HeadacheDisorders
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CanNeurostimulationBeUsedforHeadachesandMigraines?Yes,neurostimulationoftheperipheralnervesoftheheadandfaceareemergingasapotentialtreatmentoptionforpatientswithchronic,intractableanddisablingprimaryheadachedisorderslikechronicmigraines,chronicclusterheadaches,occipitalneuralgiaandevensomeformsofchronicdailyheadaches.Threeheadacheconditionsandtheirtreatment–migraine,clusterheadache,andoccipitalneuralgia–arepresentedinthisdocument.Thisoverviewisintendedforpatients,familymembers,caregivers,practitioners,referringphysicians,andthegeneralpublic.Additionalresourcesarelistedattheend.Inaddition,a2016tableinNatureReviewsNeurologysummarizescurrentandemergingneuromodulationtherapiesforheadache,at:http://bit.ly/neuromodulation-chart.Safetyandefficacydataarelimitedinquantitybutthereisaccumulatingexperienceoftheuseofneurostimulationforthetreatmentofrefractoryoccipitalneuralgia,chronicclusterheadache,chronicmigrainesandotherheadachedisorders.WhatDoes“Refractory”HeadachesMean?Refractorymeanswhennotreatmentsseemtohelpreducethepainorsuffering.
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Themedicaldefinitionfor‘refractorypain’iswhen:1)Multipleevidenced-basedbiomedicaltherapiesusedinaclinicallyappropriateandacceptablefashionhavefailedtoreachtreatmentgoalsthatmayincludepainreductionand/orimprovementindailyfunctioningorhaveresultedinintolerableadverseeffectsandwhen2)psychiatricdisordersandpsychosocialfactorsthatcouldinfluencepainoutcomeshavebeenassessedandappropriatelyaddressed.(1)WhatIsaMigraine?Amigraineisachronicneurologicaldisordercharacterizedbyepisodicattacksofheadpainwithassociatedsymptoms.Migrainessufferersmayexperiencethefollowing:
Apulsatingpaintoonesideoftheheadofmoderatetoseverepainintensity
Attacksthatlastfromafewhourstoseveraldays
Aggravationfromroutinephysicalactivities
Peripheralnervestimulationfortreatment-resistantheadachesappearssafe,effective,andwell-tolerated
NeurostimulationandHeadacheDisordersMedicallyRefractoryMigraine,ClusterHeadache,andOccipitalNeuralgia
ReviewedbyNickChristelis,MBBCH,FRCA,FFPMRCA,FANZCA,FFPMANZCACo-chair,InternationalNeuromodulationSocietyPublicEducation,Outreach,andWebsiteCommittee,2016-DirectorandCo-FounderVictoriaPainSpecialists,Richmond,Australia
August2017
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Othersymptomsmayincludenausea,sensitivitytolight(photophobia)orsensitivitytosound(phonophobia)
In20%ofpeoplemigrainesmayoccurwithanaura(reversiblechangesinvisionandothersensationslikecoordinationandspeech)
Ifmigrainesoccurwithanyweaknessofthebody,thisisadangersignandmedicalhelpshouldbesoughtimmediatelyAmigrainecanbeincapacitating!WhoGetsMigraines?Migrainesaffectanyone:
Upto18%ofwomenUpto8%ofmenUpto15%ofchildrenunderage18About12%ofuswillexperienceamigraineheadacheatsomepointinour
livesMorethanhalfofmigrainesufferershaveatleastoneattackpermonth.Forsomemigrainesufferers,certainactivitiesorfoodsmaybringonanattack.Migraineattackshavebeenlinkedtoconsumingredwineorbeer,cheese,chocolate,citrusfruitslikeoranges,andteaorcoffee.Foodsthatmaytriggeranattackarerelativelyhighinamines,whichcanalterbloodflowinthebrain.Stresscanalsobeatriggerformigraines.WhatIstheImpactofMigraines?Migrainescandramaticallyimpactwork,familyandsociallife.Estimatesplacetheannualcostofmigraineat$14billion,accordingtheU.S.NationalAcademyofSciences’2011report“RelievingPaininAmerica”.Today,researchersarestilluncoveringnewinformationaboutthecondition.Wenowknowtherecanbeageneticcomponenttomigraines.(2)HowAreMigrainesTreated?Anapproachtomanagingmigrainesshouldinclude:
EducationLifestylechangese.g.stoppingcaffeine,increasingexercise,stress
