Occipital Nerve Stimulation in Cluster Headache
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Headache. 2008 Feb;48(2):313-8.
Occipital nerve stimulation for headache: mechanisms and efficacy.
Goadsby PJ, Bartsch T, Dodick DW.
Headache Group, Institute of Neurology, The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK.
Headache disorders are common problems in medicine and it is this commonness that often provides an air of the simple or obvious. Patients expect doctors understand headache; indeed doctors expect they may understand headache, and in turn since simple treatments exist and can be purchased from a supermarket, the very concept of the difficult headache problem has a pejorative connotation. A decade ago none of the authors were using device-based therapies to any substantial extent, and now hardly a week goes by when we will not see a patient who has considerable potential to benefit from such approaches. Here we cover the most promising of the device-based approaches, neurostimulation therapy using occipital nerve stimulation. Far from proven and with much work to be done, this is an exciting potential development for patients and doctors. Other device-based therapies, such as deep brain stimulation for cluster headache and patent foramen ovale closure, are covered elsewhere.
PMID: 18234048
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Lancet Neurol. 2007 Apr;6(4):314-21.
Occipital nerve stimulation for drug-resistant chronic cluster headache: a prospective pilot study.
Magis D, Allena M, Bolla M, De Pasqua V, Remacle JM, Schoenen J.
Headache Research Unit, Department of Neurology, Liège University, CHR Citadelle, Liège, Belgium.
BACKGROUND: Drug-resistant chronic cluster headache (drCCH) is a devastating disorder for which various destructive procedures have been tried unsuccessfully. Occipital nerve stimulation (ONS) is a new, safe strategy for intractable headaches. We undertook a prospective pilot trial of ONS in drCCH to assess clinical efficacy and pain perception.
METHODS: Eight patients with drCCH had a suboccipital neurostimulator implanted on the side of the headache and were asked to record details of frequency, intensity, and symptomatic treatment for their attacks in a diary before and after continuous ONS. To detect changes in cephalic and extracephalic pain processing we measured electrical and pressure pain thresholds and the nociceptive blink reflex.
FINDINGS: Two patients were pain free after a follow-up of 16 and 22 months; one of them still had occasional autonomic attacks. Three patients had around a 90% reduction in attack frequency. Two patients, one of whom had had the implant for only 3 months, had improvement of around 40%. Mean follow-up was 15.1 months (SD 9.5, range 3-22). Intensity of attacks tends to decrease earlier than frequency during ONS and, on average, is improved by 50% in remaining attacks. All but one patient were able to substantially reduce their preventive drug treatment. Interruption of ONS by switching off the stimulator or because of an empty battery was followed within days by recurrence and increase of attacks in all improved patients. ONS did not significantly modify pain thresholds. The amplitude of the nociceptive blink reflex increased with longer durations of ONS. There were no serious adverse events.
INTERPRETATION: ONS could be an efficient treatment for drCCH and could be safer than deep hypothalamic stimulation. The delay of 2 months or more between implantation and significant clinical improvement suggests that the procedure acts via slow neuromodulatory processes at the level of upper brain stem or diencephalic centres.
PMID: 17362835
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Lancet. 2007 Mar 31;369(9567):1099-106.
Treatment of medically intractable cluster headache by occipital nerve stimulation: long-term follow-up of eight patients.
Burns B, Watkins L, Goadsby PJ.
Headache Group, Institute of Neurology, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK.
BACKGROUND: Cluster headache is a form of primary headache that features repeated attacks of excruciatingly severe headache usually occurring several times a day. Patients with chronic cluster headache have unremitting illness that necessitates daily preventive medical treatment for years. When medically intractable, the condition has previously been treatable only with cranially invasive or neurally destructive methods.
METHODS: Eight patients with medically intractable chronic cluster headache were implanted in the suboccipital region with electrodes for occipital nerve stimulation. Other than the first patient, who was initially stimulated unilaterally before being stimulated bilaterally, all patients were stimulated bilaterally during treatment.
