besides headaches) indicate that there is a dose response relationship with charge and pain reduction. Unfortunately, everybody is being real slow and cautious regarding recommendations of electrical stimulation for the head and neck so they don’t get sued for inducing a seizure or erasing somebody’s memory or something.

      The other thing worth noting is that most low cost TENS/EMS machines use what is called an “asymmetrical” biphasic square wave current, which works really well and is what I used and still sometimes recommend if price is an issue. The disadvantage of an asymmetrical current is that one of the electrodes in a channel (typically the black one) will be stronger (delivering a full dose) while the red wire feels noticeably weaker. With the better but more expensive units, like the Globus Genesy, you get a “symmetrical” biphasic square wave, so that both electrodes deliver equal charge. In practice with the asymmetrical machines, I tell people to put the black wire (stronger lead) on the weaker or more painful body part (in this case the side of the head or neck that hurts more). With the Globus machine you don’t have to worry about that.

      Yeah, I agree the gel is inconvenient. I prefer carbonized rubber electrodes, which if wet enough with water, would be less messy.

      I’m not sure if the TENS/EMS to the head is dangerous or not. There are no studies I am aware of that say how much is safe and how much is dangerous. Cefaly levels appear safe. Psychiatry is doing a lot of electric stimulation to the head but they haven’t come up with hard numbers as to what’s safe or not either. Looking at modern electroconvulsive therapy, which I recently read a very interesting book on, they also use symmetrical biphasic square wave currents but use a lot more charge upwards of 500 millicoulombs or 500,000 microcoulombs, typically only doing a couple charges of 0.5 milliseconds duration. Electroconvulsive treatment (ECT) is done with the intention of inducing a seizure, and it is turning out to be THE most effective treatment for depression, however side effects including memory loss ARE found and the “bifrontal electrode” placement often used in ECT does not appear that different from the supraorbital stimulation that I or the Cefaly uses. So caveat emptor. My personal record was working up to 30 mA (at 450 uS) supraorbital stimulation, and 65 (at 450 uS) suboccipital stimulation, both of which exceeds (by a considerable margin) anything any of my patients have found necessary or tolerable for headaches. So when all the testing is done, it might turn out that people won’t be able to comfortably tolerate enough alternating current (direct current, which I never use can cause burns) electric stimulation to the head to result in any dangerous side effects. However, I would NOT go so far as to call that a safe assumption.

      As for your link on actual vs listed Cefaly parameters, it says the discussion was deleted by a moderator, however if you can find the data elsewhere I would be interested in seeing.

      My current “go to” parameters for headaches is using 2 channels of a 4 channel machine with either 300 uS pulse width (max for EV-906) or 450 uS (max with the Globus Genesy) with a 1 second ramp on the EV-906 and a 2 second ramp on the Globus, both currently set up for 5 seconds ‘on’ time and 15 seconds rest, with a 120 Hz rate, and a run time of 12 minutes on the EV-906 and 10 minutes on the Globus (2 minutes shorter because it sets up a little faster). I’m still working with other parameters to see what works best, but the 5 ‘on’-15 ‘off seems very effective. As for EMS vs TENS, all EMS is a type of TENS, but not all TENS is EMS. EMS is typically, but not always stronger, and it allows for a rest period between contractions. EMS type currents happened to be more effective than TENS parameters I had tried for pain for other body segments, so when I tried it for headaches I was surprised how well it worked because I wasn’t trying to fatigue muscles. I think it might work, at least in part, by fatiguing sensory nerves.

      There are no precautions I am aware of for stimulating the back of the neck, however stimulating the front of the neck (over what is called the carotid sinus) is thought to be potentially dangerous as it might slow the heart rate and/or decrease blood pressure. There is no data I am aware of (and I have looked extensively) to show that this is actually dangerous and there have even been a couple studies using percutaneous electrodes in both animals and humans to control hypertension that found it was safe and modestly effective. That said, I have been putting EMS over my posterior and anterior neck muscles (directly over carotid sinus) with a record of 90 mA at 450 uS regularly over the last two years, and thus far, have gained 1 ⅜ inches of neck muscle hypertrophy without incident. However, I certainly wouldn’t suggest you do likewise, nor for headaches do I think you would need to as the occipital nerves are hit best with the posterior neck placement. My interest in anterior neck placement was more to see if anything bad might happen for the treatment of other problems such as cervical pain or dysphagia.