managementandimprovingsleephygieneRecognisingtriggersandavoidingthemDeterminingthetypeandfrequencyofmigraineattacksusinguseheadache
calendarsanddiarieswhereappropriateDetectingandtreatco-morbiditye.g.depression,anxietycommonlyco-existsIndividualisedtreatmentshouldbeprovidedbyspecialistneurologistsand
painspecialistphysiciansCombinationmedicationtherapyshouldbeusedwherepossible
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WhatIstheTreatmentforAcuteMigraineAttacks?Medicationstotreatacutemigraineattacksinclude:non-steroidalanti-inflammatorydrugs,paracetamol(acetaminophen),triptansandanti-nauseamedications.Routineuseofopioidanalgesicsisnotrecommendedforthetreatmentofacutemigraineduetothepotentialformedication-overuseheadacheandworseningtheproblem.WhatIsthePreventativeTreatmentforMigraineAttacks?Combinationpreventativemedicationtherapiesmightinclude:antiepileptics,antidepressants,beta-blockers,andanti-hypertensives.Forpreventionofmigraines,opioidanalgesicsshouldnotberoutinelyusedduetothepotentialfordevelopmentofmedication-overuseheadache.WhatAreSomeoftheNon-MedicationTherapiesforMigraines?
Lifestylechangese.g.stoppingcaffeine,increasingexercise,stressmanagementandimprovingsleephygiene
RecognisetriggersandavoidthemBotulinumtoxinAinjectionsattheback
oftheneck,wheretheoccipitalnervesmayplayaroleinchronicmigraines.Noteveryonefindsbenefitfromtheinjections,however,andrepeatinjectionsarerequired
NeurostimulationNon-invasiveNeurostimulationforChronicMigraineIn2013,theU.S.FoodandDrugAdministration(FDA)approvedaportable,single-pulsetranscranialmagneticstimulatortohalttheonsetofmigrainewithaura.Thenin2014,theFDAapprovedaheadpiecedesignedtoprevent
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migraines.Thecrown-likebandiswornacrosstheforeheadforseveralminutesadayandstimulatesthesupraorbitalnerves.(3)EmergingNeurostimulationMethodstoTreatChronicMigraineIn2015,theFDApermittedaclinicalstudyofaminiaturizedneurostimulatorasapotentialchronicmigrainetreatment.Theimplantworkswirelesslyandisinsertedbeneaththeskinoftheforeheadtostimulatetheoccipitalandsupraorbitalnerves.Anotherneurostimulationapproach,vagusnervestimulation,hasalsobeenstudiedasapotentialwaytopreventchronicmigraine.(4–8)ResearchIntoOccipitalNerveStimulation(ONS)forChronicMigraineONSstimulatestheoccipitalnerves,whichrunfromthebaseoftheskullandwraparoundtotheforehead.A2015reviewof12researchstudiesaboutmedication-resistant(“refractory”)migraineconcludedin2015that“short-termresultsindicatethattheeffectofONSis,onaverage,modestamongpatientswithchronicrefractorymigrainealthoughtheobservedeffectsmaystillbeclinicallyimportantgiventherefractorynatureofthecondition.”(9)WhatIsaClusterHeadache?Clusterheadacheisarelativelyrare,butsevere,conditionthathasbeendescribedasthemostpainfulexperienceknown,likebeingstabbedintheeyewithared-hotpoker.Thepainissoextreme,theconditionissometimescalled“suicideheadache”.WhoGetsClusterHeadaches?Unlikemigraine,clusterheadachesmostlyaffectmen,strikingsixtimesasmanymenaswomen.Clusterheadachesaffectabout1in1,000people.HowAreClusterHeadachesDiagnosed?Asthenameoftheconditionimplies,theclusterheadacheattackscomesinwaves,orclusters,overdaysormonths.Theheadacheslastfromabout15minutestothreehours.Clusterheadachesstrikemultipletimesadayoreverydayortwo,oftenatthesametimeofday.Thepainusuallyoccursaroundtheeyeandononesideofthehead.Ontheaffectedside,theeyemaywaterandthenosemaybecomestuffyorrunny.Duetothat,thedisorderissometimescalledahistamineheadache.WhatIstheCauseofClusterHeadache?Thecauseofclusterheadacheisnotfullyknown.Twochemicalmessengers,histamineandserotonin,mayplayarole.Thehypothalamus,whichhelpsorchestratesleepcycles,isalsothoughttobeinvolvedinthesecyclicalattacks.
