Occipital Nerve Stimulation
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Occipital nerve stimulation (ONS) is a form of neuromodulation therapy aimed at treating headache and craniofacial pain. This therapy involves an implantable device composed of an electrode and pulse generator. The lead is placed into the subcutaneous tissues innervated by the greater and lesser occipital nerves, and the pulse generator is implanted into a subcutaneous pocket in the chest, abdomen, or back.
Prior to implantation, a trial is performed in which leads are placed under the skin and are connected to an external battery. The trial is performed under sedation, and the patient is discharged the same day. Afterward, the patient tries the therapy for 4–7 days and keeps a detailed pain diary.
A permanent device is implanted only if the patient reports significant improvements in pain and quality of life. The permanent implantation is placed under sedation or anesthesia, and the patient is discharged the same day.
The device is programmed by a clinical specialist appointed by the manufacturer.
This type of therapy has been evolving as a treatment for intractable occipital headache syndromes since the first implant in 1993, and the data to support its use are robust. Multiple authors have reported that successful neuromodulation for occipital headache syndromes can be accomplished with subcutaneous regional electrode placement. Available literature on the use of peripheral neurostimulation for headache includes occipital nerve stimulation, supraorbital nerve stimulation, and infraorbital nerve stimulation. Recently, other neurostimulatory techniques such as cervical epidural neurostimulation have been explored for cluster headaches, as well. [1]
Neurostimulation is FDA-approved for the treatment of certain intractable pain syndromes, although it is not approved for headache, chronic migraine, and craniofacial pain and thus occipital nerve stimulation continues to represent an off-label use.
The theory of neuromodulation refers to therapeutic alteration of activity, electrically or chemically, in the central, peripheral, or autonomic nervous systems via the process of inhibition, stimulation, modification, or other forms of regulation. Occipital nerve stimulation is a form of neuromodulation that is reversible and adjustable and that can be tailored to an individual’s specific needs.
The mechanisms of action [2] for the paresthesia patterns and pain relief obtained from an occipital nerve stimulation are incompletely understood but appear to involve the following:
Subcutaneous electrical conduction
Dermatomal stimulation
Myotomal stimulation
Sympathetic stimulation
Local blood flow alteration
Peripheral nerve stimulation
Peripheral and central neurochemical mechanisms
Trigeminovascular system and Trigeminocervical tract
One prevalent theory is the involvement of the trigeminocervical system, which is the anatomic overlap of the trigeminal and occipital afferent systems at the level of C2 in the spinal cord. Trigeminal afferent pathways, and thus primary headache disorders, can be modulated at the C2 level by occipitally mediated afferents. In addition, electromodulation works to reduce blood flow to the pain-stimulating areas and to reduce abnormal excitation of the peripheral pain fibers, thus preventing central sensitization of trigeminal sensory nerve pathways, potentially reducing on-cell activity, and modulating the descending system at the level of the dorsal horn.
The gate control theory described by Melzack and Wall in 1965 (see image below) has been postulated to be one mechanism of action by which occipital nerve stimulation works for the treatment of local neuropathic pain. [3] According to this theory, stimulation activates large myelinated afferents, which “close the pain gate” in the substantia gelatinosa by enhancing the inhibitory actions of local circuit neurons in the dorsal horn on central transmission cells. Since pain states are maintained by continuous firing of unmyelinated and small myelinated afferents, a proportionately greater increase in the activation of large myelinated afferents closes the gate and stops pain transmission via presynaptic inhibition.
Indications for occipital nerve stimulation include the following:
Chronic, intractable primary headache disorder [4]
Chronic, intractable secondary headache disorders
Neuropathic pain involving the occipital or suboccipital region
Migraine affects 12% of the US population, and women account for 70% of affected individuals. It is estimated that up to 5% of persons who have migraines experience daily or near daily headaches (transformed migraine, chronic daily headaches). Furthermore, 1%–2% are so poorly responsive to medication paradigms that this failure can lead to various consequences, including narcotic dependence, severe restrictions in daily activities, failed personal and career objectives, and an overwhelming sense of hopelessness and despair.
