Advanced technologies and novel neurostimulation targets in trigeminal autonomic cephalalgias

Abstract

The trigeminal autonomic cephalalgias (TACs) are a group of rare but disabling primary headache disorders. Their management is challenging, since only few effective treatments are available and high doses may be required to control the headache, compromising patients' adherence to treatments. A significant minority of patients, who fail to respond to or tolerate established treatments, are left with enormous level of disability and disruption to their quality of life. A growing body of evidence demonstrates the efficacy of central and peripheral neuromodulation approaches for management of patients with refractory TACs. In view of the potential risks related to deep brain stimulation of the posterior hypothalamic region, occipital nerve stimulation is currently considered the first treatment option for refractory chronic TACs. However, in view of the presence of paraesthesia induced by the stimulator, no robust controlled trials have been possible so far. Additionally, the equipment used for occipital nerve stimulation is not designed specifically for peripheral nerve stimulation, thus a significant proportion of patients experience device-related complications that often require surgical revisions. To overcome these issues, new neurostimulation technologies using less invasive or non-invasive approaches and modulating different neuroanatomical targets have been recently studied.

Chronic Headache and Neuromodulation

“…TAC is a group of headache disorders characterised by unilateral headache accompanied by cranial autonomic symptoms. Although SONS has been attempted [19], ONS is the first option [27], reserving the hDBS to the most recalcitrant cases [49,50,52].…”

“…The noninvasive options include transcranial stimulation either electric [8][9][10] or magnetic [11][12][13] and transdermal stimulation of occipital [14,15], supraorbital [9,[14][15][16][17][18][19] or vagus [20][21][22][23] nerves. Invasive procedures include stimulation of occipital [5,17,24,[25][26][27][28][29][30][31][32][33][34][35], supraorbital [19,31,36], infraorbital [31] or greater auricular [37] nerves as well as sphenopalatine ganglion [38][39][40][41][42][43][44], cervical spinal cord [45][46][47][48...…”

Cortical Mechanisms of Single-Pulse Transcranial Magnetic Stimulation in Migraine

“…Non-invasive neuromodulation techniques have more recently emerged as alternatives to pharmaceuticals in the management of migraine, helped by the development of patientfriendly devices and favourable tolerability profiles [12,13]. Single-pulse transcranial magnetic stimulation (sTMS) has been used in clinical neurology for decades.…”