FINDINGS: At a median follow-up of 20 months (range 6-27 months for bilateral stimulation), six of eight patients reported responses that were sufficiently meaningful for them to recommend the treatment to similarly affected patients with chronic cluster headache. Two patients noticed a substantial improvement (90% and 95%) in their attacks; three patients noticed a moderate improvement (40%, 60%, and 20-80%) and one reported mild improvement (25%). Improvements occurred in both frequency and severity of attacks. These changes took place over weeks or months, although attacks returned in days when the device malfunctioned (eg, with battery depletion). Adverse events of concern were lead migrations in one patient and battery depletion requiring replacement in four.
INTERPRETATION: Occipital nerve stimulation in cluster headache seems to offer a safe, effective treatment option that could begin a new era of neurostimulation therapy for primary headache syndromes.
PMID: 17398309
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Cephalalgia. 2007 Mar;27(3):271-4.
Response to occipital nerve block is not useful in predicting efficacy of occipital nerve stimulation.
Schwedt TJ, Dodick DW, Trentman TL, Zimmerman RS.
Department of Neurology, mayo Clinic College of Medicine, Scottsdale, AZ, USA. schwedttj@yahoo.com
Occipital nerve stimulation (ONS) may be effective for the treatment of headaches that are recalcitrant to medical therapy. The objective of this study was to determine if response to occipital nerve block (ONB) predicts response to ONS in patients with chronic, medically intractable headaches. We evaluated 15 patients who underwent placement of occipital nerve stimulators for the treatment of chronic headaches. Data were collected regarding analgesic response to ONB and to ONS. Nine of 15 patients were ONS responders (> or =50% reduction in headache frequency or severity). Thirteen patients had ONB prior to stimulator implantation. Ten of 13 who had ONB had significant relief of head pain lasting at least 24 h, and three were ONB non-responders. Of the three ONB non-responders, two were ONS responders. Of the two patients who did not have ONB prior to ONS, one was an ONS responder and one was an ONS non-responder. In conclusion, analgesic response to ONB may not be predictive of the therapeutic effect from ONS in patients with medically refractory chronic headaches.
PMID: 17381559
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Cephalalgia. 2007 Feb;27(2):153-7.
Occipital nerve stimulation for chronic headache--long-term safety and efficacy.
Schwedt TJ, Dodick DW, Hentz J, Trentman TL, Zimmerman RS.
Mayo Clinic College of Medicine, Scottsdale, AZ 85259, USA.
The aim of this study was to examine the safety and efficacy of occipital nerve stimulation for medically intractable headache. Electrical stimulation of large sensory afferents has an antinociceptive effect. Occipital nerve stimulation may be effective for the treatment of medically intractable headache. Retrospective analysis was performed of 15 patients with medically refractory headache who underwent implantation of an occipital nerve stimulator. Pre- and postimplant data regarding headache frequency, severity, disability, depression and poststimulator complications were collected. Twelve patients were female and three male. Ages ranged from 21 to 52 years (mean 39 years). Eight patients had chronic migraine, three chronic cluster, two hemicrania continua and two had post-traumatic headache. Eight patients underwent bilateral and seven had unilateral lead placement. Patients were measured after 5-42 months (mean 19). All six mean headache measures improved significantly from baseline (P < 0.03). Headache frequency per 90 days improved by 25 days from a baseline of 89 days; headache severity (0-10) improved 2.4 points from a baseline of 7.1 points; MIDAS disability improved 70 points from a baseline of 179 points; HIT-6 scores improved 11 points from a baseline of 71 points; BDI-II improved eight points from a baseline of 20 points; and the mean subjective percent change in pain was 52%. Most patients (60%) required lead revision within 1 year. One patient required generator revision. Occipital nerve stimulation may be effective in some patients with intractable headache. Surgical revisions may be commonly required. Safety and efficacy results from prospective, randomized, sham-controlled studies in patients with medically refractory headache are needed.
PMID: 17257236
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NeuroBelgium 2006 Conference, November 10 - 11, 2006
Abstract
Long Term Follow-up Study of Occipital Nerve Stimulation (ONS) for Refractory Chronic Cluster Headache: Drastic Change From Short Term Outcome.
Magis D, Remacle JM, Schoenen J
Headache Research
Unit,
Background:Occipital nerve stimulation (ONS) is proposed as a novel safe strategy in the therapy of intractable headache and favourable results were reported in a few chronic cluster headache patients (CCH). We conducted a pilot-trial of ONS in CCH and found no improvement after 3 to 6 months (1). We now report on the results after long-term ONS exceeding 1 year.