Of patients with migraines, 3%–13% progress to chronic migraine, which is defined as headache pain more than 3–5 days per month. In many cases, the migraines are intractable to medical therapy. Patients in whom medical therapy has failed and who have headache pain that is refractory to preventive medication may benefit from occipital nerve stimulation trials.
Surgical modalities for treating the occipital nerve are reserved as a last resort after failure of medical management. The surgical modalities include decompressive, ablative, and stimulating procedure such as occipital nerve stimulation. Furthermore, occipital nerve stimulation is a nonablative procedure.
The benefits of occipital nerve stimulation have been described in a number of conditions, including the following:
Occipital neuralgia (intractable) [5]
Occipital headaches
Cervicogenic headache
Posttraumatic pain
Posttraumatic headache
Chronic daily headaches (transformed migraine)
Chronic headache attributed to whip lash
New daily persistent headache
Hemicranias continua
Headache secondary to idiopathic intracranial hypertension
If the patient’s quality of life does not improve during the trial period (see Pre-Procedure Planning), the device is not implanted.
If there is concern that the patient’s headaches are due to either medication overuse or opioid use, this may disqualify them from implantation, despite quality-of-life improvement during the trial period. [8]
Complications of occipital nerve stimulation placement are avoidable by taking certain necessary steps, as follows:
Anchoring leads to fascia at retromastoid incision
Swabbing all candidates to rule out methicillin-resistant Staphylococcus aureus (MRSA) colonization.
Preoperative (prior to implantation) antibiotic treatment to eliminate MRSA colonization
Trimming patient’s occipital region hair with clippers
Sterile surgical technique to help reduce the incidence of infection
Prior to implantation, a trial is performed in which leads are placed under the skin and are connected to an external battery. The trial is performed under sedation, and the patient is discharged the same day. Afterward, the patient tries the therapy for 4–7 days and keeps a detailed pain diary.
A permanent device is implanted only if the patient reports significant improvements in pain and quality of life.
Positive response to transcutaneous electric nerve stimulation is also a good predictor for repsonse to ONS for treatment of occipital headache. [9]
Complications of occipital nerve stimulation placement are avoidable by taking certain necessary steps, as follows:
Choosing the right candidate for surgery; this is an elective surgery, and patients should be medically optimized (eg, good control of diabetes)
Good sterile intraoperative surgical technique
Swabbing all candidates to rule out MRSA colonization
Anchoring leads to fascia at retromastoid incision
Preoperative antibiotic treatment to eliminate MRSA colonization prior to implantation.
Several studies with long-term follow-up (>10 years) demonstrate that, in more than 150 patients with implants, approximately 75% of patients rated either good or excellent long-term pain relief, with a 15% fair rating and a 10% poor rating. [2]
A 2011 study by Mogilner and Mammis found that 82% patients who underwent implantation reported continued significant benefit from stimulator use. [10]
The ONSTIM trial published data in 2011 showing that at 3 months 39% of patients reported at least 50% reduction in headache days per month or a 3-point reduction in pain intensity with adjustable stimulation, compared with 0% in the medically managed group. [11]
In 2012, Silberstein et al. published results from their multicenter, double-blind, randomized controlled trial evaluating occipital nerve stimulation for migraine. They reported that significantly more patients achieved 30% pain reduction, a reduction in headache days per month, and reductions in migraine-related disability when compared to sham stimulation. [12]
In their 2017 single center, double-blind, randomized controlled trial Mekhail et al. reported a signifciant reduction in headache days, pain intensity, and migraine-related disability in patients utilizing occipital nerve stimulation for chronic migraine. [13]
Placement of an occipital nerve stimulator is a relatively safe procedure with a low complication rate. The specific complications include the following: [14, 15, 16]
Lead migration or fracture
Surgical site infection
Wound erosion
Revision surgery for other reasons (primarily elective cosmetic adjustments to the leads)
Hardware malfunction
Battery failures
Inadequacy of stimulation-related coverage
Seromas
Hematomas
Pain and numbness at lead sites
Few major complications have been reported, and the minor complications are easily treatable and usually do not affect the efficacy of the therapy. The most common device related complications include migration, erosion, and infection. [17]
Compared with other forms of peripheral nerve stimulation, ONS generally has higher rates of complication, especially related to lead migration and infection. The long wire course from lead placement to the pulse generator, thin subcutaneous tissue in the scalp, and flexion, extension, and rotation of the head can lead to dislodgement of the leads. [18]
Wolter T, Kaube H, Mohadjer M. High cervical epidural neurostimulation for cluster headache: case report and review of the literature. Cephalalgia. 2008 Oct. 28 (10):1091-4. [Medline].
