Electroacupuncture is a “viable treatment option” for horses suffering from headshaking, research has found – as nearly two-thirds of those treated showed improvement.

A study carried out by a team at the Royal Veterinary College (RVC) found the technique had “good success” in treating equine trigeminal nerve-mediated headshaking.

TMHS causes uncontrollable, involuntary flicking and shaking of the head; it can be very painful and distressing for horses and mean sufferers are unrideable; in some of the most extreme cases, it can mean euthanasia.

“Although the exact cause has not yet been identified, it is presumed that the trigeminal nerve in affected horses reacts excessively to external stimulation,” an RVC spokesperson said. “Currently, there is no cure for the condition. However, electroacupuncture, which is the use of needles and an electric current to change the pain perception in the nerve, has been successful in treating TMHS in a small number of cases, but results from a more substantial number of cases have not yet been assessed.”

The RVC team, led by Bettina Dunkel, head of equine and professor of equine internal medicine, emergency and critical care, and with four external collaborators, retrospectively assessed electroacupuncture’s effectiveness in 42 horses treated with the technique between 2015 and 2024.

Data assessed included the horses’ history, duration and severity of TMHS, diagnostic tests, number of electroacupuncture treatments and the effect of treatment as perceived by the owner or main vet.

“The findings showed that the procedure was well tolerated by all horses and achieved a significant improvement in headshaking, with the median grade before treatment at three and after treatment at one,” the spokesperson said.

“Overall, 64% of cases showed an improvement in TMHS after their final treatment, with complete resolution of signs seen in 33% of horses. No improvement was seen in 31% of cases and two horses (4.8%) experienced worsening of clinical signs post-treatment.”

The team concluded that electroacupuncture was well tolerated with minimal complications and improvement in most horses. The advantages of the treatment include the fact it has a low complication rate and can be carried out in the yard.

Professor Dunkel said: “Electroacupuncture is a viable treatment option for horses suffering from this devastating disease. We are very pleased with the results of the study and hope that it will encourage veterinarians and horse owners to pursue this treatment option.”

Refining the technique

The team suggested that refinement of the technique over time, such as changing the duration of the treatment or electrical frequencies, could help increase the success rate and create longer remission periods.

Equine vet Sue Devereux, the author of the first study in this area in 2017 (vet clinic, 2 June 2022), told H&H the treatment is a major step forward as apart from the use of nose nets and masks, “which I wholeheartedly recommend”, the condition is so hard to manage.

“The results of this study with a larger number of horses are very encouraging as they are consistent with the earlier findings and confirm that electroacupuncture is a worthwhile treatment option for TMHS,” she said. “It is important that other possible causes of head shaking are always ruled out first.”

Ms Devereux said she was inspired to use the treatment on more horses by a dressage mare called Izzy who had been “tormented” by TMHS and had been unrideable in spring and summer for three years.

“She responded remarkably well, remaining free of signs for longer than we had dared hope and was able to compete all year round,” she said. “This encouraged me to treat other cases.”

She added that although factors such as pollen, sunlight, wind and rain can trigger headshaking, it is still not known what causes the effect on the nerve.

“If only we could establish the causes of this painful condition, then we would be closer to finding a cure,” she said.

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Some horses are more sensitive than others, and the best nose nets for horses can help those who are sensitive to flies, pollen, the sun and wind. Nose nets are also a useful bit of kit if your horse is prone to headshaking, as they can help to reduce the behaviour in some cases.

Nose nets are mostly worn while riding, although they can also be attached to a headcollar for use in the field. Most nose nets are designed to fit on bridles with traditional cavesson nosebands, but there are some that are designed to fit on anatomical bridles and bridles with grackle nosebands, too.

Can nose nets be worn in competition?

Nose nets are allowed under British Dressage, British Eventing and British Showjumping rules, but not if you’re competing under FEI rules. Some governing bodies require them to be a discreet colour – matching your horse – and only cover the nose, so it’s best to double check your rulebook beforehand.

Best nose nets for horses

LeMieux Comfort Shield Nose Filter

Colours: Black or brown | Sizes: S–L | RRP: £19.95 |

This nose net is made of a fine mesh that effectively filters dust, pollen and other air born particles. It has undergone some design improvements and now has a more secure touch-tape closure on the inside. The length can be easily adjusted by fastening the touch-tape tighter and the cut-away front section means it can accommodate flash and grackle nosebands, making it the most versatile nose net in this guide.

Legal for use in BD, BE and BS competition. It is machine washable, but LeMieux recommend hand-washing where possible.

In the UK? View now at amazon.co.uk

In the US? View now at amazon.com

Equilibrium Net Relief Muzzle Net

Colours: Black, brown or white | Sizes: S, M/L or XL | RRP: £29.99 for a pack of three |

Unlike some nets that cover the whole muzzle, this contoured design covers only the top half of the muzzle meaning it’s unobtrusive and allows saliva to escape from the mouth freely.

This net is designed to have a rough, but comfortable, thin mesh, which theoretically provides relief by gently “scratching” the horse’s nose. It needs to sit close to your horse’s muzzle and, therefore, the mesh is designed to be able to cut to length if necessary.

If you’re looking for a white nose net for a grey horse, Equilibrium is your best option.