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HowAreClusterHeadachesTreated?Clusterheadachetreatmentsaimtolimithowmanyattacksthereare,andhowseveretheyare.Medicationstopreventclusterheadacheattacksinclude:beta-blockers,anticonvulsants,divalproex,tricyclicantidepressants,nortriptyline,andcalciumchannelblockers.(10)Medicationstohaltorlimitaclusterheadacheattackonceithasbegunincludeergots,acetaminophen-isometheptene-dichloralphenazone,dihydroergotamineinjection,andtriptans.Inaddition,someover-the-countermigrainetreatmentscanbeusedforclusterheadache.Breathingpureoxygenduringaclusterheadacheattackmayalsobringsomerelief,especiallywhenattacksoccuratnight.ClusterHeadachesandNeurostimulationWhenotherformsoftreatmentfailtobringreliefforclusterheadache,neurostimulationmaybeconsidered.Earlyexperiencewithneuromodulationtechniquesforchronicpainfirststartedinthe1950swithrecognitionoftheroleofthehypothalamus–astructuredeepinthebrain.Later,otherless-invasiveneuromodulationtargetsweretriedinthespinalcordandfacialorscalpnervesoutsidetheskull–suchastheupperspinalcord,thesphenopalatineganglion(afacialnervebundle),oroccipitalnerves.Althoughneurostimulationtreatmentsarestillevolving,in2013theEuropeanHeadacheFederationrecommendedoccipitalnervestimulationandsphenopalatineganglionstimulationasfirst-linetherapyinclusterheadachepatientswhoseconditionismedication-resistant.(11)
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SphenopalatineGanglionStimulationThesphenopalatineganglion(SPG)isanervebundlenearthecheekandupperjawthathaslongbeenatargetforotherclusterheadachetherapies,suchaslocalanestheticorlesioning.SPGstimulationhasbeenavailableinEuropeforepisodicandclusterheadachesince2012.IntheU.S.,aclinicaltrialpriortoapplicationforregulatoryapprovalwasexpectedtofinishin2017.(12)OccipitalNerveStimulationOccipitalnervestimulationhasbeeninvestigatedinnearly100patientswithclusterheadache.About60%ofthemexperiencedatleasta50%reductioninheadachefrequencyand/orintensity.(8,11)DeepBrainStimulationCurrently,deepbrainstimulationismainlyusedtodecreasemotorsymptomsofmovementdisorderssuchasParkinson’sdisease.Still,by2016,atleast64patientswithmedication-resistantclusterheadachewerereportedtohavereceivedDBS,andrecommendationsforpatientselectionhavebeendeveloped.(9,13)Deepbrainstimulationtargetsforclusterheadachearedifferentthanthoseformovementdisorder;theyincludethehypothalamusortheassociatedventraltegmentalarea,whichalsoplaysaroleinthis“paincircuit”.VagusNerveStimulationFinally,sincethevagusnerveinfluencesthebalanceofnervoussystemactivity,non-invasivevagusnervestimulation(VNS)hasalsobeendevelopedasaclusterheadachetreatment.(14)WhatIsOccipitalNeuralgia?Occipitalneuralgia,alsoknownasArnold’sneuralgia,isdefinedbytheInternationalHeadacheSocietyasaunilateralorbilateralparoxysmal,shootingorstabbingpainintheposteriorpartofthescalp,inthedistributionofthegreateroccipitalnerve,lesseroccipitalnerve,orthirdoccipitalnerve,sometimesaccompaniedbydiminishedsensationordysesthesiaintheaffectedareaandcommonlyassociatedwithtendernessovertheinvolvednerve(s).(15)Ifoccipitalneuralgiafailstorespondthesimpletherapieslikemedications,localanaestheticandsteroidinjectionsaroundtheoccipitalnerve(s),botulinumtoxinAinjection,andoccipitalnervepulsedradiofrequency,thenneurostimulationcouldbeconsidered.WhatTreatmentIsAvailableIfHeadaches,MigrainesandOccipitalNeuralgiaAreMedication-Resistant(Refractory)?About20%ofthepopulationcanexperienceincapacitatingheadachesthatareresistanttomedicaltherapies.Migraines,clusterheadaches,andoccipitalneuralgiacanallbecomerefractory.