Weiner RL, Reed KL. Peripheral neurostimulation for control of intractable occipital neuralgia. Neuromodulation. 1999 Jul. 2(3):217-21. [Medline].
Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965 Nov 19. 150(3699):971-9. [Medline].
Palmisani S, Al-Kaisy A, Arcioni R, Smith T, Negro A, Lambru G, et al. A six year retrospective review of occipital nerve stimulation practice–controversies and challenges of an emerging technique for treating refractory headache syndromes. J Headache Pain. 2013 Aug 6. 14:67. [Medline].
Sweet JA, Mitchell LS, Narouze S, Sharan AD, Falowski SM, Schwalb JM, et al. Occipital Nerve Stimulation for the Treatment of Patients With Medically Refractory Occipital Neuralgia: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline. Neurosurgery. 2015 Sep. 77 (3):332-41. [Medline].
Yang Y, Song M, Fan Y, Ma K. Occipital Nerve Stimulation for Migraine: A Systematic Review. Pain Pract. 2015 Apr 11. [Medline].
Chen YF, Bramley G, Unwin G, Hanu-Cernat D, Dretzke J, Moore D, et al. Occipital nerve stimulation for chronic migraine–a systematic review and meta-analysis. PLoS One. 2015. 10 (3):e0116786. [Medline].
Dodick DW, Silberstein SD, Reed KL, Deer TR, Slavin KV, Huh B, et al. Safety and efficacy of peripheral nerve stimulation of the occipital nerves for the management of chronic migraine: long-term results from a randomized, multicenter, double-blinded, controlled study. Cephalalgia. 2015 Apr. 35 (4):344-58. [Medline].
Nguyen JP, Nizard J, Kuhn E, Carduner F, Penverne F, Verleysen-Robin MC, et al. A good preoperative response to transcutaneous electrical nerve stimulation predicts a better therapeutic effect of implanted occipital nerve stimulation in pharmacologically intractable headaches. Neurophysiol Clin. 2016 Feb. 46 (1):69-75. [Medline].
Mammis, A and Mogilner E. Peripheral Neuromodulation for Headache and Craniofacial Pain: Indications, Outcomes, and Complications. CNS meeting. Washington DC: 2011.
Saper JR, Dodick DW, Silberstein SD, McCarville S, Sun M, Goadsby PJ, et al. Occipital nerve stimulation for the treatment of intractable chronic migraine headache: ONSTIM feasibility study. Cephalalgia. 2011 Feb. 31 (3):271-85. [Medline].
Silberstein SD, Dodick DW, Saper J, Huh B, Slavin KV, Sharan A, et al. Safety and efficacy of peripheral nerve stimulation of the occipital nerves for the management of chronic migraine: results from a randomized, multicenter, double-blinded, controlled study. Cephalalgia. 2012 Dec. 32 (16):1165-79. [Medline].
Mekhail NA, Estemalik E, Azer G, Davis K, Tepper SJ. Safety and Efficacy of Occipital Nerves Stimulation for the Treatment of Chronic Migraines: Randomized, Double-blind, Controlled Single-center Experience. Pain Pract. 2017 Jun. 17 (5):669-677. [Medline].