In the UK? View now at amazon.co.uk, equilibriumproducts.com, viovet.co.uk, gsequestrian.co.uk or naylors.com

In the US? View now at amazon.com

Equilibrium Net Relief Muzzle Net for Micklem bridles

Colours: Black | Sizes: Cob/horse | RRP: £34.99 for a pack of three |

This nose net has all the same features as the standard Equilibrium net, but is designed specifically for the Micklem and other anatomical bridles.

Unlike some nets that cover the whole muzzle, this contoured design covers only the top half of the muzzle meaning it’s unobtrusive and allows saliva to escape from the mouth freely.

This net is designed to have a rough, but comfortable, thin mesh, which theoretically provides relief by gently “scratching” the horse’s nose. It needs to sit close to your horse’s muzzle and, therefore, the mesh is designed to be able to cut to length if necessary.

In the UK? View now at equilibriumproducts.com, viovet.co.uk or gsequestrian.co.uk

In the US? View now at amazon.com

Equilibrium Net Relief Muzzle Net for grackle bridles

Colours: Black | Sizes: Cob/horse | RRP: £34.99 for a pack of three |

This nose net has all the same features as the standard Equilibrium net, but is designed specifically for bridles with grackle nosebands.

Unlike some nets that cover the whole muzzle, this contoured design covers only the top half of the muzzle meaning it’s unobtrusive and allows saliva to escape from the mouth freely.

This net is designed to have a rough, but comfortable, thin mesh, which theoretically provides relief by gently “scratching” the horse’s nose. It needs to sit close to your horse’s muzzle and, therefore, the mesh is designed to be able to cut to length if necessary.

In the UK? View now at equilibriumproducts.com, viovet.co.uk or gsequestrian.co.uk

In the US? View now at amazon.com

Hy Nose Shield

Colours: Black | Sizes: Pony, cob/full or extra-full | RRP: £10.99 |

This nose net is shaped to cover the muzzle, and fastens with ties at each end.

In the UK? View now at amazon.co.uk, viovet.co.uk or gsequestrian.co.uk

Busse Fly Protector Nose Net

Colours: Black | Sizes: Pony or cob/full | RRP: £12 |

This nose net fastens to the bridle or headcollar with Velcro, protecting your horse from annoying insects and UV rays. It is machine washable.

In the UK? View now at ebay.co.uk

HKM Nose Nets

Colours: Black | Sizes: One size | RRP: £14.95 for a pack of three |

These nets are available in one size only, but are easy to fit to your horse by simply folding them up until they fit the muzzle. The set includes three black nets and one reusable velcro strap. Machine washable.

In the UK? View now at gsequestrian.co.uk or ebay.co.uk

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Tributes have been paid to a “unique” event horse who overcame difficulties with headshaking to compete at advanced level.

David and Viv Chadwick’s Welton Hawkes Bay, bred by the late Sam Barr of Welton Stud, has been put down in retirement aged 20. The son of Welton Ambassador started his early eventing career with John Marsden and later Paul Sims, before Tyler Cassells took over the reins in 2010.

Tyler told H&H gaining the ride on “Kes” had been a brilliant opportunity.

“The partnership took some work to begin with. Kes was very sensitive and a headshaker. We clicked quite quickly but the biggest thing was getting him happy in his mouth,” he said.

“Around a year after I took him on we had him tested for allergies and found he was allergic to stainless steel so he went on to do everything in a rubber snaffle. I would warm him up in a fly mask, take it off just before going down the centre line, and soon his dressage scores became more consistent. It was about managing him.”

Tyler and Kes moved up the levels and completed their first advanced together at Weston Park in 2012 where they went double clear.

“Kes took me round some of the biggest courses and a highlight was jumping one of the London 2012 cross-country fences at Aston-le-Walls, after the fences had been distributed following the Olympics,” said Tyler.

“He had a unique jump where he really put in the power and we grew together. He lived in an outdoor stable at the top of the yard and thought he was the bees’ knees – he knew he was number one.”

Kes stepped down from top-level eventing in 2015 and returned to his owners for a quieter life with their daughter Ellen Little and became a regular at Pony Club, where he was used to teach riders the ropes.

“He mellowed with age and was a good first horse for people. I always stayed in touch with David and Viv and even taught Kes once at Pony Club, which was lovely,” said Tyler.

Tyler said the gelding had a “great summer” but had been starting to “feel his age”. He had become uncomfortable in his joints and had arthritis in his feet, so the decision was made to put him down before winter.

“He was such a character and a trier and a character. I will always have very fond memories of his unusual technique and him always trying his heart out for me,” he said.

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The owner of a horse who was given about a 50% chance of survival as he was in such pain says she will never trim whiskers again.

Eloise Towning’s former racehorse Blue Blooded (BB) progressed from his normal self to an unrideable head-shaker within weeks, in summer 2017. She spent thousands of pounds trying to get to the bottom of his new behaviour, to no avail.

“I love him more than anything but when I got to [the equine hospital] in the October, and the vet said if he didn’t get better after the treatment, he’d have to be put to sleep, by that point, I just wanted him not to be in pain,” Eloise told H&H.

“It didn’t matter what I wanted; if that was the only option, we’d have done it.”

Eloise had bought BB in 2016. He had suffered a check ligament injury, and was coming back into work in the next summer, so she tidied him up, including trimming his whiskers, as she and her family had always done.

“I never made the connection,” she said. “He started nodding, and over the next five weeks, it got to the point where he’d stand at the back of his stable with his eyes closed and wouldn’t move, it was awful.

