Neurostimulation for Refractory Cervicogenic Headache: A Three-Year Retrospective 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.

Efficacy and safety of ultrasound-guided pulsed radiofrequency in the treatment of the ophthalmic branch of postherpetic trigeminal neuralgia

Objective

To investigate the efficacy and safety of ultrasound-guided pulsed radiofrequency (PRF) targeting the supraorbital nerve for treating the ophthalmic branch of postherpetic trigeminal neuralgia.

Methods

A retrospective cohort study was conducted involving patients who presented at the Department of Pain, Affiliated Hospital of Southwest Medical University from January 2015 to January 2022. The patients were diagnosed with the first branch of postherpetic trigeminal neuralgia. In total, 63 patients were included based on the inclusion and exclusion criteria. The patients were divided into the following two groups based on the treatment method used: the nerve block (NB) group (n = 32) and the PRF + NB group (radiofrequency group, n = 31). The visual analog scale (VAS) score, Pittsburgh Sleep Quality Index (PSQI) score, and pregabalin dose were compared between the two groups before treatment, 1 week after the procedure, and 1, 3, and 6 months post-procedure, and the complications, such as local infection, local hematoma, and decreased visual acuity, were monitored post-treatment.

Results

No significant difference was found in terms of pretreatment age, sex, course of disease, preoperative VAS score, preoperative PSQI score, and preoperative pregabalin dose between the two groups (P > 0.05). The postoperative VAS score, PSQI score, and pregabalin dose were significantly decreased in both groups. Furthermore, significant differences were found between the two groups at each preoperative and postoperative time point (P < 0.05). The VAS score was lower in the radiofrequency group than in the NB group at 1, 3, and 6 months, and the difference was statistically significant (P < 0.05). The PSQI score was lower in the radiofrequency group than in the NB group at 1 week, 1, 3, and 6 months post-procedure, and the difference was statistically significant (P < 0.05). The dose of pregabalin was lower in the radiofrequency group than in the NB group at 1 week, 1, 3, and 6 months post-procedure, and the difference was statistically significant at 3 and 6 months (P < 0.05). After 6 months of treatment, the excellent rate of VAS score in the radiofrequency group was 70.96%, and the overall effective rate was 90.32%, which was higher than that in the NB group. The difference in the efficacy was statistically significant (P < 0.05).

Conclusion

PRF targeting the supraorbital nerve can effectively control the pain in the first branch of the trigeminal nerve after herpes, enhance sleep quality, and reduce the dose of pregabalin. Thus, this study shows that PRF is safe under ultrasound guidance and is worthy of clinical application.

A surgical decision aid for occipital neuralgia with literature review and single center case series

BACKGROUND

Occipital neuralgia (ON) is a debilitating headache disorder. Due to the rarity of this disorder and lack of high-level evidence, a clear framework for choosing the optimal surgical approach for medically refractory ON incorporating shared decision making with patients does not exist.

METHODS

A literature review of studies reporting pain outcomes of patients who underwent surgical treatment for ON was performed, as well as a retrospective chart review of patients who underwent surgery for ON within our institution.

RESULTS

Thirty-two articles met the inclusion criteria. A majority of the articles were retrospective case series (22/32). The mean number of patients across the studies was 34 (standard deviation (SD) 39). Among the 13 studies that reported change in pain score on 10-point scales, a study of 20 patients who had undergone C2 and/or C3 ganglionectomies reported the greatest reduction in pain intensity after surgery. The studies evaluating percutaneous ablative methods including radiofrequency ablation and cryoablation showed the smallest reduction in pain scores overall. At our institution from 2014 to 2023, 11 patients received surgical treatment for ON with a mean follow-up of 187 days (SD 426).

CONCLUSION

Based on these results, the first decision aid for selecting a surgical approach to medically refractory ON is presented. The algorithm prioritizes nerve sparing followed by non-nerve sparing techniques with the incorporation of patient preference. Shared decision making is critical in the treatment of ON given the lack of clear scientific evidence regarding the superiority of a particular surgical method.

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.

Long term outcomes of occipital nerve stimulation

Background

Occipital nerve stimulation (ONS) has been investigated as a potential treatment for disabling headaches and has shown promise for disorders such as chronic migraine and cluster headache. Long term outcomes stratified by headache subtype have had limited exploration, and literature on outcomes of this neuromodulatory intervention spanning 2 or more years is scarce.