  3. Yes, I see that the discussion about Cefaly tech specs I was referring to has been deleted by the moderator. Thats interesting. It was an 11 month old discussion, which I resurrected yesterday to ask about the difference in parameters. Today all the messagesab out Cefaly parameters and using a normal TENS machine on the head, has been deleted by the moderator. I guess that they don’t want people to know for some reason. Luckily enough I was able to find the discussions on google cache, I have it all saved down as a pdf which I can email to you if you want. Anyway, the parameters he listed was these:

    – the pulse width: P1 – 500; P2 – 600; P3 – 500 (microseconds)
    – pulses per second: P1 – 100; P2 – 6; P3 – 125
    – maximum current: P1 – 18; P2 – 18; P3 – 15.5
    Intensity (current) for all three programs starts very low and gradually increases over 14 minutes till the maximum is reached and then it holds it there for about 5 minutes, then decreases quickly for about 30-60 seconds.
    P1 and P3 are almost identical and feel similar – at lower intensities they can feel like a soothing massage P2 feels more like rapid shocks. All three programs are initially quite painful at full intensity but its tolerable.

    Program no. 2 is the prevention program and should have the same data as presented by Cefaly. Its quite a big difference. Although, I wouldn’t call this a trustworthy source of information – its just a post on a message board. Maybe he has miscalculated the pulse width and it should be only half, and maybe he forgot a zero on frequency of P2…

    I have a couple of more questions:

    The parameters you use for headache, are they only for abortion of a current pain or also for daily prevention?
    Cefaly is primarily a device for prevention that has to be used for 20-40 minutes every day. The EU model also has an abortion program (P1) for an ongoing headache, in the manual it says that the user might have to run the program repeatedly up to 6 times to be successful in the abortion. It is possible to restart the program, then the unit works at full power for the whole duration of the program, without the 12 minutes startup phase. So abortion of an ongoing headache can take 120 minutes of continues stimulation according to the Cefaly manual

    Do you use the same parameters for both supraorbital and suboccipital stimulation?
    Do you recommend supraorbital and suboccipital stimulation at the same time or one at a time?

    Regarding stimulating the neck muscles. OK, so what I might want to avoid is stimulating the arteries, as it might slow the heart rate and/or decrease blood pressure. Correct?
    I want to stimulate the on the side of the neck, but a further back than the arteries. There is something that feels like a thread, running all the way on the side of the neck under the skin. This thread gets very sensitive when a migraine attack is coming and pressing it flares up a migraine like feeling in the front of the head, the feeling disappears when I release the pressure again. I thought it was a trigger point and have tried to massage, but it makes no difference. So I want to try TENS on it to see what happens. Maybe its an inflamed nerve?

    Lastly, I want to send a big thanks to you. Im so grateful for you researching this and sharing this information with me and others. Im soaking it all up like a sponge!

    • Interesting info about the Cefaly. For sure email me the pdf if you can.

      It sounds like the Cefaly ramps up in intensity on it’s own, while with my EMS/TENS machines I have my patients raise the intensity manually to their tolerance. I encourage them to go as high as they can, and work up from there over the next 10-12 minutes. I thought the Cefaly rate felt like pin pricks, while my preferred rate of 120 hz felt like a more comfortable buzz. The more comfort, from the higher hz and larger carbonized rubber electrodes, I think might let people work up to higher stimulation intensities, and thus have a better pain reduction effect.

      I should add that while I have tested all the parameters on myself before trying them with patients so I know what they all feel like, I don’t suffer headaches so besides what my patients tell me, I can’t directly relate. It’s funny, I got into all this from an idea of using EMS to increase strength, it was just a cool coincidence that it reduced pain so effectively.

      For my treatments it has all been with the idea of immediate pain elimination, which is what I use EMS and TENS for in all my other pain patients. So prevention is an interesting idea that I hadn’t heard about before reading the Cefaly paper. It makes me wonder if they did the study on prevention first because it wasn’t that effective at aborting pain episodes. After reading the paper I did talk to the two former employees I had who had chronic migraines about using the machine regularly to see if it helped lessen frequency and I think both of them said maybe it did, but they were never that consistent using their machines when their heads didn’t hurt. They also commented that EMS helped best to eliminate pain if they did it right away when the headaches started, or when they could feel they were about to start, rather than waiting until pain was intense.