“The vet had said head-shaking was something that didn’t often end well; the horse often has to be put to sleep and I thought ‘What do you mean?’ I’d never heard of head-shaking or neuralgia.”

Head-shaking can be caused by hypersensitivity of the trigeminal nerve in the head, which responds as if it has encountered a painful stimulus. Although it is a misfire, the pain felt by the horse is real.

By the end of September, Eloise had had a battery of tests carried out but was no nearer to finding the cause of BB’s issues.

“He was so uncomfortable; walking round the field, flipping his head or in the back of his stable,” she said. “He was referred to the equine hospital, where the vet said if the treatment they were going to do didn’t work, he’d pretty much have to be put to sleep.

“She said he was in so much pain; it’s sensory overload, and like having a migraine, and ants running all over your head.”

BB was given PENS neuromodulation treatment, which is also used in humans to give relief from neuropathic pain. The aim was to try to override the nervous system and almost reset the trigeminal nerve.

“He had another treatment three days later so he had to stay there,” Eloise said. “I was dying because I couldn’t see him, and they kept texting to say there was no improvement.

“Two weeks later, he had another go, and when he got home, he was slightly better, but still head-shaking.”

Over the next few weeks, BB got better and better; by November, he was back in ridden work, and he has not looked back since.

“It lasted from August to December, and that’s how long his whiskers took to grow back,” Eloise said. “My vet, who’s incredible but old-school, told me not to be so stupid, that can’t have been the cause, but the more I think about it, the more it makes sense.”

Owing to the ligament injury, that summer was the first time Eloise had trimmed BB’s whiskers. She was warned it can often be a seasonal conditions, so she dared not plan any competitions the following spring, but he has not suffered since.

“There’s no science behind it being his whiskers and lots of people think differently; he could have just got better, but the more I investigated, the more it made sense,” she said. “The vet kept saying he had sensory overload, it was all in the head, and the whiskers are sensory, and it’s all the same area.

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“Some head-shakers only do it in daylight, but he did it all the time; it makes you think.”

Eloise said she had always trimmed whiskers, without realising their true function.

“I had no idea,” she said. “I’m never touching them again.”

H&H vet Karen Coumbe said: “The whiskers provide almost constant sensory input from all the nerve signals received from their touch receptors, which dampen other signals going to the brain. So, if the whiskers are removed, it can alter pain perception.

“It is very possible that this will affect the horse’s brain and potentially trigger head-shaking. It will be interesting to see if the new legislation will reduce the incidence of head-shaking going forward.”

Horse & Hound magazine, out every Thursday, is packed with all the latest news and reports, as well as interviews, specials, nostalgia, vet and training advice. Find how you can enjoy the magazine delivered to your door every week, plus options to upgrade to access our H&H Plus online service which brings you breaking news as it happens as well as other benefits.

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• This article has been edited and approved by Karen Coumbe MRCVS, H&H’s veterinary advisor since 1991.

The horse repeatedly tossing the head vertically or rubbing its nose on a foreleg are typical signs of the condition known as headshaking in horses. This frustrating and painful syndrome can have a significant impact on the horse’s welfare.

Back in the 1980s, headshaking was assumed to be bad behaviour but is now known to be a distressing and debilitating medical condition.

Headshaking is found in 4.5% of the UK horse population, and one in five diagnosed horses do it at rest, while the remainder only headshake when ridden or lunged. It is reported to be more common in geldings than mares and stallions, and although it can appear at any age, it often first occurs between the ages of six and 12.

If a horse cannot be ridden due to this condition, or it’s clearly in pain when not ridden, then retirement or euthanasia may have to be considered. Since the 1980s a range of treatment options have been developed that can help many horses, but they do not work in all affected equines.

Headshaking in horses [1,564 words]: Causes | Management | Diagnosis | Treatment | Current research | Prognosis

Why do horses headshake?

There is a range of potential reasons for a horse to shake its head. Some cases are caused by allergies, sinusitis, dental pain, and a number of other conditions. These all need to be ruled out as part of the clinical investigations into the cause of the condition.

The form of headshaking called trigeminal-mediated headshaking is a different disease than other potential causes of headshaking-like behaviour. It is caused by hypersensitivity of the trigeminal nerve – the nerve in the head that provides sensory information around the eyes, teeth and nostrils among other areas.In the case of trigeminal-mediated headshaking, the nerve responds as if it has encountered a painful stimulus, but it’s a nerve ‘misfire’ rather than a ‘real’ stimulus, although the pain felt is real.

Experts believe that when triggered, the nerve sends an electric shock-like sensation to the horse’s brain, leading to the extreme response. This is based on the experiences of people who have a condition called trigeminal neuralgia, which is similar in certain respects.

While vets have compared headshaking to trigeminal neuralgia in humans, it is not the same disease. In humans, it’s associated with delamination of the myelin sheath, the membrane that wraps around nerves. Researchers have looked at the myelin sheaths of affected horses and found no damage, thus the nerve functions abnormally while appearing normal. This has lead to speculation that there is another underlying condition.

About 60% of headshakers are worse in the summer, which leads some to believe the condition is related to an allergy of some kind. Experts believe that while it is related to the environment in some way, as these horses are responding to an environmental stimulus, they can’t yet say what or why in every case. Known triggers include bright sunlight, wind and pollen.

