Article
Invasive subcutaneous peripheral nerve field stimulation of the greater occipital nerve in patients with refractory migraine or headache syndromes
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Authors
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Dirk Rasche
- Department of Neurosurgery, University of Lübeck, Germany
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Volker M. Tronnier
- Department of Neurosurgery, University of Lübeck, Germany
| Published: | May 21, 2013 |
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Outline
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Objective: A certain percentage of patients with chronic migraine or headache syndromes are refractory to any conservative, pharmacological, psychological and additional therapies. Also the injection of botulinum toxine is not an option for long term treatment in these patients. The clinical significance of subcutaneous peripheral nerve field stimulation of the greater occipital nerve (ONS) is discussed and a single center experience presented.
Method: One or more experienced headache specialists stated the diagnoses according to the criteria of the International Headache Society in all patients. Patients had a pain history of >12 months and were refractory to various treatment options. Informed consent was given to the percutaneous implantation of the leads at the level of the lamina of C1/C2 under local anesthesia. A test trial was conducted with externalized extensions for at least 5 days. The prospective series includes 30 patients with chronic cluster headache (CCH, 12 pat.), chronic migraine (CM, 7 pat.), combined CCH and CM (7 pat.) and occipital neuralgia (ON, 4 pat.).
Results: In all patients intraoperative test stimulation was able to provoke paraesthesias covering the dermatoma of the greater and sometimes also minor occipital nerve. By active suprathreshold stimulation positive effects were documented by 28/30 patients. Clinical effects ranged from slight improvement of pain and better night rest up to pain reduction more than 90%. Most patients reported a decrease in attack frequency, intensity and duration. During follow-up of up to 78 months (mean 33, range 2-76 months) two cases of lead dislocation and breakage were observed and re-operated. In two cases the positive effect of the stimulation diminished after 6/15 months.
Conclusions: ONS is a minimal invasive and and low-risk procedure for experienced neuromodulatory pain specialists. A significant pin reduction can be achieved in these refractory and chronic cases. The evidence and treatment recommendation must be evaluated by a multi-center prospective randomized trial comparing ONS with best medical and conservative treatment.
