Occipital Nerve Stimulation Research Articles

Effect of Occipital Nerve Stimulation (ONS) on the Orbicularis Oculi Reflex Triggered by a Standardized Air Flow in Patients with Chronic Migraine-A Prospective, Randomized, Interventional Study.

IntroductionOccipital nerve stimulation (ONS) is a specific form of peripheral neuromodulation used in the treatment of chronic pain disorders. A particular field of application is in the therapy of treatment-refractory headaches, especially of chronic migraine. The precise mode of action is unknown. It is presumed that central and peripheral sensitization are reduced in patients with chronic headache. The aim of this study was to examine the effect of ONS on pain-modulatory mechanisms in the trigeminocervical area in patients with chronic migraine.MethodsIn a balanced repeated measurements design in eight patients with chronic migraine with and without active ONS, we analyzed which effects ONS had on the orbicularis oculi reflex dynamically elicited by corneal air flow.ResultsThe orbicularis oculi reflex in active ONS (7.38 ± 20.14 eyelid closures/minute) compared to inactive ONS (18.73 ± 14.30 eyelid closures/minute) is significantly reduced (p = 0.021).ConclusionsThe results show that under active ONS compared to inactive ONS in patients with chronic migraine, the orbicularis oculi reflex, dynamically triggered by a standardized air flow, is significantly reduced. This suggests that ONS is able to directly counteract the trigeminally mediated central sensitization in chronic migraine and protectively reduce the effects of aversive peripheral stimulation.

Occipital Nerve Stimulation for Pain Modulation in Drug-Resistant Chronic Cluster Headache.

Occipital nerve stimulation (ONS) is a surgical treatment proposed for drug-resistant chronic cluster headache (drCCH). Long-term series assessing its efficacy are scarce. We designed a retrospective observational study with consecutive sampling, evaluating the follow-up of 17 drCCH patients who underwent ONS. Our main endpoint was the reduction the rate of attacks per week. We also evaluated the pain intensity through the Visual Analogue Scale (VAS), patient overall perceived improvement and decrease in oral medication intake. After a median follow-up of 6.0 years (4.5–9.0), patients decreased from a median of 30 weekly attacks to 22.5 (5.6–37.5, p = 0.012), 7.5 at 1 year (p = 0.006) and 15.0 at the end of follow-up (p = 0.041). The VAS decreased from a median of 10.0 to 8.0 (p = 0.011) at three months, to 7.0 (p = 0.008) at twelve months and 7.0 (p = 0.003) at the end of the follow-up. A total of 23.5% had an overall perceived improvement of ≥70% at 3 months, 41.2% at 1 year and 27.8% at the end of follow-up. Reducing prophylactic oral medication was possible in 76.5% and it was stopped in 17.7%. Triptan use decreased in all the responder patients and 17.7% stopped its intake. A total of 41.2% presented mild adverse events. In conclusion, our long-term experience suggests that ONS could be an interesting option for drCCH-selected patients, as it is a beneficial and minimally invasive procedure with no serious adverse events.

Long-Term Efficacy of Occipital Nerve Stimulation for Medically Intractable Cluster Headache.

Occipital nerve stimulation (ONS) has been proposed to treat refractory chronic cluster headache (rCCH) but its efficacy has only been showed in small short-term series. To evaluate ONS long-term efficacy in rCCH. We studied 105 patients with rCCH, treated by ONS within a multicenter ONS prospective registry. Efficacy was evaluated by frequency, intensity of pain attacks, quality of life (QoL) EuroQol 5 dimensions (EQ5D), functional (Headache Impact Test-6, Migraine Disability Assessment) and emotional (Hospital Anxiety Depression Scale [HAD]) impacts, and medication consumption. At last follow-up (mean 43.8 mo), attack frequency was reduced >50% in 69% of the patients. Mean weekly attack frequency decreased from 22.5 at baseline to 9.9 (P<.001) after ONS. Preventive and abortive medications were significantly decreased. Functional impact, anxiety, and QoL significantly improved after ONS. In excellent responders (59% of the patients), attack frequency decreased by 80% and QoL (EQ5D visual analog scale) dramatically improved from 37.8/100 to 73.2/100. When comparing baseline and 1-yr and last follow-up outcomes, efficacy was sustained over time. In multivariable analysis, low preoperative HAD-depression score was correlated to a higher risk of ONS failure. During the follow-up, 67 patients experienced at least one complication, 29 requiring an additional surgery: infection (6%), lead migration (12%) or fracture (4.5%), hardware dysfunction (8.2%), and local pain (20%). Our results showed that long-term efficacy of ONS in CCH was maintained over time. In responders, ONS induced a major reduction of functional and emotional headache-related impacts and a dramatic improvement of QoL. These results obtained in real-life conditions support its use and dissemination in rCCH patients.