Ways to manage headshaking in horses

Steroids and other drugs commonly used to treat allergies do not have any significant effect on trigeminal-mediated headshakers. However, there have been cases where a horse has improved when moved to a different yard, or where the horse doesn’t headshake when it arrives at a veterinary clinic for further investigations. This remains one of the most confusing aspects of this disease.

If a horse is a suspected headshaker, vets sometimes recommend the owner does a bute trial, while emphasising that neuropathic pain is unlikely to be altered by this. If a horse responds positively to a bute trial, it has head pain somewhere, but it is not a trigeminal-mediated headshaker. Often with bute trials, it’s assumed that if the bute doesn’t work, the problem is behavioural, but because of the nature of neuropathic pain, that’s not the case. However, it can provide vets with information.

Nose nets are usually the first line of treatment recommended — a mesh fitting over the noseband of a bridle or halter that covers the horses’ nostrils. This leads to an improvement in about 25% of horses by around 75%. So, if you have a mild headshaker, this could be a useful piece of equipment to try. It was originally thought that nose nets work because they affect the particles or the moisture and airflow within the nostrils. But now experts believe they work by constantly stimulating sensory nerve endings in the nose, which can suppress the overactive nerves that are sending sharp pain signals to the brain. This reduces the painful sensation rather like rubbing part of your body after you bang it on something.

If sunlight is considered to be the trigger, then affected horses may be stabled during sunny spells or turned out with an ultra-violet blocking face mask.

Diagnosing trigeminal-mediated headshaking

When horses come into a specialist equine hospital, the diagnostic procedures they undergo mainly rule everything else out. The condition can be challenging to diagnose as horses can vary from day-to-day, or season-to-season, so video footage supplied by the horse’s owner can be very helpful.

There is only one test that definitively diagnoses trigeminal-mediated headshaking, and it involves stimulating nerves on the gum of a horse under general anaesthesia and measuring the response, but because of the risks involved, this is not performed in the UK. The vet will do an examination of the eyes and mouth and possibly a CT scan of the head, which will show any structural abnormalities including dental disease, sinusitis, or any other ‘gross pathology’ — meaning something you can see.

They would also do an endoscopy of the upper airway and look for any pathology such as lesions or swelling inside the nasal passages or throat that might cause the behaviour.

Obviously if the vets see anything, they treat it, but if the CT scan and endoscopy do not show any abnormalities, that moves the horse towards a presumptive diagnosis of trigeminal-mediated headshaking. Effectively, it’s a diagnosis of exclusion.

On occasions the vets will do a nerve block of the maxilliary nerve. If this eliminates the behaviour, it means the problem is in that part of the nerve, but a negative response does not rule neuropathic pain out. The source of the pain could be behind the nerve block further up the same nerve closer to the brain. But as with other diagnostics, it may give the vet more information. The procedure is tricky to perform and can exacerbate the headshaking, hence it is not always undertaken.

Treatment options for headshaking in horses: can drugs help?

While there are drugs that treat neuropathic pain in humans, such as Gabapentin, they do not work well in horses. Some combinations of anti-histamines and anti-epileptics have been tried with mixed results, but they are not licenced for use in horses and can cause sedation as a side effect. Dexamethasone, a steroid, has been tried, with no clear evidence of improvement. Also, plenty of horse owners have tried supplements and homeopathy, but none of these have withstood rigorous scientific assessment, although anecdotally some may help in some cases.

Neurectomy

Most owners are aware of neurectomy as a treatment for lameness — cutting a nerve so the horse no longer feels pain. So, might this work for trigeminal-mediated headshaking? It was tried on 18 horses in the 1980s. Three got better, but it left the horses unable to feel their face, which caused serious welfare issues. While it helped to advance veterinary medicine’s understanding of the disease, it was not humane.

Coil surgery

The only accepted surgery for headshaking involves placing platinum coils in the back of the intraorbital canal. The coils expand gradually and cause pressure on the nerve. It’s done under general anaesthesia and has significant risks. After surgery, it can irritate the nostrils and nasal cavity and be quite distressing for the horse and its handlers. The success rate is around 50%. However, out of 58 horses in a study that had the surgery, four were put down due to the serious side effects. It’s generally only chosen in cases where the headshaking is severe and has not responded to any less invasive treatment, leaving euthanasia as the only other option.

EquiPENS

One treatment option that is currently in use is called EquiPENS. It’s a form of neuromodulation — altering the nerve activity by firing either an electrical or chemical stimulus into it — that was first used in humans (called PENS therapy). A probe is passed through the skin and placed over the nerve in the face and it sends an electrical impulse while the horse is under standing sedation. In a study of 168 horses, half responded positively but only one-quarter of those stayed in remission long-term. However, with top-up treatments, some of those who reverted back to headshaking stayed in remission longer.

The good news is that PENS treatments have few side effects or complications, but it is costly at around £700 per treatment. Horses initially get three treatments, but may need further ones which means the cost easily gets prohibitive to the average owner.

Electroacupuncture

A similar treatment called electroacupuncture, which also stimulates the nerve with electric impulses, is currently being studied at the Royal Veterinary College. A separate study using six horses showed encouraging remission times in three of the horses.

Electroacupuncture is far cheaper than PENS, and if it withstands a rigorous study, it’s potentially a viable option for more owners. The treatment can be performed at the stable yard, avoiding the need for the horse to travel.

Current research

Researchers at Bristol University are conducting a study of amino acids that stabilise nerve membranes in people, rats, and cats. Amino acids have less side effects than conventional pharmaceuticals and are competition-legal.