Chen YF, Bramley G, Unwin G, Hanu-Cernat D, Dretzke J, Moore D, et al. Occipital nerve stimulation for chronic migraine–a systematic review and meta-analysis. PLoS One. 2015. 10 (3):e0116786. [Medline].
Brewer AC, Trentman TL, Ivancic MG, Vargas BB, Rebecca AM, Zimmerman RS, et al. Long-term outcome in occipital nerve stimulation patients with medically intractable primary headache disorders. Neuromodulation. 2013 Nov-Dec. 16 (6):557-62; discussion 563-4. [Medline].
Dodick DW, Silberstein SD, Reed KL, Deer TR, Slavin KV, Huh B, et al. Safety and efficacy of peripheral nerve stimulation of the occipital nerves for the management of chronic migraine: long-term results from a randomized, multicenter, double-blinded, controlled study. Cephalalgia. 2015 Apr. 35 (4):344-58. [Medline].
Doran J, Ward M, Ward B, Paskhover B, Umanoff M, Mammis A. Investigating Complications Associated With Occipital Nerve Stimulation: A MAUDE Study. Neuromodulation. 2018 Apr. 21 (3):296-301. [Medline].
Slotty PJ, Bara G, Kowatz L, Gendolla A, Wille C, Schu S, et al. Occipital nerve stimulation for chronic migraine: a randomized trial on subthreshold stimulation. Cephalalgia. 2015 Jan. 35 (1):73-8. [Medline].
Alo KM Holsheimer, J. New trends in neuromodulation for the management of neuropathic pain. Neurosurgery. 2002. 50 (4):690–704.
Alo’, K.M. and Popeney, C.A. Peripheral nerve stimulation (PNS) relieves the symptoms of transformed migraine and reduces associated disability. Neurocontact (Newsletter/Articles from the Editorial Board – Summarial Abstract from Headache Summer 2004, Medicus International. 2004. 43:369-73.
Bahra A, Matharu MS, Buchel C, Frackowiak RS, Goadsby PJ. Brainstem activation specific to migraine headache. Lancet. 2001 Mar 31. 357(9261):1016-7. [Medline].
Burns B, Watkins L, Goadsby PJ. Treatment of medically intractable cluster headache by occipital nerve stimulation: long-term follow-up of eight patients. Lancet. 2007 Mar 31. 369(9567):1099-106. [Medline].
Goadsby PJ, Knight YE, Hoskin KL. Stimulation of the greater occipital nerve increases metabolic activity in the trigeminal nucleus caudalis and cervical dorsal horn of the cat. Pain. 1997 Oct. 73(1):23-8. [Medline].
Johnstone CS, Sundaraj R. Occipital nerve stimulation for the treatment of occipital neuralgia-eight case studies. Neuromodulation. 2006 Jan. 9(1):41-7. [Medline].
Krames ES, Peckham PH, Rezai AR. Neuromodulation. 2009. Volume 1:Page 132.
Magis D, Allena M, Bolla M, De Pasqua V, Remacle JM, Schoenen J. Occipital nerve stimulation for drug-resistant chronic cluster headache: a prospective pilot study. Lancet Neurol. 2007 Apr. 6(4):314-21. [Medline].
Mammis, A and Mogilner E. Peripheral Neuromodulation for Headache and Craniofacial Pain: Indications, Outcomes, and Complications. Washington DC: CNS meeting; 2011.
Matharu MS, Bartsch T, Ward N, Frackowiak RS, Weiner R, Goadsby PJ. Central neuromodulation in chronic migraine patients with suboccipital stimulators: a PET study. Brain. 2004 Jan. 127(Pt 1):220-30. [Medline].
Matharu MS, Bartsch T, Ward N, Frackowiak RS, Weiner R, Goadsby PJ. Central neuromodulation in chronic migraine patients with suboccipital stimulators: a PET study. Brain. 2004 Jan. 127(Pt 1):220-30. [Medline].
Melvin EA Jr, Jordan FR, Weiner RL, Primm D. Using peripheral stimulation to reduce the pain of C2-mediated occipital headaches: a preliminary report. Pain Physician. 2007 May. 10(3):453-60. [Medline].