      As for running the program over again, in the few patients I had who didn’t have a big reduction or elimination in pain intensity, running the program over again (which I have probably done only 5-6 times) didn’t seem to help. If I were you and I had the machine I would certainly try it, but in my limited data, it didn’t seem to help. I’ve only had them try it twice, and never considered 6 times, but it’s all worth a try. In all my treating and testing (maybe 75 headaches thus far that I’ve witnessed) the worst thing that has happened is it didn’t work, nobody has been made worse. Still 120 minutes makes me think that even if it did work, it really didn’t, because the headache might have gone away anyway in that time.

      I use the same machine but different channels on the suboccipital and supraorbital stimulation run together. So all the parameters are identical with the exception of milliamps (mA) because each channel of my machines has it’s own intensity button. Everyone used more on their suboccipital region than on their supraorbital region. In fact as I think about it, the occipital nerve stimulation (ONS) stimulation might not be as good as what I do, because I’m hitting the nerve closer to its origin at the back of the neck. Plus, with part of my electrodes placed over the neck and using EMS, I’m probably doing some cervical muscle strengthening at the same time, which can’t hurt.

      As for the arteries, yeah that’s thought to be correct, you are supposed to avoid putting electrodes over the carotid sinus in particular.

      I still do it (on myself) though (with a LOT of current) blood pressure and heart rate go up, I think due to the intense isometric contraction. In people I have had try it while I monitored their blood pressure and heart rate I have not noticed any effect. For what it’s worth, I am looking to get data published on this because I don’t know anyone else that’s doing it. In your case, trying the stim on the side of the neck might be getting close to the carotid sinus, so I’m not going to tell you to try, but you could maybe do it while wearing a heart rate monitor and blood pressure cuff and see if there is any effect, which right or wrong, is how I test it. The cool thing about having a combination EMS/TENS machine is you can try most anything you want and just see what helps most. With the larger rubber carbon electrodes (3.5 to 4”) you don’t have to be that exact with placement as it hits a much larger area.

      One thing I would add is electrodes are fairly easy to come by, but for the large 3.5” rubber carbon electrodes, it was difficult for me to find good elastic straps that are wide enough and strong enough to hold the entire electrode tight against the skin. A 2” wide strap doesn’t work that well with a 4” electrode. So I had to have some custom made and bulk ordered them from Japan, so if you need any and you are in the US I could flat rate ship them to you for $5.00 per 4” x 24” strap. For headaches you would probably want two, one for the forehead and one for the neck. I’ve been meaning to set up a webstore for that stuff but haven’t yet.

  4. Now I have had the opurtunity to try Cefaly program 1, to abort a migraine attack. Didn’t work for me. I ran it about 5 times in a row. When the device was running it gave comfort and the pain was not felt, really relaxing. If lying down I will go into deep sleep, until the program finishes with a loud beep. Sleep is usually impossible when in an intense migraine attack. Unfortunately, when I removed the Cefaly the pain came back within a few minutes.

    Ive been doing some online research about suboccipital stimulation, and it seems that its being used only for chronic forms of migraine. I have normal episodic migraine with about one attack per week, so I don’t know if it will work. But anything is worth a try.

    Im gonna try this Cefaly device for the full 60 days trial period (they offer money back) and see if it helps to lessen the frequency and intensity of migraine attacks. Then I will probably buy a normal TENS/EMS unit to try also sub-occipital stimming.
    In case I get a TENS/EMS unit then Im definitively interested in the straps you offer, Ill have to get back to you on that later.

    About the carbon rubber electrodes, Ive looked at the internet and it seems that they all need to use gel. Is that a different type of carbon rubber or can they be used both with or without gel?

    • Interesting, I would try the regular TENS machine and see what happens. All of my headache patients had combined supraorbital and suboccipital stimulation, so it might work. My patients with episodic migraines did better than those with chronic migraines.

      For headaches, if you can find one of these machines, it might work great. I always purchase 4-channel machines so I can work more body parts at once, but for headaches I never use more than 2 channels. I think you can find them on the web for like $50-75 retail. They are more than strong enough for what you want to do, and you can program it. They are asymmetrical biphasic rather than symmetric biphasic, but that shouldn’t be a big deal.