A recently published study from the University of Californina, Davis, California, has show that supplementation of the diet with magnesium and boron can reduce headshaking behaviour in some affected horses.

There is much still to be learnt about this condition as it is very variable and the majority of cases only headshake when tacked up and lunged and ridden, and far fewer horses do it just in the field or stable.

Prognosis

Currently the future for horses diagnosed with trigeminal-mediated headshaking is questionable at best. Some cases can be managed by simply wearing a nosenet during ridden exercise and appear unbothered by the condition while not working, while others clearly suffer from considerable ongoing pain, leaving euthanasia as the only option on welfare grounds. However, it is hoped that the continued research into new treatments for the condition will mean a brighter outcome for future cases of headshaking in horses.

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A veterinary student has received funding to investigate whether dietary potassium levels could be the “missing link” in solving the root cause of headshaking.

Emily Westwood, who is studying at the Royal (Dick) School, has been awarded a bursary by World Horse Welfare to conduct a soil analysis comparing stable yards where there are headshakers to establishments without any cases.

An “extremely promising” preliminary study conducted last year revealed 70% of fields where there were headshakers had high or very high potassium levels.

Potassium is an electrolyte central to cellular and electrical function, forming part of the sodium-potassium pump that transmits nerve impulses.

Emily’s theory is that the more potassium there is in a cell, the more positively charged the cell will be, so it is more likely to react.

“In some horses there may be a misregulation that makes them susceptible to problems when there are high potassium levels in the diet,” she said.

Emily was prompted to analyse soil samples after her own horse started headshaking following a yard move from Lancashire to Cheshire and speculated that high potassium levels could be behind the debilitating condition.

“Once I moved my horse again, the problem stopped,” she said. “Potassium levels in Cheshire were double what they are here.”

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Headshakers are thought to suffer from an as-yet unidentified pathology which causes stimuli such as pollen, rain, wind, bright sunlight or ridden work to provoke the characteristic vertical head-tossing.

While milder cases can be managed, some severely affected horses have to be put to sleep as the nerve pain in their faces can seriously impair their quality of life or make them dangerous to ride and handle.

Emily said that while vets are able to analyse the levels of potassium within the blood, they are not able to establish the levels within the cells — which carry a much higher concentration.

“Given the fact that there is 140mmol/l of potassium inside a cell, compared to only 4mmol/l outside (extracellular), we are only seeing the tip of the iceberg when we are blood-testing,” Emily said.

“It is near-impossible to test for intracellular potassium levels, however if we find that the soil these horses are grazed on, or the haylage cut from this pasture has excessive levels of potassium in comparison to pasture which hasn’t been fertilised etc, it may be possible to suggest that it is in fact the horses diet that may be contributing to this condition.

“Hopefully cutting the amount of potassium in the diet may prove enough to significantly reduce symptoms.”

Insulin and adrenalin are substances that can cause more potassium to be drawn into cells, and Emily believes modern management may be contributing to the increase in headshaking cases.

“We have fatter horses now [causing higher levels of insulin],” she said.

“The affect of adrenalin on potassium uptake might also explain why some horses only start to display headshaking symptoms 10 or 15 mins after they start work.”

Emily said the study would be taking place over the next 18 months, and she hopes the results will reinforce her preliminary findings.

“I am extremely excited about this study as research into the cases of idiopathic headshaking is extremely limited and I feel that any investigation into an explanation of this upsetting and frustrating condition is very much needed,” she said.

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Rick Farr of Farr & Pursey Equine Vets shares his expert advice on PENS therapy in relation to head shaking

Q: “PENS Therapy: Have any of you sent your horse for PENS Therapy for headshaking? My vet seems keen to try this if the current drug trial doesn’t help, but reading about it I can’t see much point realistically. I understand that it seems to take two or three goes to bring about any short term benefits and then appears to need a “top up” as and when afterwards. At £1,500/2,000 a go, it’s a no-go for me after the insurance money has run out. However, if anyone has a success story I’d love to hear it, plus any advice you might be able to share. The headshaking problem has been ongoing for nearly a year (on and off) and I’m no nearer to finding what triggers it off.”

A: Most horse owners have either seen, or experienced, a classical headshaker and can understand the frustrations that come with its management; so is PENS therapy a potential solution?

PENS therapy stands for “Percutaneous electrical nerve stimulation (PENS)”, which is used in the treatment of neuropathic (nerve-related) pain that has not responded to other treatments. It is very important to note that there are many potential causes of headshaking in horses, ranging from dental and sinus disease to primary orthopaedic pain. With this in mind, it is essential that all patients who would be considered for PENS therapy undergo a CT scan to rule out other potential causes of headshaking first; it is more common to find other causes!

PENS therapy has been a recognised treatment in people with neuropathic pain and has even been assessed by ‘NICE’ (National Institute for Health and Care Excellence) since 2013. It essentially involves placing a small needle under the skin in order to stimulate a nerve (usually the Trigeminal Nerve). This is a minimally invasive procedure and is well tolerated by the majority of patients. An initial course involves three treatments, with five days between the first and the second treatments, and 10 days between the second and the third treatments.