Occipital Neuralgia: Advances in the Operative Management.

Occipital neuralgia (ON) is a primary headache disorder characterized by sharp, shooting, or electric shock-like pain in the distribution of the greater, lesser, or third occipital nerves. To review the existing literature on the management of ON and to describe our technique of an endoscopic-assisted approach to decompress the GON proximally in areas of fibrous and muscular compression, as well as distally by thorough decompression of the occipital artery from the nerve. Relevant literature on the medical and surgical management of ON was reviewed. Literature on the anatomical relationships of occipital nerves and their clinical relevance were also reviewed. While initial treatment of ON is conservative, peripheral nerve blocks and many surgical management approaches are available for patients with pain refractory to the medical treatment. These include greater occipital nerve blocks, occipital nerve stimulation, Botulinum toxin injections locally, pulsed radiofrequency ablation, cryoneuroablation, C-2 ganglionectomy, and endoscopic-assisted ON decompression. Patients of ON refractory to medical management can be benefitted by surgical approaches and occipital nerve blocks. Endoscopic-assisted ON decompression provides one such approach for the patients with vascular, fibrous or muscular compressions of occipital nerves resulting in intractable ON.

SUNCT and SUNA: An Update.

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache with autonomic symptoms (SUNA) are rare and disabling primary headache disorders that are subtypes of Short-lasting unilateral neuralgiform headache attacks (SUNHA). The aim of this narrative review was to provide a comprehensive update on headache phenotype, pathophysiology, and various treatment options available for SUNCT and SUNA. References for this review were identified by searches of articles published in the English language in PubMed between 1978 and October 2020 using "short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)", "short-lasting unilateral neuralgiform headache with autonomic symptoms (SUNA)", "short-lasting unilateral neuralgiform headache attacks (SUNHA)", "trigeminal autonomic cephalalgias" as keywords in various combinations. Of a potential 1103 articles, seven case series describing clinical characteristics of SUNCT/SUNA patients were identified for this review. For symptomatic/secondary SUNCT/SUNA, 53 individual case reports, and one case series were reviewed. One placebo-controlled trial and 11 open-label case series that evaluated various medical and surgical treatments in SUNCT/SUNA were also reviewed. Available literature suggests that SUNCT and SUNA are subtypes of the same disorder characterized by severe side locked short duration headache with ipsilateral prominent cranial autonomic symptoms and signs. Pathophysiology may involve both peripheral and central mechanisms. Lamotrigine is the most effective preventive therapy while intravenous lidocaine is the most efficacious drug as transitional therapy for severe disabling attacks. Surgical options including microvascular decompression in those having neurovascular conflict, occipital nerve stimulation, and hypothalamic deep brain stimulation can be alternative treatment options for medically refractory patients.

Effectiveness and Acceptability of Noninvasive Brain and Nerve Stimulation Techniques for Migraine Prophylaxis: A Network Meta-Analysis of Randomized Controlled Trials

