Treatment of chronic cluster headache with burst and tonic occipital nerve stimulation: A case series

Abstract

Objectives and BackgroundChronic cluster headache (CCH) is a rare but severely debilitating primary headache condition. A growing amount of evidence suggests that occipital nerve stimulation (ONS) can offer effective treatment in patients with severe CCH for whom conventional medical therapy does not have a sufficient effect. The paresthesia evoked by conventional (tonic) stimulation can be bothersome and may thus limit therapy. Burst ONS produces paresthesia‐free stimulation, but the amount of evidence on the efficacy of burst ONS as a treatment for intractable CCH is scarce.MethodsIn this case series, we report 15 patients with CCH treated with ONS at Aarhus University Hospital, Denmark, from 2013 to 2020. Nine of these received burst stimulation either as primary treatment or as a supplement to tonic stimulation. The results were assessed in terms of the frequency of headache attacks per week and their intensity on the Numeric Rating Scale, as well as the Patient Global Impression of Change (PGIC) with ONS treatment.ResultsAt a median (range) follow‐up of 38 (16–96) months, 12 of the 15 patients (80%) reported a reduction in attack frequency of ≥50% (a reduction from a median of 35 to 1 attack/week, p < 0.001). Seven of these patients were treated with burst ONS. A significant reduction was also seen in maximum pain intensity. Overall, 10 patients stated a clinically important improvement in their headache condition following ONS treatment, rated on the PGIC scale. A total of 16 adverse events (nine of which were in the same patient) were registered.ConclusionOccipital nerve stimulation significantly reduced the number of weekly headache attacks and their intensity. Burst ONS seems to function well alone or as a supplement to conventional tonic ONS as a preventive treatment for CCH; however, larger prospective studies are needed to determine whether the effect can be confirmed and whether the efficacy of the two stimulation paradigms is even.

The HortONS study. Treatment of chronic cluster headache with transcutaneous electrical nerve stimulation and occipital nerve stimulation: study protocol for a prospective, investigator-initiated, double-blinded, randomized, placebo-controlled trial

“…Based on our previous experience with ONS treatment [ 26 ], we estimate that 50% of the participants who receive active treatment with burst ONS will reach the primary endpoint of a 30% reduction in attack frequency. A blinded trial with burst ONS and placebo has to our knowledge not been carried out earlier, but we hypothesize that no more than 10% in the placebo group will meet the primary endpoint [ 35 ].…”

“…A novel stimulation paradigm termed burst stimulation, originally designed for spinal cord stimulation for chronic neuropathic pain, has given rise to paresthesia-free stimulation [ 24 ]. The scientific evidence on burst stimulation used for ONS is scarce, but in two small studies, it has been suggested that paresthesia-free burst stimulation may have a similar effect as tonic ONS reducing attack frequency in CCH patients [ 25 , 26 ].…”