Continued below…

Related articles:

• H&H forum: find out what H&H readers suggested
• Understanding headshaking
• Headshaker success story *H&H VIP*

One of the first papers to cover its use in horses was published in 2015 which, although only covering seven horses, showed promising results, with its efficacy increasing with the number of treatments over the short to medium term. It is always difficult to recommend any treatment while in its infancy in any new species, however, in 2016, a further abstract was published showing the results of 48 horses from five referral centres since 2013. So what were the results?:

• Out of the 48 horses seen, 138 treatments were conducted; no significant adverse effects were reported.
• All but seven horses underwent the ‘standard’ initial three procedure course.
• Success was judged as remission of clinical signs sufficient enough as to allow ridden exercise to the horse’s previous level; 16 out of 41 cases attained this (i.e. 39% of the horses treated returned to their previous level of ridden work).
• The average (mean) remission length was 10 months (range from 0.5-27 months).
• Remission of at least two months’ duration was obtained in 34% of the horses treated.

In summary, the treatments resulted in remission of the head shaking (to allow ridden exercise) in approximately one-third of patients.

Genuine head shakers, which have undergone a CT scan and are unresponsive to other conventional therapies such as nose nets, “bute” trials, environmental changes and even the use of contact lenses do, in my opinion, warrant PENS therapy, even despite the 34% success rate to remission for two months. These cases are not only distressing for owners to see but are even more distressing for patients. Cost is always an issue and, with an initial course (three treatments) costing around £1,800, I appreciate it is a substantial investment.

There are several referral centres throughout the UK offering this treatment and I would highly recommend pursuing this treatment course if your horse falls into this very specific category.

For all the latest equestrian news and reports don’t miss Horse & Hound magazine, out every Thursday

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Blue skies and a burgeoning competition schedule mean most riders long for the summer, but for some owners it’s not all plain sailing. Agnes Stamp meets one owner whose horse has been struggling with headshaking, and finds out what they've been doing to combat it

The horse: Benji, a 13-year-old 16.3hh eventer

The problem: headshaking

Symptoms: Frankie Lampl bought ex-National Hunt thoroughbred Benji in the summer of 2013. Looking back, Frankie admits he did headshake once or twice but “he was quite stiff and tense at the time so I put it down to schooling — it wasn’t enough to indicate a problem, plus I’d had him vetted.”

By the following summer, Benji’s headshaking was becoming more noticeable.

“It was particularly bad when we went past certain hedges,” remembers Frankie, “and worse at certain venues compared to others.”

The vet gave Benji a full workup, including X-rays and blood tests, which diagnosed his headshaking as a probable allergy.

By July 2016 Benji’s headshaking was so bad could barely get through the dressage and he would violently rub his face against the side of the lorry. This year the headshaking has started even earlier — in February — and seems to be getting worse.

“It is visibly distressing for him,” says Frankie. “If it continues on its current path, retirement in a field does not look like an option. If only I could cryogenically freeze him over summer — he’s a fabulous hunter.”

Continued below…

Laminitis: how to spot the signs, plus treatments and ways to prevent it

Sweet itch in horses: what all horse owners need to know

Management strategy: after the vet’s initial diagnosis Benji was prescribed steroid inhalers (which didn’t seem to have an effect) but riding him in a nose net seemed to help. Frankie has also tried riding Benji in a fly mask, riding inside and riding in the evening.

“All these things gave occasional moderate improvement but it may just be coincidental,” says Frankie.

Frankie has also administered Piriton Allergy tablets, starting with a dose of six tablets daily in 2015. This year she plans to up the dose to 20-30 tablets a day.

“They should work as the headshaking was originally diagnosed as an allergy (the blood test showed histamine) but results were mixed last year — perhaps I didn’t give him enough.”

“Piriton is on the FEI prohibited substance list, so even if it works he will not be able to event any more. The priority for now is just to make him comfortable.”

If you are concerned about any summer ailments your horse is suffering from, please contact your vet

This article was first published in the 1 June 2017 issue of Horse & Hound magazine

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Just eight months after buying her Polish warmblood gelding Theo, Zoe Chilcott discovered that the seven-year-old developed signs of headshaking, writes Veronica Roberts MRCVS (author of the featured study).

“In October 2013 he suddenly started to headshake,” explains Zoe. “He was so frantic with shaking and rubbing his head that he became unsafe to lead on a headcollar, let alone ride. His future looked bleak.”

Zoe’s local vet was aware of a trial I was running with colleagues at Langford Veterinary Services, using a revolutionary treatment aimed at relieving the effects of headshaking. After referral, Theo underwent three treatments and has remained in remission since February.

“Theo is still a sensitive horse but no longer has any restrictions, and you would never guess he had been diagnosed as a headshaker,” says Zoe. “The treatment has given him a future.”

Most of us know of at least one headshaker. This distressing condition currently carries a poor prognosis, with many horses becoming unrideable due to frequent and uncontrollable vertical headshaking, often accompanied by signs of nasal irritation such as snorting and nose-rubbing.

Traditional treatment is often ineffective. Yet this new research, to appear in the Equine Veterinary Journal, indicates that in certain cases the condition can be brought under control.

Many horses displaying classic headshaking signs are suffering facial pain from a neuropathy (nerve disease) of the trigeminal nerve, the main sensory nerve to the face.

Further studies are needed to find out how many horses suffer from trigeminal-mediated headshaking, but it is thought that 1-2% of the UK equine population (between 10,000 and 20,000 horses) are affected.

Horses usually develop the condition somewhere between the ages of five and 12, and it may be a little more common in geldings. Onset is more likely to be sudden, as in Theo’s case. Owners typically report that the horse reacted as if a bee had flown up his nose.

