Occipital Nerve Stimulation in Chronic Migraine: The Relationship Between Perceived Sensory Quality, Perceived Sensory Location, and Clinical Efficacy-A Prospective, Observational, Non-Interventional Study

Four Decades of Occipital Nerve Stimulation for Headache Disorders: A Systematic Review

PURPOSE OF REVIEW

Chronic headaches are a significant source of disability worldwide. Despite the development of conventional strategies, a subset of patients remain refractory and/or experience side effects following these treatments. Hence, occipital nerve stimulation (ONS) should be considered as an alternative strategy for intractable chronic headaches. This review aims to provide a comprehensive overview of the effectiveness, safety, mechanisms and practical application of ONS for the treatment of headache disorders.

RECENT FINDINGS

Overall response rate of ONS is 35.7-100%, 17-100%, and 63-100% in patients with cluster headache, chronic migraine and occipital neuralgia respectively. Regarding the long-term effectivity in all groups, 41.6-88.0% of patients remain responders after ≥ 18.3 months. The most frequently reported adverse events include lead migration/fracture (13%) and local pain (7.3%). Based on our results, ONS can be considered a safe and effective treatment for chronic intractable headache disorders. To support more widespread application of ONS, additional research with larger sample sizes should be conducted.

The Untold Story of Occipital Nerve Stimulation in Patients With Cluster Headache: Surgical Technique in Relation to Clinical Efficacy

OBJECTIVES

Approximately one in every 1000 adults experiences cluster headache (CH). Although occipital nerve stimulation (ONS) appears encouraging in treatment for most patients with refractory CH, some patients do not reach adequate pain relief with ONS. A reason for failure of ONS might be anatomical variations and different surgical approaches. Therefore, an extensive literature analysis was performed, and cadaveric experimentation was combined with our clinical experience to provide a standardized proposal for ONS and obtain optimal management of patients with refractory CH.

MATERIALS AND METHODS

Data from 36 articles published between 1998 and 2023 were analyzed to retrieve information on the anatomical landmarks and surgical technique of ONS. For the cadaveric experimentation (N = 1), two electrodes were inserted from the region over the foramen magnum and projected toward the lower third of the mastoid process.

RESULTS

The existence of multiple approaches of ONS has been confirmed by the present analysis. Discrepancies have been found in the anatomical locations and corresponding landmarks of the greater and lesser occipital nerve. The surgical approaches differed in patient positioning, electrode placement, and imaging techniques, with an overall efficacy range of 35.7% to 90%.

CONCLUSIONS

Reports on the surgical approach of ONS remain contradictory, hence emphasizing the need for standardization. Only if all implanting physicians perform the ONS surgery using a standardized protocol, can future data be combined and outcomes compared and analyzed.

Breaking the cycle: unraveling the diagnostic, pathophysiological and treatment challenges of refractory migraine

Background

Refractory migraine is a poorly described complication of migraine in which migraine has chronified and become resistant to standard treatments. The true prevalence is unknown, but medication resistance is common in headache clinic patient populations. Given the lack of response to treatment, this patient population is extremely difficult to treat with limited guidance in the literature.

Objective

To review the diagnostic, pathophysiological, and management challenges in the refractory migraine population.

Discussion

There are no accepted, or even ICHD-3 appendix, diagnostic criteria for refractory migraine though several proposed criteria exist. Current proposed criteria often have low bars for refractoriness while also not meeting the needs of pediatrics, lower socioeconomic status, and developing nations. Pathophysiology is unknown but can be hypothesized as a persistent "on" state as a progression from chronic migraine with increasing central sensitization, but there may be heterogeneity in the underlying pathophysiology. No guidelines exist for treatment of refractory migraine; once all guideline-based treatments are tried, treatment consists of n-of-1 treatment trials paired with non-pharmacologic management.

Conclusion

Refractory migraine is poorly described diagnostically, its pathophysiology can only be guessed at by extension of chronic migraine, and treatment is more the art than science of medicine. Navigating care of this refractory population will require multidisciplinary care models and an emphasis on future research to answer these unknowns.

Update of Neuromodulation in Chronic Migraine

Purpose of Review

Neuromodulation devices have become an attractive alternative to traditional pharmacotherapy for migraine, especially for patients intolerant to medication or who prefer non-pharmacological options. In the past decades, many studies demonstrated the efficacy of neuromodulation devices in patients with episodic migraine (EM). However, the benefit of these devices on chronic migraine (CM), which is typically more debilitating and refractory than EM, remains not well studied.

Recent Findings

We reviewed the literature within the last five years on using FDA-cleared and investigational devices for CM. There were eight randomized controlled trials and 15 open-label observational studies on ten neuromodulation devices.