      As for carbon electrodes, I just use tap water and make sure they are very wet. If you are putting them over hair, I would make sure the hair is wet. I think the guys on the web want to sell you gel just so they have something to sell since the rubber carbon electrodes seem to last indefinitely.

  5. Hello again,

    Now i have got a normal tens unit with the capability to make all the necesary manual settings, it even has symetric waveform. And I have tried it and compare with the cefaly (actually Im sitting with it on right now).
    I can confirm that with the given settings (60hz, 250 uS pulsewidth and 16 amps) it feels exactly the same as using Cefaly.
    So I will refund my cefaly – it costs about 5 times as much as this unit and the electrodes too are so expensive.

    There are 3 points that I see negative with a normal tens unit:

    The wires hanging in front of the eyes.

    There is a danger for those who are not careful, and may use wrong settings.

    Cefaly increases the strength very smoothly. This unit increases in steps of 1 mA, and when reaching above 12, every step feels really big and uncomfortable. With the cefaly you can just lie down and relax while it increases strength and most of the times fall asleep, not possible with normal tens since you got to increase the strength from time to time.

    I have one question for you. The cefaly team claims that their special shape of the electrodes is important. What do you think of that? Can i cut normal electrodes to the same shape?

    • Rikard, thanks for getting back and providing the interesting comments. What machine did you end up getting? I don’t have a favorite two channel machine that does symmetrical square wave, so if I like the parameters, I might get one to try out.

      You can strap the wires on so they go up instead of down, but no matter what you’ll still look ridiculous wearing it. Also, for your settings I’m pretty sure you are talking about milliamps rather than amps or you would be getting quite the jolt. I thought the 60 hz when I tried it felt prickly, while 120 hz feels like a pleasant buzz. I wouldn’t expect an increased rate to have any additional risk as it wouldn’t penetrate any deeper (though I could be wrong). If your machine has a frequency modulated setting, you might like that too.

      If you are using the sticky electrodes you should be able to trim them with scissors, and if you keep the wire in the center I’d expect everything to be ok. I’d be curious what happens when you do so. I expect what will happen is the stimulation will be less comfortable as smaller electrodes put the same amount of electric stimulation through a smaller number of skin sensors, increasing “current density”, which for a given current usually hurts more. There was, however, one paper that found noxious stimulation beneficial for cluster headaches, so there’s that. I’m skeptical that shape has anything to do with the effects. I personally think one of the reasons I seem to get better results is the use of electrodes that are both larger in size and better in material. Looking at the distribution of the supraorbital nerve and photos of the Cefaly, I thought their pad placement was a bit on the narrow side. That said, I read all the discussion about the Cefaly and someone said their electrodes being real close together would keep the electric stimulation superficial, perhaps avoiding any brain stimulation, so it might improve safety (or might just decrease effectiveness).

      As you experiment, good or bad, I would love to hear how it works out.

  6. Hi Chad,

    The machine I got is this one:

    I find it very good. Nice quality and it has all the features and manual settings available. But I’m not sure that the waveform is symmetrical, to me it feels stronger on the black one on low setting. When I turn it up to 16 mA it feels the same on both sides. The only thing it lacks is that it doesn’t have a lot user storage for different programs, only one storage program in each mode.

    Now I have also tried rubber carbon electrodes. I got squares in size 5*3 cm for the forehead and 50*10 cm for the back of head. I might try to trim them to the Cefaly shape also. I find them quit nice, but on the front they do give some painful sensations higher up on the scalp – like needles prickling – it might be because of the bigger size.

    One thing crossed my mind.. If i do ONS and SONS at the same time, do you think that there might be a risk that a little bit of the current traveling to the other electrode pair – through the brain?

    When giving both ONS and SONS at the same time, how do you attach the electrodes? do you have 2 separate straps or the same for both?
    And even more difficult; how do you fasten the rubber electrodes when doing EMS further down the neck? Seems easier to use sticky electrodes over there.