Headshaking can occur at rest but is usually worse with exercise and is rarely seen in a horse turned out in a field. About a third of horses are affected only during spring and summer months.

The cause of headshaking is not clearly understood. All we know is that the trigeminal nerve is sensitised and therefore “fires” at a lower than normal threshold.

Diagnosis and treatment

My starting point for diagnosis is to listen to the horse’s history before performing a thorough clinical examination.

Establishing whether the headshaking is occurring due to facial pain can be achieved with nerve blocks, in exactly the same way that an orthopaedic clinician uses nerve blocks to locate the source of lameness.

I observe the horse headshaking, usually at exercise, then inject local anaesthetic around the trigeminal nerve by inserting a 10cm needle behind the horse’s eyes.

The horse is then exercised in the same conditions. If the problem has resolved, this confirms that the headshaking is due to facial pain. If not, it does not necessarily rule this out as a cause.

I then look for gross pathology (visual evidence) that could be responsible, by examining the mouth and eyes, performing endoscopy of the upper respiratory tract and guttural pouches and carrying out computed tomography (a CT scan) of the head.

If we find no abnormalities, it is most likely that the horse is a trigeminal-mediated headshaker. Severity can be graded out of three. Unfortunately, the outlook is often poor.

Using a nose-net improves signs in about a quarter of horses. This is thought to work by rubbing the nose and constantly stimulating the nerve — in a similar way that rubbing your elbow if you bang it makes it feel better. A nose-net is non-invasive, cheap and can be used in competition, so it is the first treatment to try.

A number of medications used for human neuropathic pain can be tried and some horses will respond. These treatments have limited efficacy, however.

Tablets can be expensive and are prohibited in competition.

There is a surgical procedure to compress the nerve using platinum coils, which carries a long-term success rate of about 50%. In a study we performed, however, four out of 58 horses had to be euthanased due to side effects — so I wouldn’t recommend surgery unless euthanasia is the only other option.

While myriad treatments and feed supplements can be found online, but for a true trigeminal-mediated headshaker these will largely be ineffectual.

A management breakthrough?

Working in collaboration with the neuroscience team at Bristol’s Southmead Hospital, we have been trying a treatment used in humans for neuropathic pain on horses with trigeminal-mediated headshaking.

Called neuromodulation, the treatment involves percutaneous electrical nerve stimulation (PENS) therapy and aims to reset the threshold level of the nerve for firing to normal. A probe is placed directly over the nerve and stimulates it for a set time.

In humans, the only reported side effects are a bruise at the site of probe insertion. If humans respond to treatment they can expect pain relief for a few hours, perhaps up to week, after the first treatment.

Relief can last from a few days up to two weeks after the second treatment, and from two months to occasionally six months after the third.

After three treatments, required treatment interval seems to remain the same.

We have just published results from a clinical trial in seven horses with grade 2/3 or 3/3 headshaking. The procedure was safe and well-tolerated by all under standing sedation.

Five horses responded well and returned to ridden work, with duration of remission after the third treatment being between 2½ months and still ongoing at 10 months in one horse.

The procedure is still in its infancy, and is merely a management technique rather than a cure. However, early results in some cases have been good and the risk of adverse effects appears to be low, although there are always risks to performing procedures with horses under standing sedation.

In the absence of an effective, safe and well-established cure for trigeminal-mediated headshaking, I am trying this as a first-line treatment where nose-nets have failed to work.

Ref: Horse & Hound; 25 December 2014

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Riders who are contemplating having their animal put to sleep because of headshaking are asked to donate their horse to researchers trying to find a cure for the condition.

Veronica Roberts of the University of Bristol’s vet school, is studying similarities between equine headshaking behaviour and human complaints like neuralgia.

She needs horses whose headshaking has been proven to be due to facial pain.

“I have limited funding, but it is enough for me to fund post mortems for five headshakers and five normal horses,” Veronica told H&H.

“I need three more headshakers, but they must have undergone a good veterinary investigation to show their headshaking is due to facial pain.”

The most common cause of neuralgia in humans is demyelination of the infraorbital nerve — where a nerve running through the face loses its insulation and becomes hypersensitive.

If this proves to be a cause of headshaking in horses, treatment for human sufferers could be adapted for equines.

“That is a long way down the line. First, I need to find out what is causing the facial pain — is it demyelination? — and why,” said Veronica.

If your think your horse fits Veronica’s profile, ask your vet to contact her at Veronica.Roberts@bristol.ac.uk

You will need to transport your horse to Bristol University for it to be put to sleep, but Veronica will pay your travel and euthanasia costs.

This news story was first published in the currrent issue of H&H (10 January 2013)

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A new nose net to help horses irritated by flies has been launched.

The Cashel Crusader Quiet Ride Nose Net aims to provide relief from flies, bugs, pollen and other irritants to reduce head shaking.

It attaches to the noseband on any standard bridle or ties down with a velcros hook and loop fixing and covers the horses nostrils and protects from flies bugs and other irritants.

“I am really excited about this new addition to the Cashel range,” said Karl Middleton, managing director of KM Elite Products, who supply the range.

“We have tested this nose net on a large number of horses that either head shake or have irritation from flies and have had excellent feedback from owners saying they have seen a significant improvement when riding.”

The nose net is also legal to use under British Dressage and British Eventing rules and retails at £7.99.