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Ifthepainisconsideredrefractory,occipitalnervestimulationcouldbeconsidered.Occipitalnervestimulationwasoriginallyusedtotreatoccipitalneuralgiabuthasapplicationforotherrefractoryheadachedisorders.(16)OccipitalNerveStimulationExplainedThetechniqueofneurostimulationdeliversmildelectricalcurrentsthroughsmallelectrodesthatareembeddedinathinandsoftflexiblewirethatisplacedundertheskin,throughaneedle.Thewire(lead)sitsjustundertheskin,atthebaseoftheskull,neartheoccipitalnerves.Patientsreceiveasmallhandheldremotecontrolthattheyusetoturnstimulationonandoff,usingsettingsadjustedbytheirpainspecialist.Aneurostimulationsystemisfirsttriedonatemporarybasisforuptotwoweeksandifthepainreductionduringthistimeisgreaterthan50%orifthemigraineseverityand/orfrequencyisgreatlyreduced,thenapermanentimplantofthedevicecouldbeconsidered.Whenpermanentlyimplanted,theelectricalimpulsesaredeliveredbyasmall,pacemaker-likebatterythatisplacedundertheskinusuallyundertheskinonthechestwall,nearthecollarbone,likeapacemakerusedforheartconditions.Ithasbeenshownthatelectricalstimulationofnervesstimulatesthereleaseofnaturalchemicalsthatcausepainreductionbyquietingover-excitablenerves.Electricalstimulationofnervesmayalsoenhancelocalbloodcirculation.(17)Whenwestimulatenerveswithcurrent,wemodulatethenervefunction,hencethetermneuromodulation.Oftenneuromodulationtherapiesrefertothelocationofstimulation.Forinstance,whenwestimulatethespinalcord,wecallitspinalcordstimulation(SCS).Whenwestimulatesmallnervesoutsidethespinalcordwecallitperipheralnervestimulation(PNS).
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Occipitalnervestimulationisatypeofperipheralnervestimulationdevelopedforpainrelief.In2003,occipitalnervestimulationwasusedtotreatchronicandrefractorymigraine.(18)Occipitalnervestimulationhasalsobeenusedtotreatclusterheadaches.(19)Inaddition,occipitalnervestimulationwasinvestigatedasaformoftherapyforfibromyalgia.(20)ABitMoreDetailonOccipitalNerveStimulationIn1999,theInternationalNeuromodulationSociety’sjournalNeuromodulation:TechnologyattheNeuralInterfacepublishedclinicalobservationsdescribinguseofneurostimulationtoreducethesevereheadpainofoccipitalneuralgiathatgenerallyoccurstotherearofthehead,inareassuppliedbytheoccipitalnerves.Theauthorsnotedthat,similartotreatingneuropathicpainwithspinalcordstimulation,usingperipheralneurostimulationontheoccipitalnervesinducedapleasanttinglingsensation.Theyreporttheeffectrelievedthelightning-likepainconditionbyatleasthalfinthepatientswhoseconditionsweremonitoredfrom18monthsto6years.(16)Recentclinicalresultshaveseemedtosupporttheexpectationofsomecliniciansthatapplyingaperipheralnervestimulatortoacombinationoftheoccipitalnervesandnervesthatsupplythefacemightresultinabetteroutcome.(21-23)(Apartialconvergenceofthesetwosystemsoccursatthetrigeminocervicalcomplex.)Indeed,theresponserateforpatientswithrefractoryhead-widepainwhoweretreatedwithneurostimulationtotheoccipitalandtrigeminalnervesystemsisreportedtobebetterthan90%.(21-23)Thisisanimprovementfromusingonlystimulationtotheoccipitalnervesforhead-widepainsyndromes,whichisreportedtobringaboutjusta40%response.