Summary

Neuromodulation is promising for use in CM, although efficacy varies among devices or individuals. Noninvasive devices are usually considered safe with minimal adverse events. However, stimulation protocol and methodology differ between studies. More well-designed studies adhering to the guideline may facilitate FDA clearance and better insurance coverage.

In vitro and in vivo studies on the biocompatibility of a self-powered pacemaker with a flexible buckling piezoelectric vibration energy harvester for rats

Background

Scavenging energy from biomechanical motions in vivo by energy converting devices, i.e., implantable harvesters, to obtain sustainable electrical energy is the ideal way to power implantable medical devices which require long term and continuous power supply. A novel self-powered cardiac pacemaker is designed to achieve self-powered pacing. The kinetic energy of the heart was collected by an implanted piezoelectric energy collector and supplied to the cardiac pacemaker, and then the cardiac tissue was stimulated by the pacing electrode pierced from the outside of the heart to realize effective pacing effect and self-powered pacing. In this study, we evaluated the stability and biocompatibility of our previously described flexible buckling piezoelectric vibration energy harvester in vitro and in vivo. The biocompatibility, in vivo stability, and safety of the self-powered pacemaker with a flexible flexion piezoelectric vibratory energy harvesting device prepared were analyzed by performing cell and in vivo animal experiments.

Methods

The MTT(3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) assay was used to detect the cell proliferation of H9C2 cells and HUVECs at 24, 48, and 72 hours. Computed tomography (CT) and cardiac ultrasound were used to evaluate the position and heart rate of pacemakers 12 weeks after implantation, and the changes of plasma biochemical indexes were detected by a biochemical detector.

Results

At 12 weeks after implantation, CT results showed that there were no changes in the position of the self-powered pacemaker. The device implanted into the thoracic cavity of rats demonstrated certain effects on cardiac function, while it did not have a significant effect on their blood biochemical indexes.

Conclusions

the flexible buckling piezoelectric vibratory energy collector did not produce adverse effects on the myocardial tissue or on the normal proliferation of myocardial cells.

An experimental study on a piezoelectric vibration energy harvester for self-powered cardiac pacemakers

Background

Over the past half-century, cardiac pacing technology has been reported. In this study, we designed, prepared, and tested the performance of a self-energized cardiac pacemaker driven by piezoelectric vibration energy collection technology, which converts the kinetic energy of the heart into electrical energy. A record in vivo output current of 54 nA was obtained in an adult rat by the implanted piezoelectric transducer.

Methods

First, the kinetic energy of the heart was collected by an implanted piezoelectric energy collector and supplied to the cardiac pacemaker. Then, the heart was pierced from the outside, and the cardiac tissue was stimulated by the pacing electrode, and self-powered pacing.

Results

The average voltage and average current of the piezoelectric vibration energy harvester in vitro were 3.5 mV and 60 nA, respectively. After implantation of the device into rats, the average voltage and current were measured immediately and reached 3.2 mV and 54 nA, respectively. The average voltage and average current reached 3.0 mV and 48 nA after 1 week, and 2.1 mV and 31 nA after 12 weeks. The electrical performance of the self-powered pacemaker in this study is based on piezoelectric energy collection technology. The implanted piezoelectric vibration energy collector drives the pacemaker to generate electrical pulses, which directly stimulates the myocardial tissue through the epicardium to achieve the pacing effect.

Conclusions

These results evidence the feasibility of the in-situ epicardial pacing strategy. This research will promote the design and development of self-powered cardiac pacemakers.

Effect of Occipital Nerve Stimulation (ONS) on the Orbicularis Oculi Reflex Triggered by a Standardized Air Flow in Patients with Chronic Migraine-A Prospective, Randomized, Interventional Study

Introduction

Occipital nerve stimulation (ONS) is a specific form of peripheral neuromodulation used in the treatment of chronic pain disorders. A particular field of application is in the therapy of treatment-refractory headaches, especially of chronic migraine. The precise mode of action is unknown. It is presumed that central and peripheral sensitization are reduced in patients with chronic headache. The aim of this study was to examine the effect of ONS on pain-modulatory mechanisms in the trigeminocervical area in patients with chronic migraine.

Methods

In a balanced repeated measurements design in eight patients with chronic migraine with and without active ONS, we analyzed which effects ONS had on the orbicularis oculi reflex dynamically elicited by corneal air flow.

Results

The orbicularis oculi reflex in active ONS (7.38 ± 20.14 eyelid closures/minute) compared to inactive ONS (18.73 ± 14.30 eyelid closures/minute) is significantly reduced (p = 0.021).

Conclusions

The results show that under active ONS compared to inactive ONS in patients with chronic migraine, the orbicularis oculi reflex, dynamically triggered by a standardized air flow, is significantly reduced. This suggests that ONS is able to directly counteract the trigeminally mediated central sensitization in chronic migraine and protectively reduce the effects of aversive peripheral stimulation.