    • Yeah, if the black wire feels stronger it’s probably an asymmetrical square wave. It should still work fine. My go to electrodes are 10 cm circular, which I use for both the ONS and SONS. You might run into problems if your straps aren’t wide enough to fully cover the electrodes which might be the cause of the prickly sensation for your SONS, but also the smaller electrode area will do that. On my blog about electrode material, I added a video showing what I like and don’t like, which is new since I last linked it. Prickly feelings are generally due to small electrode size or poor connection, either because they aren’t wet enough or the straps not tight enough.

      If you have one channel for ONS and the other channel for SONS the current will be local between the individual leads but not between channels so you should be good there. If you mix and match all bets are off.

      For straps I use one like a headband for the SONS and another around the neck for the ONS. If it’s lower than the neck strap will handle then I generally have my patients lay down on their back on the electrodes (with no pillow) and bodyweight holds them on in place. This is the position I use for headaches because it’s a good cervical retraction posture/stretch which I thinks helps with headaches also. Sticky electrodes generally stick on for a short period, and given that they don’t transmit electricity as good, I think there is always a compromise. However, if you have them and they work well enough for you, I’d use them.

  7. I have a Slendertone Revive professional muscle conditioner (EMS). It comes with extremely large pads and the instructions say not to place the pads near the neck or on the head. The pads are too large to place on the neck, but I am unsure whether the instructions to not place the pads on the neck are because of the pads or b/c of the system. If other pads are compatible with this unit (are pads universal? slendertone doesn’t sell smaller ones for this unit; can I just purchase smaller pads?), could I use this unit for neck pain? I really rather not have multiple units.

    B/c I am leaving my e-mail address, will I receive a notification if you respond? Thanks!

    • Hi Bunny,

      Sorry for getting back to you so late. I was in India over the holidays studying yoga. I’m not familiar with all the parameters of the Slendertone, but if the current is biphasic symmetrical square wave, and it can be programmed for strength I personally would try it on my neck and see what happens. But I wouldn’t tell you to put it on your neck because every EMS machine says not to, based on a 1970s precautions that were never tested and evaluated. However, since then there has been a moderate amount of research suggesting it’s safe. At best EMS to the neck is only a partial answer, correcting faulty posture that probably 90% of the time causes the pain, is still most of the answer. But I think EMS can be a powerful adjunct.

      If your machine has the standard size 2mm (I think) pin electrodes most electrodes should fit. The sticky electrodes I assume you have can usually be trimmed with scissors but rubber carbon electrodes are still better for all these reasons. I totally hear what you are saying about not wanting multiple units. I’ll send a copy of this to your email.

  8. Hello Chad,
    Thank you so much for all the information you have in this post. It has been very helpful for me to read through. I am interested in purchasing a machine called the Sys Stim 208 made be Mettler Electronics, so that I can use it to assist in my constitutional hydrotherapy treatments on myself at home. After trying to buy the machine online I see that you must have a license or a prescription, both of which I do not have. The reason for using the device to assist the treatment is because it has been shown to improve the benefits of the treatment by raising white blood cell count quite significantly during the treatment period. The intention of the treatment is mainly detoxification and immune support when illness is present. If you are familiar with this machine and the treatment that I am hoping to use it for, I wonder if you might be willing to suggest a equal alternative that I can buy without prescription? I am having trouble figuring out if the Sys Stim 208 device is considered to be strictly EMS or EMS/TENS. Whichever one it is, is what I would like to stay with.

    • Hi Amber,

      If you want to reproduce my programs your best bet would be to order a “Globus Triathlon” from Italy off of ebay. I’m not sure where you are located but the USA models, otherwise exactly the same, have the “programmability” feature disabled so my programs can’t be written in. You would still want to get the rubber carbon electrodes and a strap to hold them in place to make the stimulation comfortable. If you can’t find them elsewhere, and you’re in the USA I still have some.

      I don’t have time to fully research the Sys Stim 208, but personally I would be very skeptical of the claims you are talking about. A brief look at it, makes me think it’s overpriced for what it is. The Globus Triathlon is the best stimulator I have used, ever. The Globus Genesy models are just as awesome, programable, but are medical rather than sport models and probably need a prescription. I hope that helps!

      • I looked on ebay for the Twin Stim 4, which is an amazing 2 channel unit for the price. Not as good as the Globus and a bit harder to work with but a lot cheaper. I don’t know anything about this reseller, but it’s this machine. Only the 4 is good, the older 3 or less models use a junky wave form.


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