(24)(Onaverage,patientswhoonlyhavepainintherearofthehead,aposterioroccipitalsyndrome,showimprovementaveraging88%fromoccipitalnervestimulation,withtherangerunningfrom71–100%.)Complicationsofoccipitalnervestimulationareusuallyminor.Theseincludemedicalcomplications,suchasinfection,bleedingorfluidcollectionundertheskin(seroma).Thedeviceandtheconnectionscansometimesbethecauseofcomplicationsandmightincludemovementoftheelectricallead(leadmigrationisoneofthecommonestcomplications),breakage/fractureoftheleads,orbattery(pulsegenerator)problems.Theresultsseembestwhenthetinglingsensation(paresthesia),occursinalltheprimarynervedistributionsinvolved(occipitaland/ortrigeminal).Thereisagrowingbodyofliteraturesupportingthesetechniques,althoughcontinuedhighqualitystudiesareneededtofurtherassesstheirlong-termeffectiveness.Insummary,clinicalevidenceandmedicalexperienceshowsthatperipheralnervestimulation,whenusedformedicallyrefractoryheadpainsyndromeslikemigrainesandoccipitalneuralgia,appearstobesafe,effectiveandwelltolerated.
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Pleasenote:Thisinformationshouldnotbeusedasasubstituteformedicaltreatmentandadvice.Alwaysconsultamedicalprofessionalaboutanyhealth-relatedquestionsorconcerns.ResourcesAmericanChronicPainAssociationP.O.Box850Rocklin,[email protected]://www.theacpa.org (916)632-0922;(800)533-3231NationalHeadacheFoundation820N.OrleansSuite411Chicago,[email protected]://www.headaches.org (312)274-2650;(888)643-5552
MagisD,JensenR,SchoenenJ.Neurostimulationtherapiesforprimaryheadachedisorders:presentandfuture.CurrOpinNeurol.2012;25:269-76.
MillerS,SinclairAJ,DaviesB,MatharuM.Neurostimulationinthetreatmentofprimaryheadaches.PractNeurol.2016;16:362-375.
SchusterNM,RapoportAM.Newstrategiesforthetreatmentandpreventionofprimaryheadachedisorders.Nat.Rev.Neurol.2016;12:635-50.
SlavinKV,ColpanME,MunawarN,WessC,NersesyanH.Trigeminalandoccipitalperipheralnervestimulationforcraniofacialpain:asingle-institutionexperienceandreviewoftheliterature.NeurosurgFocus.2006;21:E5.Forfurtherinformationsee:WIKISTIMathttp://www.wikistim.org–Thisfree-to-usecollaborative,searchablewikiofpublishedprimaryneuromodulationtherapyresearchwascreatedin2013asaresourcefortheglobalneuromodulationcommunitytoextendtheutilityofpublishedclinicalresearch.ThegoalsofWIKISTIMaretoimprovepatientcareandthequalityofresearchreports,fostereducationandcommunication,revealresearchneeds,andsupportthepracticeofevidence–basedmedicine.
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Cephalalgia.Mar2010;30(3):260-271.22.SlavinK,WessC.Trigeminalbranchstimulationforintractableneuropathicpain:technicalnote.Neuromodulation:TechnologyattheNeuralInterface.2005;8:7-13.23.MammisA,GudesblattM,MogilnerA.Peripheralneurostimulationforthetreatmentofrefractoryclusterheadache,long-termfollow-up:CaseReport.Neuromodulation:TechnologyattheNeuralInterface.2011;14(5):432-435.24.SaperJR,DodickDW,SilbersteinSD,McCarvilleS,SunM,GoadsbyPJ.Occipitalnervestimulationforthetreatmentofintractablechronicmigraineheadache:ONSTIMfeasibilitystudy.Cephalalgia.Feb;31(3):271-285.
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