Methods:Five patients with refractory CCH were treated with ONS (2). We monitored attack frequency and intensity, and the need for drug prophylaxis before and after ONS. Mean follow-up time was 16.02±0.47 months.
Results: Patient 1 switched his stimulator off after 4 months because of lack of efficacy. In the remaining patients, daily attacks were reduced on average by 36% and mean intensity by 37%. Patient 2 had a 5-month improvement of attack frequency (-57%) and intensity 11 months after implantation. Patient 3 shifted from 4 severe attacks/day to 1 attack of very mild intensity after 10 months. In patient 4, frequency drastically decreased from 1.16 attacks/day to 1 attack/month after 7.5 months. Cluster attacks totally disappeared after 3 months in patient 5. Patients 2, 3 and 5 were able to reduce but not to interrupt preventive medication. Switching off the stimulator led to an almost immediate recurrence of attacks in all improved patients.
Conclusions:ONS could be a good alternative to deep brain stimulation in CCH. Our study shows that the delay between implantation and significant clinical improvement may be very long and exceed 5-6 months. This suggests that slow neuromodulatory processes may be needed before disease modification occurs.
References:
1. Magis D,
2. Oh MY, Ortega J, Bellotte JB, Whiting DM and Aló K. Peripheral nerve stimulation for the treatment of occipital neuralgia and transformed migraine using C1-2-3 subcutaneous paddle style electrode: a technical report. Neuromodulation 2004; 7: 103-112.
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Implanted Device Wipes Out Cluster Headaches
Reuters Health 09/26/2002
LONDON (Reuters Health) - An implanted device has helped a patient who was
suffering up to five attacks of cluster headache daily remain headache-free for
7 months, a US-based researcher said Thursday.
The device, which is implanted under the skin and stimulates the occipital nerve
at the back of the head, could be helpful for a range of difficult-to-treat
headache disorders, said Dr. David Dodick of the Mayo Clinic in Scottsdale,
Arizona. He reported the findings here Thursday at the Migraine Trust
International Symposium.
The occipital and trigeminal nerves converge. These nerves connect with all of the pain-sensitive structures in the skull. Dodick explained that stimulating the occipital nerve inhibits activity in the trigeminal nerve.
The 40+ year old patient had been a chronic clusterhead for 2 years. "He was on every conceivable medication. In fact, when I saw him he was on five medications," Dodick said. "We admitted him to hospital and blocked his occipital nerve and for 3 days he was pain-free, which was remarkable for him, but his attacks came back. Then we blocked him again, and for a week he was cluster-free, so then we had the idea, lets try an occipital-nerve stimulator."
The stimulator is a pacemaker-sized device that sends impulses via electrodes placed under the skin over the occipital nerves on the back of the neck, under local
anaesthetic.
Currently patients with untreatable cluster headaches undergo procedures to destroy part of the trigeminal nerve. "Those are destructive procedures and while they may be effective, they have the potential for pretty serious side effects," the researcher said.
"We put a stimulating electrode in on the right side, because that's where 90% of his attacks were, and for 2 weeks he had no cluster headaches, except for one on the opposite side, which cluster patients are sometimes known to do," Dodick said.
"We then took the stimulating electrode out from around the occipital nerve, left him for 2 weeks and he went back to having his cluster headaches, so we decided then to go in and implant two electrodes, on either side over each occipital nerve. He's done remarkably well since then, and that's about 7 months ago."
In the past few weeks, another two patients have had stimulators implanted, but no results are available yet. The researcher said a study would also be under way shortly looking at the utility of occipital nerve stimulators in patients with chronic migraine.
"The trigeminal nerve is the substrate for pain experienced during migraine, cluster headache and other primary headache disorders," Dodick said. "That's why this kind of an approach may be applicable not just to cluster but to migraine, and possibly other primary headache disorders, too."
Professor Peter Goadsby, chairman of the symposium, said the neuromodulation data presented at the conference, including the work presented by Dodick and another presentation by Dr. Massimo Leone on a deep brain stimulator in the hypothalamus in 7 patients with cluster headache, was among the most exciting of the conference.
"These things turn on, and (the headache) turns off--that's pretty watershed stuff," Goadsby said.
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