Occipital Nerve Stimulation for Refractory Chronic Migraine: Results of a Long-Term Prospective Study

Abstract

Background: Refractory chronic migraine affects approximately 4% of the population worldwide and results in severe pain, lifestyle limitations, and decreased quality of life. Occipital nerve stimulation (ONS) refers to the electric stimulation of the distal branches of greater and lesser occipital nerves; the surgical technique has previously been described and has demonstrated efficacy in the treatment of a wide variety of headache disorders. Objectives: The aim of this study is to evaluate the long-term efficacy and tolerability of ONS for medically intractable chronic migraine. Study Design: Prospective, long-term, open-label, uncontrolled observational study. Setting: Single public university hospital. Methods: Patients who met the International Headache Society criteria for chronic migraine, all of them having been previously treated with other therapeutic alternatives, and who met all inclusion and exclusion criteria for neurostimulation, received the implantation of an ONS system after a positive psychological evaluation and a positive response to a preliminary occipital nerve blockage. The implantation was performed in 2 phases: a 10 day trial with implanted occipital leads connected to an external stimulator and, if more than 50% pain relief was obtained, permanent pulse generator implantation and connection to the previously implanted leads. After the surgery, the patients were thoroughly evaluated annually using different scales: pain Visual Analogue Scale (VAS), number of migraine attacks per month, sleep quality, functionality in social and labor activities, reduction in pain medication, patient satisfaction, tolerability, and reasons for termination. The average follow-up time was 9.4 ± 6.1 years, and 31 patients completed a 7-year follow-up period. Results: Thirty-seven patients were enrolled and classified according to the location and quality of their pain, accompanying symptoms, work status, and psychological effects. Substantial pain reduction was obtained in most patients, and the VAS decreased by 4.9 ± 2.0 points. These results remained stable over the followup period. Five of the 35 permanently implanted patients with migraine attacks at baseline were free from these attacks at their last visits, whereas the pain severity decreased 3.8 ± 2.5 (according to the VAS) in the remaining patients. Seven of the 35 permanent implanted devices were definitively removed: 2 devices because of treatment inefficacy, and 5 devices because the patients were asymptomatic and considered to be cured from their pain, even with the stimulation off. Systemic side effects were not observed. Limitations: Limitations of the current study include its uncontrolled and open-label design. Additionally, not all patients completed the 7-year follow-up period. Conclusions: We consider that the trigemino-cervical autonomous and cervical connection may explain why ONS might relieve chronic migraine pain, but this is just a theoretical explanation which should be demonstrated in future studies. The results achieved in this study suggest that ONS may provide longterm benefits for patients with medically intractable chronic migraine. These outcomes are slightly better than previous reports and were maintained over the 7-year follow-up. We believe that an accurate selection of patients, realization of diagnostic occipital nerve blocks, psychological evaluations, rigorous surgical technique, and appropriate parameter programming helped us achieve these outcomes. Key words: Refractory chronic migraine, headache, occipital nerve stimulatino, peripheral nerve stimulation, occipital nerve block

Burst Occipital Nerve Stimulation for Chronic Migraine and Chronic Cluster Headache

“…This is in accordance with an early report of good results in occipital neuralgia (22). Tonic ONS in CM has been subjected to four randomized controlled trials (RCTs) (25)(26)(27)(28) and there are additionally several published case series (29)(30)(31)(32)(33). The way the results of treatment have been evaluated has not been entirely consistent from study to study, complicating comparison, but three of the RCTs reported a similar measure of the number of days per month affected by prolonged moderate-to-severe headache (25,27,28).…”

“…A total of 12 patients had bONS for CM, 3 male and 9 female, with a mean age at treatment of 46 years (range 25-73). Preoperatively, the mean number of headache days per month was 26.5 (range [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30]. The headache was present every day in 8 cases.…”

The greater occipital nerve and its spinal and brainstem afferent projections: A stereological and tract‐tracing study in the rat

“…Yet, only in two studies, using transganglionic transport of HRP, were the GON and/or its central projections specifically examined (Neuhuber & Zenker, ; Scheurer et al, ). And second, as the interest in the upper cervical afferents in that context seemed to wane, the GON got renewed attention after evidence accumulated on its involvement in the pathophysiology of referred pain in some chronic headache disorders (Magis & Schoenen, ; Rodrigo, Acin & Bermejo, ; Tang et al, ). Clinical findings were supported by the demonstration in different species of overlapping projections of trigeminal and cervical afferents in the upper cervical and caudal spinal trigeminal nucleus (Bartsch & Goadsby, ; Goadsby & Bartsch, ; Pfaller & Arvidsson, ; Xiong & Matsushita, ).…”

“…Moreover, after a number of open‐label clinical trials reported beneficial effects of GON subcutaneous stimulation for various painful craniofacial conditions, a randomized, double‐blind and controlled study (Saper et al, ) showed that GON stimulation provided significant improvement to medically intractable chronic migraine cases, including some who did not respond to GON block. Unsurprisingly, GON stimulation has been increasingly used along the last decade to treat refractory migraine and trigeminal autonomic cephalalgias (Dodick et al, ; Lambru et al, ; Lambru, Shanahan, Watkins & Matharu, ; Miller, Watkins & Matharu, ; Miller, Watkins & Matharu, ; Rodrigo et al, ).…”

Modulation of mechanosensory vibrissal responses in the trigeminocervical complex by stimulation of the greater occipital nerve in a rat model of trigeminal neuropathic pain

“…Chronic refractory headaches are favored targets for neuromodulation, in particular neurovascular or autonomic-related cephalalgias, such as chronic migraine, cluster headache or hemicrania continua [4][5][6][7][8], and painful neuropathies originating in a trigeminal branch or occipital nerve [9][10][11]. The stimulation of the greater occipital nerve (GON) has proved successful for medically intractable chronic migraine and neurovascular headaches [12][13][14][15], and a few studies have reported promising results in treating refractory trigeminal neuralgia [16].…”