Popeney CA Alo KM. C1-2-3 peripheral nerve stimulation (PNS) for the treatment of disability associated with transformed migraine. Headache 43:. 2003. 369–73.
Rodrigo-Royo MD, Azcona JM, Quero J, Lorente MC, Acín P, Azcona J. Peripheral neurostimulation in the management of cervicogenic headache: four case reports. Neuromodulation. 2005 Oct. 8(4):241-8. [Medline].
Schwedt TJ, Dodick DW, Hentz J, Trentman TL, Zimmerman RS. Occipital nerve stimulation for chronic headache–long-term safety and efficacy. Cephalalgia. 2007 Feb. 27(2):153-7. [Medline].
Slavin KV, Nersesyan H, Wess C. Peripheral neurostimulation for treatment of intractable occipital neuralgia. Neurosurgery. 2006 Jan. 58(1):112-9; discussion 112-9. [Medline].
Weiner RL, Alo, KM, Reed K. Peripheral neurostimulation for control of intractable occipital headaches. Abstracts of the World Pain Meeting 2000. San Francisco, CA: President Elliot Krames; July 2000.
Weiner, RL. Occipital neurostimulation (ONS) for treatment of intractable headache disorders. Pain Med. 2006. 7:S137–S139.
Antonios Mammis, MD Assistant Professor of Neurological Surgery, Director, Functional and Restorative Neurosurgery, Director, Center for Neuromodulation, Director, Rutgers Center for Headache, Orofacial, and Neuropathic Pain, Rutgers New Jersey Medical School
Antonios Mammis, MD is a member of the following medical societies: American Academy of Pain Medicine, American Association of Neurological Surgeons, American Medical Association, Medical Society of the State of New York, World Society for Stereotactic and Functional Neurosurgery, Congress of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery
Disclosure: Nothing to disclose.
Mickey E Abraham, MSc Rutgers New Jersey Medical School
Disclosure: Nothing to disclose.
Yehuda Herschman, MD Resident Physician, Department of Neurosurgery, Rutgers New Jersey Medical School
Disclosure: Nothing to disclose.
Max Ward Rutgers New Jersey Medical School
Max Ward is a member of the following medical societies: American Association of Neurological Surgeons, American College of Surgeons, American Medical Association
Disclosure: Nothing to disclose.
Gaurav Gupta, MD Assistant Professor, Section Head, Endovascular and Cerebrovascular Neurosurgery, Fellowship Director, Endovascular Neurosurgery Fellowship (Site), Department of Surgery, Division of Neurosurgery, Rutgers Robert Wood Johnson Medical School
Gaurav Gupta, MD is a member of the following medical societies: American Academy of Neurology, American Association for the Advancement of Science, American Association of Neurological Surgeons, American College of Surgeons, American Heart Association, American Medical Association, Congress of Neurological Surgeons, Facial Pain Association, Society for Neuroscience, Society of NeuroInterventional Surgery
Disclosure: Nothing to disclose.
Jonathan P Miller, MD Director, Functional and Restorative Neurosurgery, Director of Epilepsy Surgery, Attending Neurosurgeon, University Hospitals Cleveland Medical Center; Director, Functional and Restorative Neurosurgery Center, UH Cleveland Medical Center Neurological Institute; Associate Professor of Neurosurgery, Fellowship Director, Functional and Stereotactic Neurosurgery, Associate Residency Program Director, Department of Neurosurgery, Surgical Director, Neuromodulation Center, Case Western Reserve University School of Medicine
Jonathan P Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, American College of Surgeons, American Epilepsy Society, American Society for Stereotactic and Functional Neurosurgery, Congress of Neurological Surgeons, International Neuromodulation Society, North American Neuromodulation Society, Ohio State Neurosurgical Society, Society of Neurological Surgeons
Disclosure: Nothing to disclose.
Ahmed Meleis, MD Resident Physician, Department of Neurosurgery, Rutgers New Jersey Medical School
Disclosure: Nothing to disclose.
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