Background: Current pharmacologic prophylactic strategies for migraine have exhibited limited efficacy, with response rates as low as 40%–50%. In addition to the limited efficacy, the acceptability of those pharmacologic prophylactic strategies were unacceptable. Although noninvasive brain/nerve stimulation strategies may be effective, the evidence has been inconsistent. The aim of this network meta-analysis (NMA) was to compare strategies of noninvasive brain/nerve stimulation for migraine prophylaxis with respect to their effectiveness and acceptability. Methods: The PubMed, Embase, ScienceDirect, ProQuest, ClinicalTrials.gov, ClinicalKey, Cochrane CENTRAL, Web of Science, and ClinicalTrials.gov databases were searched for randomized controlled trials (RCTs). Patients with diagnosis of migraine, either episodic migraine or chronic migraine, were included. The primary outcome was the changes in monthly migraine days and response rate, and the acceptability was defined as the drop-out rate. All NMA procedures were conducted under the frequentist model. Findings: Nineteen randomized controlled trials were included (N=1493; mean age=38.2 years; 82.0% women). We determined that the high frequency repetitive transcranial magnetic stimulation (rTMS) over C3 yielded the most decreased monthly migraine days among all the interventions [mean difference=-8.70 days, 95% confidence intervals (95%CIs): -14.45 to -2.95 compared to sham/control groups]. In addition, high-frequency (100 Hz) transcutaneous occipital nerve stimulation (tONS) over the Oz provided the highest response rate in migraine prophylaxis [rate ratio (RR)=9.00, 95%CIs: 1.24 to 65.16 compared to sham/control groups]. Only alternative frequency (2/100 Hz) tONS over the Oz (RR=0.36, 95%CIs: 0.16 to 0.82) yielded a significantly lower drop-out rate than the sham/control groups did. Interpretation: The current study provided a new direction for the design of more methodologically robust and larger RCTs based on the findings of the potentially beneficial effect on migraine prophylaxis in participants with migraine by different noninvasive brain/nerve stimulation, especially the application of rTMS and tONS. Funding Information: None. Declaration of Interests: The authors report no financial interests or potential conflicts of interest.

Peripheral Neuromodulation for the Management of Headache.

ContextNeuromodulation is an expanding field of study for headache treatment to reduce pain by targeting structures within the nervous system that are commonly involved in headache pathophysiology, such as the vagus nerve (VNS), occipital nerves, or sphenopalatine ganglion (SPG) for stimulation. Pharmaceutical medical therapies for abortive and prophylactic treatment, such as triptans, NSAIDs, beta-blockers, TCAs, and antiepileptics, are effective for some individuals, but the role that technology plays in investigating other therapeutic modalities is essential. Peripheral neuromodulation has gained popularity and FDA approval for use in treating certain headaches and migraine headache conditions, particularly in those who are refractory to treatment. Early trials found FDA approved neurostimulatory implant devices, including Cephaly and SpringTMS, improved patient-oriented outcomes with reductions in headaches per month (frequency) and severity.Evidence AcquisitionThis was a narrative review. The sources for this review are as follows: Searching on PubMed, Google Scholar, Medline, and ScienceDirect from 1990 - 2019 using keywords: Peripheral Neuromodulation, Headache, vagus nerve, occipital nerves, sphenopalatine ganglion.ResultsThe first noninvasive neurostimulator device approved for migraine treatment was the Cefaly device, an external trigeminal nerve stimulation device (e-TNS) that transcutaneously excites the supratrochlear and supraorbital branches of the ophthalmic nerve. The second noninvasive neurostimulation device receiving FDA approval was the single-pulse transcranial magnetic stimulator, SpringTMS, positioned at the occiput to treat migraine with aura. GammaCore is a handheld transcutaneous vagal nerve stimulator applied directly to the neck at home by the patient for treatment of cluster headache (CH) and migraine. Several other devices are in development for the treatment of headaches and target headache evolution at different levels and inputs. The Scion device is a caloric vestibular stimulator (CVS) which interfaces with the user through a set of small cones resting in the ear canal on either side and held in place by modified over-ear headphones. The pulsante SPG Microstimulator is a patient-controlled device implanted in the patient’s upper jaw via an hour-long oral procedure to target the sphenopalatine ganglion. The occipital nerve stimulator (ONS) is an invasive neuromodulation device for headache treatment that consists of an implanted pulse generator on the chest wall connected to a subcutaneous lead with 4 - 8 electrodes that is tunneled the occiput.ConclusionsThe aim of this review is to provide a comprehensive overview of the efficacy, preliminary outcomes, and limitations of neurostimulatory implants available for use in the US and those pending further development.

