neurostimulation and headache disorders stimulation for

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

www.neuromodulation.com

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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

http://www.neuromodulation.com/for-patientsCopyright2017 2 C-H.8.17

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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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References 1.DeerTR,CarawayDL,WallaceMS.ADefinitionofRefractoryPaintoHelpDetermineSuitabilityforDeviceImplantation.Neuromodulation2014;17:711-7152.2.WessmanM1,TerwindtGM,KaunistoMA,PalotieA,OphoffRA.Migraine:acomplexgeneticdisorder.LancetNeurol.2007Jun;6(6):521-32.3.“FDAAllowsMarketingofFirstDevicetoRelieveMigraineHeadachePain”(Pressrelease).Dec.13,2013.AccessedOct.14,2016.4.http://www.massdevice.com/fda-approves-breakthrough-migraine-prevention-deviceArezuSarvestani(March12,2014).“FDAApprovesBreakthroughMigrainePreventionDevice”.MassDevice.AccessedOct.14,2016.5.http://www.univadis.com/viewarticle/migraine-prevention-transcutaneous-supraorbital-nerve-stimulation-effective-316399?s1=newsLaurieBarclay(Oct.14,2015).“MigrainePrevention:TranscutaneousSupraorbitalNerveStimulationEffective”.Univadis.AccessedOct.4,2016.6.http://www.medicaldaily.com/new-device-stimrelieve-halo-migraine-treatment-385856LeciaBushak(May12,2016).“TinyNewForeheadDevice,‘StimRelieveHalo,’ProvidesMigraineTreatmentWithElectricPulses”.MedicalDaily.AccessedOct.14,2016.7.SilbersteinSD,CalhounAH,LiptonRB,GrosbergBM,CadyRK,DorlasS,SimmonsKA,MullinC,LieblerEJ,GoadsbyPJ,SaperJR;EVENTStudyGroup.Chronicmigraineheadachepreventionwithnoninvasivevagusnervestimulation:TheEVENTstudy.Neurology.2016Aug2;87(5):529-38.doi:10.1212/WNL.0000000000002918.Epub2016Jul13.PubMedPMID:27412146;PubMedCentralPMCID:PMC4970666.8.NeurostimulationforTreatmentofMigraineandClusterHeadache.SchwedtTJ,VargasB.PainMed.2015Sep;16(9):1827-34.doi:10.1111/pme.12792.Epub2015Jul14.Review.PMID:261776129.Chen,Y.F.,Bramley,G.,Unwin,G.,Cernat,D.H.,Dretzke,J.,etal(2015).OccipitalNerveStimulationforChronicMigraine-ASystematicReviewandMeta-Analysis.PLoSOne,10(3),e0116786.10.http://www.emedicinehealth.com/cluster_headache/page5_em.htmEdwardLubin(April4,2016).”ClusterHeadache”.eMedicineHealth.P.5.AccessedOct.14,2016.11.MartelletiP,JensenR,AntalA,etal.Neuromodulationofchronicheadaches:PositionstatementfromtheEuropeanHeadacheFederation.JHeadachePain.2013;14:86.12.PietzschJB,GarnerA,GaulC,MayA.Cost-effectivenessofstimulationofthesphenopalatineganglion(SPG)forthetreatmentofchronicclusterheadache:amodel-basedanalysisbasedonthePathwayCH-1study.TheJournalofHeadacheandPain.2015;16:48.doi:10.1186/s10194-015-0530-8.doi:10.1177/0333102412473667.13.SillayKA,SaniS,StarrPA.Deepbrainstimulationformedicallyintractableclusterheadache.NeurobiolDis.2010;38:361–8.14.http://www.medscape.com/viewarticle/878763“FDAApprovesVagusNerveStimulationDeviceforClusterHeadache”.Medscape.AccessedSept.12,2017.15.ManolitsisN,ElahiF1.Pulsedradiofrequencyforoccipitalneuralgia.PainPhysician.2014Nov-Dec;17(6):E709-17.16.WeinerRR,KL.PeripheralNeurostimulationforControlofIntractableOccipitalNeuralgia.Neuromodulation:TechnologyattheNeuralInterface.1999;2(3):217-221.17.5.5aumShaparin,MD,KarinaGritsenko,MD,DiegoFernandezGarcia-Roves,MD,UshmaShah,MD,ToddSchultz,MD,andOscarDeLeon-Casasola,PeripheralneuromodulationforthetreatmentofrefractorytrigeminalneuralgiaPainResManag.2015Mar-Apr;20(2):63–66.18.PopeneyCA,AloKM.Peripheralneurostimulationforthetreatmentofchronic,disablingtransformedmigraine.Headache.Apr2003;43(4):369-375.19.MayA,LeoneM,AfraJ,LindeM,SándorPS,EversS,GoadsbyPJ;EFNSTaskForce.EFNSguidelinesonthetreatmentofclusterheadacheandothertrigeminal-autonomiccephalalgias.EurJNeurol.2006Oct;13(10):1066-77.20.PlazierM,DekelverI,VannesteS,StassijnsG,MenovskyT,ThimineurM,DeRidderD.Occipitalnervestimulationinfibromyalgia:adouble-blindplacebo-controlledpilotstudywithasix-monthfollow-up.Neuromodulation.2014Apr;17(3):256-63;discussion263-4.21.ReedKL,BlackSB,BantaCJ,2nd,WillKR.Combinedoccipitalandsupraorbitalneurostimulationforthetreatmentofchronicmigraineheadaches:initialexperience.

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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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