A six year retrospective review of occipital nerve stimulation practice - controversies and challenges of an emerging technique for treating refractory headache syndromes

Abstract

BackgroundA retrospective review of patients treated with Occipital Nerve Stimulation (ONS) at two large tertiary referral centres has been audited in order to optimise future treatment pathways.MethodsPatient’s medical records were retrospectively reviewed, and each patient was contacted by a trained headache expert to confirm clinical diagnosis and system efficacy. Results were compared to reported outcomes in current literature on ONS for primary headaches.ResultsTwenty-five patients underwent a trial of ONS between January 2007 and December 2012, and 23 patients went on to have permanent implantation of ONS. All 23 patients reached one-year follow/up, and 14 of them (61%) exceeded two years of follow-up. Seventeen of the 23 had refractory chronic migraine (rCM), and 3 refractory occipital neuralgia (ON). 11 of the 19 rCM patients had been referred with an incorrect headache diagnosis. Nine of the rCM patients (53%) reported 50% or more reduction in headache pain intensity and or frequency at long term follow-up (11–77 months). All 3 ON patients reported more than 50% reduction in pain intensity and/or frequency at 28–31 months. Ten (43%) subjects underwent surgical revision after an average of 11 ± 7 months from permanent implantation - in 90% of cases due to lead problems. Seven patients attended a specifically designed, multi-disciplinary, two-week pre-implant programme and showed improved scores across all measured psychological and functional parameters independent of response to subsequent ONS.ConclusionsOur retrospective review: 1) confirms the long-term ONS success rate in refractory chronic headaches, consistent with previously published studies; 2) suggests that some headaches types may respond better to ONS than others (ON vs CM); 3) calls into question the role of trial stimulation in ONS; 4) confirms the high rate of complications related to the equipment not originally designed for ONS; 5) emphasises the need for specialist multidisciplinary care in these patients.

Occipital Neuralgia as a Sequela of Sports Concussion

“…In those who have a diagnosis of ON supported by a positive diagnostic block but did not respond to pulsed radiofrequency stimulation, occipital nerve stimulation with implanted stimulating leads and associated implantable pulse generator may be performed (Fig. 2) (24). …”

Occipital Nerve Stimulation for Migraine: Update from Recent Multicenter Trials

“…Two large centers that specialize in neuromodulation examined, retrospectively, their experiences with ONS over a 6-year period (2007-2012) [27] . Twenty-five patients had an ONS implanted but only 23 were analyzed.…”

Long-Term Clinical Outcome of Peripheral Nerve Stimulation for Chronic Headache and Complication Prevention

“…This technique has been used to the cranial nerves for treatment of chronic intractable headache of various types (2-4), including migraine (5-7), cluster headache (8, 9), occipital neuralgia (10, 11) cervicogenic headache (12) and supraorbital neuralgia (13). Promising outcomes have been reported, with efficacy rates in pain reduction and functional improvement ranging from 40% to100% (2-4, 8, 14, 15). While this positive response is encouraging, complications of the therapy, that include acute and late-onset infections, lead migration and skin erosion, have been of concern (3, 4, 6-8, 14-16).…”

“…Promising outcomes have been reported, with efficacy rates in pain reduction and functional improvement ranging from 40% to100% (2-4, 8, 14, 15). While this positive response is encouraging, complications of the therapy, that include acute and late-onset infections, lead migration and skin erosion, have been of concern (3, 4, 6-8, 14-16). These complications significantly impact the clinical application of this treatment modality, and could impede a more widespread use of it in the future.…”