Peripheral Nerve Stimulation of the Occipital Nerve to Treat Postherpetic Neuralgia

Background: Herpes zoster infection and subsequent postherpetic neuralgia can cause chronic neuropathic pain. Patients who do not respond well to pharmacotherapy require therapeutic options that are typically more invasive; our goal was to minimize invasiveness. Case Presentation: We present a case of intractable postherpetic neuralgia refractory to conservative pharmacological treatment and multiple occipital nerve blocks, which was successfully treated using peripheral occipital nerve stimulation (ONS) with an external implantable pulse generator (IPG). Conclusion: For interventionalists, one of the technical difficulties during ONS placement involves tunneling leads through the high-risk and difficult anatomy of the posterior neck. Further complicating placement and increasing patient discomfort are the long leads required for internal IPG implantation. The most commonly cited complication is lead migration or lead breakage. This difficulty can be attenuated by using an external IPG, such as was used in this case. An external IPG makes the ONS procedure significantly less invasive and reduces trauma and discomfort for the patient. Key words: Peripheral nerve stimulation (PNS), occipital nerve, postherpetic neuralgia (PHN), occipital nerve stimulation (ONS), implantable pulse generator (IPG), external IPG

Dedicated Lead for Occipital Nerve Stimulation for Treatment of Refractory Head Pain: Technical Note

Dedicated Lead for Occipital Nerve Stimulation for Treatment of Refractory Head Pain: Technical Note

Occipital Nerve Stimulation in Chronic Migraine: The Relationship Between Perceived Sensory Quality, Perceived Sensory Location, and Clinical Efficacy-A Prospective, Observational, Non-Interventional Study.

IntroductionOccipital nerve stimulation (ONS) is used to treat therapy-resistant chronic migraine. Clinical use has resulted in a wide intraindividual and interindividual variation of clinical efficacy. The aim of this study was to analyze a potential relationship between sociodemographic variables, headache parameters, perceived sensory quality, perceived sensory location, as well as clinical efficacy.MethodsThirty-two subjects (21.9% male, mean age 45.77 years) suffering from chronic migraine refractory to other treatment and therefore treated with ONS were included in this study. We used a computer-based imaging method for mapping the ONS-induced perceived sensory location, the perceived spatial sensory field size, as well as the perceived sensory quality in a long-term course over 21 months in weekly time intervals. Additionally, the effect of ONS on the migraine headache was documented weekly by the participants using a verbal rating scale. Over the observation period, a total of 808 individual weekly data sets were recorded and a potential relationship between ONS-induced perceptions and headache parameters could be analyzed.ResultsWe found that 48.9% of stimulation intervals were reported as effective by patients. Women displayed a significantly higher responder rate than men. The reported effectiveness did not differ depending on age, the average number of migraine days per month, the MIDAS score, or the duration of the migraine disorder prior to ONS treatment. Implantation with trial period led to significantly lower responder rates than without the trial period. The most frequently perceived sensory quality of “tingling” was found significantly more frequently in non-responders than in responders. Responders displayed significantly lower pleasantness scores for their reported perceptions than non-responders. Sensations that were spatially perceived above the line connecting the external acoustic meati with the external occipital protuberance (MOP line) led to patients reporting a positive clinical effect significantly more frequently than sensations spatially perceived below the MOP line. Spatially small fields of sensory perception were correlated with a higher responder rate than those covering broader areas.ConclusionsThe ONS-induced sensory location, the size of the spatial sensory field, as well as the sensory quality are significantly correlated with the reported clinical effectiveness. The results suggest that besides surgical technique, the individual and continuous programming of the stimulation parameters is clinically relevant in increasing the therapeutic effectiveness.

Modulation of mechanosensory vibrissal responses in the trigeminocervical complex by stimulation of the greater occipital nerve in a rat model of trigeminal neuropathic pain

BackgroundStimulation of the occipital or trigeminal nerves has been successfully used to treat chronic refractory neurovascular headaches such as migraine or cluster headache, and painful neuropathies. Convergence of trigeminal and occipital sensory afferents in the ‘trigeminocervical complex’ (TCC) from cutaneous, muscular, dural, and visceral sources is a key mechanism for the input-induced central sensitization that may underlie the altered nociception. Both excitatory (glutamatergic) and inhibitory (GABAergic and glycinergic) mechanisms are involved in modulating nociception in the spinal and medullary dorsal horn neurons, but the mechanisms by which nerve stimulation effects occur are unclear. This study was aimed at investigating the acute effects of electrical stimulation of the greater occipital nerve (GON) on the responses of neurons in the TCC to the mechanical stimulation of the vibrissal pad.MethodsAdult male Wistar rats were used. Neuronal recordings were obtained in laminae II-IV in the TCC in control, sham and infraorbital chronic constriction injury (CCI-IoN) animals. The GON was isolated and electrically stimulated. Responses to the stimulation of vibrissae by brief air pulses were analyzed before and after GON stimulation. In order to understand the role of the neurotransmitters involved, specific receptor blockers of NMDA (AP-5), GABAA (bicuculline, Bic) and Glycine (strychnine, Str) were applied locally.ResultsGON stimulation produced a facilitation of the response to light facial mechanical stimuli in controls, and an inhibition in CCI-IoN cases. AP-5 reduced responses to GON and vibrissal stimulation and blocked the facilitation of GON on vibrissal responses found in controls. The application of Bic or Str significantly reduced the facilitatory effect of GON stimulation on the response to vibrissal stimulation in controls. However, the opposite effect was found when GABAergic or Glycinergic transmission was prevented in CCI-IoN cases.ConclusionsGON stimulation modulates the responses of TCC neurons to light mechanical input from the face in opposite directions in controls and under CCI-IoN. This modulation is mediated by GABAergic and Glycinergic mechanisms. These results will help to elucidate the neural mechanisms underlying the effectiveness of nerve stimulation in controlling painful craniofacial disorders, and may be instrumental in identifying new therapeutic targets for their prevention and treatment.

