gms | German Medical Science

Objective: The current treatments of chronic headache syndromes (CHS) are conservative and pharmacological, accompanied by psychological and behavioural therapies. A certain percentage of patients remains refractory or suffers from major medication side effects. The significance of subcutaneous peripheral nerve stimulation of the greater occipital nerve (ONS) is demonstrated and recommendations for indication and patient selection in CHS presented.

Methods: In all patients a thorough neurological evaluation by an experienced headache specialist is mandatory. Pain symptoms lead to a diagnosis according the criteria of the International Headache Society. Prior treatment includes at least various pharmacological therapies and pain duration of > 12 months. Implantation of the leads is performed as a minimal invasive approach by percutaneous leads and fluoroscopic guidance subcutaneously at the level of the lamina of C1/C2. The patient sample includes a prospective series of 15 patients with chronic cluster headache (CCH, 6 pat.), chronic migraine (CM, 3 pat.), combination of CCH and CM (3 pat.) and occipital neuralgia (ON, 3 pat.).

Results: After lead implantation, a test phase of at least 7 days was performed and different stimulation parameters programmed. Individual adjustment of the stimulation intensity was possible by the patient to achieve the best coverage of evoked paraesthesias. In 13/15 patients a positive effect with pain reduction was reported by active suprathreshold ONS. These patients reported a decrease in the frequency, intensity and duration of the attacks. In these 13 patients, the implantation of a neurostimulator was performed. In the long-term follow-up of up to 60 months (mean 25, range 4–60 months) two cases of lead dislocation and breakage of either the lead or the extension wire and one case of misconnection of the extension to the neurostimulator was observed and re-operated.

Conclusions: The indication and patient selection for ONS is an interdisciplinary approach by headache and invasive pain specialists with experience in neuromodulation. The ONS is a simple and low-risk procedure and should be offered to refractory patients with CCH, CM or ON. The results of the reported patient sample and the literature demonstrate that a significant pain reduction can be achieved in these refractory cases. There is an urgent need for a prospective randomized trial comparing ONS with best medical and conservative treatment.