Neuromodulation of chronic headaches: position statement from the European Headache Federation

Abstract

The medical treatment of patients with chronic primary headache syndromes (chronic migraine, chronic tension-type headache, chronic cluster headache, hemicrania continua) is challenging as serious side effects frequently complicate the course of medical treatment and some patients may be even medically intractable. When a definitive lack of responsiveness to conservative treatments is ascertained and medication overuse headache is excluded, neuromodulation options can be considered in selected cases.Here, the various invasive and non-invasive approaches, such as hypothalamic deep brain stimulation, occipital nerve stimulation, stimulation of sphenopalatine ganglion, cervical spinal cord stimulation, vagus nerve stimulation, transcranial direct current stimulation, repetitive transcranial magnetic stimulation, and transcutaneous electrical nerve stimulation are extensively published although proper RCT-based evidence is limited. The European Headache Federation herewith provides a consensus statement on the clinical use of neuromodulation in headache, based on theoretical background, clinical data, and side effect of each method. This international consensus further gives recommendations for future studies on these new approaches.In spite of a growing field of stimulation devices in headaches treatment, further controlled studies to validate, strengthen and disseminate the use of neurostimulation are clearly warranted. Consequently, until these data are available any neurostimulation device should only be used in patients with medically intractable syndromes from tertiary headache centers either as part of a valid study or have shown to be effective in such controlled studies with an acceptable side effect profile.

Targeting pericranial nerve branches to treat migraine: Current approaches and perspectives

“…Although evidence of benefit is lacking, tSNS and tVNS could also be proposed as addon to drug-resistant chronic migraine patients, before turning to more invasive and expensive devices (48).…”

Advanced technologies and novel neurostimulation targets in trigeminal autonomic cephalalgias

“…Based on published evidence, in refractory CCH, it would be advisable to use ONS and SPG stimulation as first line treatments, followed by the more invasive DBS of the posterior hypothalamus [27]. However, if the recent promising open label evidence in the use of transcutaneous VNS in CH is confirmed in controlled trials, it is arguable that application of a noninvasive device, which is relatively harmless and less costly than other procedures, may be tried before the more invasive neurostimulation modalities.…”

Cluster headache management and beyond

“…Despite promising new data, the European Headache Federation recommends caution in using these techniques [26] because only few controlled studies have, as yet, been carried out. It is important to avoid the disillusion produced in CCH patients when, more than 10 years ago, the scientific community celebrated as decisive, an extremely invasive and harmful therapeutic proposal [27], now abandoned [26,28].…”