Measures

We performed a narrative review on long term outcomes with ONS for treatment of headache disorders. We surveyed the available literature for studies that have outcomes for 24 months or greater to see if there is a habituation in response over time. Review of the literature revealed evidence in treatment of occipital neuralgia, chronic migraine, cluster headache, cervicogenic headache, short lasting unilateral neuralgiform headache attacks (SUNHA) and paroxysmal hemicrania. While the term "response" varied per individual study, a total of 17 studies showed outcomes in ONS with long term sustained responses (as defined per this review) in the majority of patients with specific headache types 177/311 (56%). Only 7 studies in total (3 cluster, 1 occipital neuralgia, 1 cervicogenic headache, 1 SUNHA, 1 paroxysmal hemicrania) provided both short-term and long-term responses up to 24 months to ONS. In cluster headache, the majority of patients (64%) were long term responders (as defined per this review) and only a minority of patients 12/62 (19%) had loss of efficacy (e.g., habituation). There was a high number 313/439 (71%) of adverse events per total number of patients in the studies including lead migration, requirements of revision surgery, allergy to surgical materials, infection and intolerable paresthesias.

Conclusions

With the evidence available, the response to ONS was sustained in the majority of patients with cluster headache with low rates of loss of efficacy in this patient population. There was a high percent of adverse events per number of patients in long term follow-up and likely related to the off-label use of leads typically used for spinal cord stimulation. Further longitudinal assessments of outcomes in occipital nerve stimulation with devices labelled for use in peripheral nerve stimulation are needed to evaluate the extent of habituation to treatment in headache.

CEFALEIA CERVICOGÊNICA

Objetivo: Contextualizar a cefaleia cervicogênica descrevendo sua etiologia, fisiopatologia, quadro clínico, critérios diagnósticos e tratamentos, para nortear a sociedade médica diante da patologia que está em crescente aumento de sua incidência. Métodos: O presente estudo realizou buscas nas bases de dados PubMed, Nature, Scielo e Wiley, utilizando os descritores cefaleia cervicogênica, e foram analisados trabalhos publicados entre os anos de 1980 e 2022, em todos os idiomas, além das respectivas traduções em inglês. Como fator de inclusão foi considerado: “trabalhos publicados dentro do escopo do estudo dentro do intervalo de tempo citado e relacionados a cefaleia cervicogênica e como fator de exclusão foi considerado: “trabalhos não relacionados ao tema de estudo e com relatos já ultrapassados de acordo com a literatura atual”. Resultados: Foram encontrados 1.319 artigos, após leitura e análise dos artigos foram selecionados 27 artigos, e de acordo com a relevância no assunto fazem parte do escopo do trabalho. Em relação a cefaleia cervicogênica é possível classifica-la como uma cefaleia secundária, atribuída a transtornos cervicais, com sintomatologia heterogênea, geralmente apresentando-se como uma cefaleia unilateral, não latenjante e não excruciante, podendo ser desencadeada por pontos gatilhos em região cervical podendo ainda se apresentar com pródomos autonômicos. Sua etiologia e fisiopatologia tem ligação direta com transtornos cervicais e irritação das fibras aferentes de C1-C2-C3, além da convergência para o núcleo trigêmeo-cervical aumentando a variabilidade de sintomas. Seu diagnóstico é baseado em critérios diagnósticos e existem uma grande variedade de tratamentos com eficácia limitada. Conclusão: A cefaleia cervicogênica pode se apresentar de formas heterogêneas dificultado seu diagnóstico e sendo subdiagnosticada e tratada erroneamente em até 50% dos casos, seu aumento em decorrência da pandemia alerta para a melhoria no diagnóstico e tratamento da cefaleia cervicogênica e os distúrbios osteomusculares associados.  

Position Paper on Post-Traumatic Headache: The Relationship Between Head Trauma, Stress Disorder, and Migraine

Traumatic brain injury (mTBI) is a major public health concern, with mild TBI (mTBI) constituting the vast majority of the injuries. Post-traumatic headache (PTH) is one of the most frequent symptoms that follow a mTBI, occurring in isolation with a tension-type or migraine phenotype, or more often as part of a complex neurobehavioural array of symptoms. The existence of PTH as a separate entity from the primary headaches is still a matter of debate. Classification issues and a lack of methodologically robust epidemiological and clinical studies have made it difficult to elucidate the mechanisms underlying acute and even more persistent PTH (PPTH). Furthermore, psychiatric comorbidities such as post-traumatic stress disorder (PTSD), previous history of migraine, and legal issues often reported by PPTH patients have complicated the understanding of this condition, hence treatment approaches for PTH remain problematic. Recent findings from structural and functional neuroimaging studies have attempted to describe the brain architecture of PPTH, suggesting the involvement of different networks compared to migraine. It also seems that calcitonin gene-related peptide (CGRP) levels are not particularly raised in PPTH, although CGRP monoclonal antibodies have obtained positive initial open-label evidence of efficacy in PPTH, and more trials assessing the efficacy of this class of treatments are underway. The broad overlap between PTH, migraine, and PTSD suggests that research in this field should start with a re-appraisal of the diagnostic criteria, followed by methodologically sound epidemiological and clinical studies. Preclinical research should strive to create more reliable PTH models to support human neuroimaging, neurochemical, and neurogenetic studies, aiming to underpin new pathophysiological hypotheses that may expand treatment targets and improve the management of PTH patients.

