Therapeutische Neuromodulation bei primären Kopfschmerzsyndromen

Abstract

Neuromodulatory techniques have developed rapidly in the therapeutic management of refractory headaches. Invasive procedures comprise peripheral nerve stimulation (particularly occipital nerve stimulation), vagus nerve stimulation, cervical spinal cord stimulation and hypothalamic deep brain stimulation. Transcutaneous electrical nerve stimulation, repetitive transcranial magnetic stimulation and transcranial direct current stimulation are noninvasive variants. Based on current neuroimaging, neurophysiological and clinical studies occipital nerve stimulation and hypothalamic deep brain stimulation are recommended for patients with chronic cluster headache. Less convincing evidence can be found for their use in other refractory headaches such as chronic migraine. No clear recommendation can be given for the other neuromodulatory techniques. The emerging concept of intermittent stimulation of the sphenopalatine ganglion is nonetheless promising. Robust randomized and sham-controlled multicenter studies are needed before these therapeutic approaches are widely implemented. Due to the experimental nature all patients should be treated in clinical studies. It is essential to confirm the correct headache diagnosis and the refractory nature before an invasive approach is considered. Patients should generally be referred to specialized interdisciplinary outpatient departments which closely collaborate with neurosurgeons who are experienced in the implantation of neuromodulatory devices. It is crucial to ensure a competent postoperative follow-up with optimization of stimulation parameters and adjustment of medication.

Central Sensitization: Clinical Implications for Chronic Head and Neck Pain

“…The resulting depression, anxiety, sleep fragmentation, allodynia, and hyperalgesia characterize a number of chronic pain disorders. [2][3][4][5][6][7][8][9][10][11][12][13] At least two etiological pathways are posited for central sensitization. The first is chronification of nociceptive pain; and involves neuroplastic changes, and peripheral sensitization as precursors to central sensitization and the resulting clinical pain.…”

“…This contributes to dysfunctional sleep, and anxiety via increased norepinephrine levels. [6,[21][22][23][24][25] • Decreased medullary descending inhibition of nociception, This increases the effective peripheral nociceptive input, and is reflected in lowered pain thresholds, hyperalgesia, allodynia, and greater impact of peripheral sensitization. [8,11,12,[15][16][17]23,[26][27][28][29][30][31][32] • Hypoactivity of the hypothalamic-pituitary-adrenal axis, and autonomic nervous system alterations, produce increased sympathetic tone, low vagal tone, and contribute to immune abnormalities.…”

“…Within these two broad categories we have both pharmacological and non-pharmacological therapeutic options. [1,4,6,8,13,14,[40][41][42][43][44] may reduce levels of peripheral stimulus, but do not directly treat the central sensitization. [13] Many of the drugs that we use to address central sensitization will have a beneficial effect on the ability of the patient to cope with the pain, as well as to diminish the central sensitization itself.…”

“…As such, PENS is one of our few cost-effective, non-invasive, low co-morbidity options for the treatment of central sensitization itself, as opposed to responding to the deleterious effects of CS. [1,2,5,6,[8][9][10][12][13][14][15][20][21][22][23][25][26][27][28][42][43][44]53,55] The other broad category of non-pharmaceutical CS intervention encompasses manual therapy, virtual reality, improving stress tolerance, and transcutaneous electric nerve stimulation. These can be thought of as addressing the functional deficits created by the CS.…”

Einsatz neuromodulierender Verfahren bei primären Kopfschmerzen

“…Daher wird im Folgenden der Begriff Neuromodulation anstelle von Neurostimulation verwendet. Bei gleichem Wirkungsmechanismus ist der wesentliche Vorteil im Vergleich zu ablativen Verfahren die Reversibilität und meist geringere Invasivität der Verfahren (54).…”