For more information visit: www.kmeliteproducts.co.uk

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Headshaking is an extremely frustrating and disabling condition for affected horses and their owners.

It may manifest as just an occasional nod or jerk of the head, or it may develop into violent, exaggerated head movements that prevent any work or training.

It is often seasonal and linked to bright sunlight.

The list of possible causes seems almost endless, from allergies to photophobia, neuralgia to ear mites and toothache to sinusitis.

And treatments are wide-ranging — nose nets, antihistamines, anticonvulsants, surgery on the nerves, dental work, ear plugs — you name it, it has probably been tried.

The fact that no one therapy works for all shows the problem cannot have just one cause: the headshaking is a sign of irritation, stress or distress which may be caused by any number of factors.

Cambridge University vets have recently reported another therapy: sodium cromoglygate eye drops.

In a number of horses, seasonal and light-stimulated head-shaking was either cured or significantly improved by daily usage.

The drug is normally used to control allergic asthma in humans as it prevents the liberation of allergic chemicals by cells of the immune system.

Just how or why it might work in the eyes of head-shaking horses is unclear, but it does, and it gives vets another tool in their growing head-shaking treatment toolbox.

This article was first published in Horse & Hound (27 November, 08)

The Philip Leverhulme Equine Hospital at the University of Liverpool is currently undertaking an experiment to try to alleviate the symptoms of headshaking.

The trial involves feeding a natural supplement and a placebo to a horse/pony who suffers from headshaking.

A technician from the university will video the horse’s behaviour before, during and after the trial, which will run over the summer.

Owners of headshaking horses who wish to take part are asked to contact (tel: 0151 7946008) for further information.

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Helen Vos owns Keiman Crays (“Casey”), a 13-year-old Welsh section D. He is a riding club all-rounder, with British Dressage points. Casey’s headshaking left him almost unrideable from spring to autumn.

Problem

“Casey began headshaking at the age of five and on warm days or when the flies were out, he would twitch and flick. On a really bad day, he would become very overbent, tucking his nose between his legs and sometimes dragging it along the ground. Riding in woods or near hedgerows was a problem. He would sneeze and rub his nose against the stable wall after he had been ridden, as if to alleviate a bad itch.

“Sometimes, I’d arrive at a dressage competition but would have to withdraw because Casey was so distressed. In dressage classes, I’d get comments such as ‘unsteadiness of head’ and ‘twitched up centre line’.”

Advice given

“I had Casey endoscoped, and his teeth and tack checked. Vets tried acupuncture and homeopathy — neither helped at all. The vet suggested I bought a TSE machine, which is a bit like a TENS machine and is strapped to the horse’s neck. The endorphins released are supposed to relax the horse. I would put it on Casey every day and he loved it. But it didn’t make any difference to his headshaking.”

What she tried

“People had lots of ideas, such as rubbing Vaseline around Casey’s nostrils to trap the flies, rubbing xylocaine, a local anaesthetic cream, around the nostrils to numb them, applying fly repellent or even shaving off his whiskers.

“He used to wear a full-muzzle nose net. This worked fine for about 10min, until it filled with saliva, stuck to Casey’s nostrils and upset him a lot more.

“When Casey was nine, the Equilibrium Net Relief half-muzzle mask (as pictured above right) came on to the market. It works really well and he can now be ridden all year round. The mask is subtle and can be used in some competitions if arrangements are made with the affiliated body or organisers.

“I’d bet I was one of the first to get my dispensation form from British Dressage.”

This feature on summer horse care problems was first published in H&H (16 June, ’05)

Headshaking can be seasonal, where the signs are only present during defined periods of the year, or non-seasonal, when it occurs all year round. This has led to the misconception that the disease is akin to hayfever in humans. There is no evidence that this is in fact the case.

It is more likely that a localised allergy in the nose or a direct physical irritation – either inside the nose or on the face, eyes or mouth – is a trigger for the disease. These trigger factors can be seasonal or non-seasonal, such as smoke, stable bedding fumes, sunlight, wind, cold, rain or dry.

The condition, which we believe is a neurological one affecting some components of the main sensory nerve to the head of the horse, is present in headshakers, but a trigger is needed to kickstart the symptoms.

Therefore headshaking can be explained as: disease + trigger factor = clinical signs.

The other aspect to consider is the frequency of outbreaks. An intermittent headshaker only shows signs under defined conditions, such as ridden work, in a certain lane or school, or in bright sunlight.

It is important to recognise that in some cases the trigger is, in fact, disease – for example, dental disease, sinusitis, oral pain or ear mites. Some horses have previously had head trauma (such as a kick, fall or cut) and others have had head or facial surgery. Try to find out as much about your horse’s history as you can.

We know very little about the disease but we do know that it is not a vice – the horse is in fact in pain during these episodes and should be treated sympathetically. It is not acceptable to simply fit a standing martingale.

For now, treatments are poor at best. Drugs that may help all cause some problems in horses. Many people turn to various natural and homeopathic remedies, but results can be disappointing.

Accepting the fact that we cannot, at present, do much, the best approach is to:

1. Establish the situations under which the condition is best/worst and avoid circumstances that combine the trigger factor with the cause. This explains why face/nose/ear masks help in some cases.

2. Get your vet to perform a full neurological examination and facial investigation.

3. Check competition records over previous years to see whether the horse has been out of competition for regular periods.