Outcomes of Occipital Nerve Stimulation for Craniofacial Pain Syndromes

OBJECTIVES

Occipital nerve regional stimulation (ONS) is reported to improve pain in several studies. We examined long-term pain and functional outcomes of ONS in an open-label prospective study.

METHODS

Patients with medically refractory and disabling craniofacial pain were prospectively selected for ONS. Primary outcome was a change in mean daily pain intensity on the numeric pain rating scale (NPRS) at 6 months. Secondary outcomes included changes in NPRS, Headache Impact Test-6 (HIT-6), Migraine Disability Assessment (MIDAS), Pain Disability Index (PDI), Center for Epidemiologic Studies Depression Scale - Revised (CESD-R), and Short Form-36 version 2 (SF36) at last follow-up.

RESULTS

Thirteen patients (mean age 49.7 ± 8.4) diagnosed with occipital neuralgia (6), hemicrania continua (2), persistent idiopathic facial pain (2), post-traumatic facial pain (1), cluster headache (1), and chronic migraine (1) were enrolled. Mean NPRS improved by 2.1 ± 2.1 at 6 months and 2.1 ± 1.9 at last follow-up (23.5 ± 18.1 months). HIT-6 decreased by 8.7 ± 8.8, MIDAS decreased by 61.3 ± 71.6, and PDI decreased by 17.9 ± 18. SF36 physical functioning, bodily pain, and social functioning improved by 16.4 ± 19.6, 18.0 ± 31.6, and 26.1 ± 37.3, respectively. Moderate to severe headache days (defined as ≥50% of baseline mean NPRS) were reduced by 8.9 ± 10.2 days per month with ONS.

CONCLUSION

ONS reduced the long-term NPRS and moderate-severe monthly headache days by 30% and improved functional outcomes and quality of life. A prospective registry for ONS would be helpful in accumulating a larger cohort with longer follow-up in order to improve the use of ONS.

Neuromodulation in headache and craniofacial neuralgia: guidelines from the Spanish Society of Neurology and the Spanish Society of Neurosurgery

INTRODUCTION

Numerous invasive and non-invasive neuromodulation devices have been developed and applied to patients with headache and neuralgia in recent years. However, no updated review addresses their safety and efficacy, and no healthcare institution has issued specific recommendations on their use for these 2 conditions.

METHODS

Neurologists from the Spanish Society of Neurology's (SEN) Headache Study Group and neurosurgeons specialising in functional neurosurgery, selected by the Spanish Society of Neurosurgery (SENEC), performed a comprehensive review of articles on the MEDLINE database addressing the use of the technique in patients with headache and neuralgia.

RESULTS

We present an updated review and establish the first set of consensus recommendations of the SEN and SENC on the use of neuromodulation to treat headache and neuralgia, analysing the current levels of evidence on its effectiveness for each specific condition.

CONCLUSIONS

Current evidence supports the indication of neuromodulation techniques for patients with refractory headache and neuralgia (especially migraine, cluster headache, and trigeminal neuralgia) selected by neurologists and headache specialists, after pharmacological treatment options are exhausted. Furthermore, we recommend that invasive neuromodulation be debated by multidisciplinary committees, and that the procedure be performed by teams of neurosurgeons specialising in functional neurosurgery, with acceptable rates of morbidity and mortality.

Occipital Neuralgia and Cervicogenic Headache: Diagnosis and Management

PURPOSE OF REVIEW

Occipital neuralgia (ON) and cervicogenic headache (CGH) are secondary headache disorders with occipital pain as a key feature. Due to significant phenotypic overlap, differentiating ON and CGH from primary headache disorders such as migraine or tension-type headache, or other secondary headache disorders, can be clinically challenging. This article reviews the anatomy, clinical features, unique diagnostic considerations, and management approaches relating to ON and CGH.

RECENT FINDINGS

Conservative therapeutic approaches are considered first-line. Anesthetic nerve blocks may have a dual role in both supporting diagnosis and providing pain relief. Newer minimally invasive procedures, such as pulsed radiofrequency (PRF) and occipital nerve stimulation (ONS), represent an exciting therapeutic avenue for severe/refractory cases. Surgical interventions should be reserved for select patient populations who have failed all other conservative and minimally invasive options, to be weighed against potential risk. ON and CGH represent an ongoing diagnostic challenge. Further studies are required to consolidate efficacy regarding the comprehensive management of ON and CGH.