Study Describes Use of Occipital Nerve Stimulation to Treat Refractory Headaches

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Occipital pain is linked to migraine, but the 2 conditions are sometimes difficult to separate.

A recent study carried out at one institution said that occipital nerve stimulation (ONS) via a surgical implant is an effective therapy for patients with painful intractable occipital headaches (OH), but noted that the complications that might arise given the implanted devices should factor into any decision about whether or not to have the procedure.

The researchers, working at a center in France, conducted a retrospective analysis of 60 patients with intractable OH treated with ONS. The patients were sent to the center between October 2008 and October 2014.

The American Migraine Foundation has said that occipital neuralgia is linked to migraine and the 2 conditions are often related, although sometimes difficult to sort out. It usually presents as shooting or stabbing pain in the back of the head and may radiate.

In most cases, the researchers said, it may be triggered by trauma, osteoarthritis in the neck, inflammation linked to rheumatoid arthritis, and other causes. Treatment depends on the course of the pain, such as whether it is more neuropathic or nociceptive. ONS is generally effective only on the neuropathic part of the pain.

In this study, participants were 38 women and 22 men aged from 22 to 82 years. Mean disease duration was 7 years (range, 3-20 years).

The development of OH was clear in 28 cases: post‐traumatic (n = 11), postsurgical (n = 10), arthritis (n = 6), and cervical dystonia (n = 1). Clinical symptoms were OH or cervicogenic headache. Headache was unilateral in 18 cases and bilateral in 10 cases. However, there was no clear etiology in 32 patients.

In this study, patients were first treated with a transcutaneous electrical nerve stimulation (TENS) unit applied over the occipital nerve at the back of the head, which was shaved. Based on their response—if they had an improvement of greater than 30% in the visual analogue scale (VAS)—they were considered for selection for the implant.

After 1 year of treatment with ONS, there was a 72.2% reduction in the mean VAS, from 8.4/10 to 2.8/10 (P  <  .001). A little more than three-quarters (76%) of patients had at least a 50% decrease in mean VAS score.

The mean Medication Quantification Scale score decreased from 18 to 8.8, and pain medication usage fell by an average of 50%.

At 1 year, 26 patients (43%) received only acetaminophen if needed; other medications, including opioids, antidepressants, and antiepileptics, were stopped.

Twenty percent, or 12 patients, were affected by adverse events: 6 with electrode displacement or fracture and 6 patients with infection associated with the pulse generator. During a follow-up period of between 13 and 72 months, all but 4 patients continued to use the ONS, the researchers said. The prior use of a TENS device may help guide patient selection, they said.

Reference

Raoul S, Nguyen JM, Kuhn E, et al. Efficacy of occipital nerve stimulation to treat refractory occipital headaches: a single‐institution study of 60 patients. Neuromodulation. Published online July 28, 2020. doi:10.1111/ner.13223