Peripheral Nerve Stimulation for Occipital Neuralgia.

Chronic headaches are the second most prevalent disease and second most common cause for years lived with disability worldwide. Occipital neuralgia can cause headaches or be present in addition to other more prevalent causes of headache. If these headaches fail to respond to conservative and pharmacological therapy, physicians proceed to more invasive treatments, starting with infiltration of the greater occipital nerve with local anesthetic with or without corticosteroids, followed by nerve ablation or stimulation. Occipital nerve stimulation gained more popularity as the technology improved and more pain physicians received training on interventional procedures. In this manuscript, we are presenting our experience with ultrasound-guided implant of occipital nerve stimulators using peripheral nerve stimulator systems. After confirming appropriateness of treatment by a successful occipital nerve block (i.e., resulting in >50% relief in patients' pain intensity), we implanted five stimulator systems in three patients (two bilateral). We followed these patients for an average of eight months, and the average pain reduction was ∼50%. We did not observe any adverse events during or immediately after surgery. One patient developed an adverse reaction to the adhesive of the battery transmitter, but it was not severe enough to stop her from using the stimulator. Considering the ease of implant and minimal side effects, implant of peripheral nerve stimulators to stimulate the occipital nerve is a promising treatment modality for patients with chronic headache who present with features of occipital neuralgia. However, wider use of this treatment modality is subject to further studies.

Successful Treatment of Chemotherapy-Induced Headaches With Occipital Nerve Stimulation: A Case Report

Successful Treatment of Chemotherapy-Induced Headaches With Occipital Nerve Stimulation: A Case Report

Neuromodulation in primary headaches: current evidence and integration into clinical practice.

Neuromodulatory approaches add to our armamentarium of therapeutic tools for the treatment of primary headaches. This review provides a comprehensive overview of current controlled studies on the different neuromodulation techniques and recommendations for clinical practice. Evidence for efficacy of transcutaneous vagal nerve stimulation (tVNS) is limited to acute use in migraine with ambiguous results and episodic cluster headache as well as chronic cluster headache if applied in addition to conventional treatment. Transcutaneous stimulation of the supraorbital and supratrochlear nerve was effective in both acute and preventive stimulation (the latter with ambiguous results) in episodic migraines. Thus, invasive procedures should be reserved for severe and refractory cases only. Occipital nerve stimulation for chronic refractory cluster headache is the only available invasive approach with a Conformité Européenne mark. Neuromodulation can complement conventional therapy, with noninvasive procedures being used preferably. Given the limited number of studies for each modality and the lack of head-to-head studies, it is difficult to place neuromodulation techniques in a conventional treatment algorithm.

The MOOD Study - External Combined Occipital and Trigeminal Nerve Stimulation (eCOT-NS) for the Treatment of Major Depressive Disorder (MDD)

The MOOD Study - External Combined Occipital and Trigeminal Nerve Stimulation (eCOT-NS) for the Treatment of Major Depressive Disorder (MDD)

Occipital nerve stimulation and deep brain stimulation for refractory cluster headache: a prospective analysis of efficacy over time.

Occipital nerve stimulation (ONS) and deep brain stimulation (DBS) are widely used surgical treatments for chronic refractory cluster headache (CH). However, there is little literature regarding long-term follow-up of these treatments. The authors describe two prospective cohorts of patients with refractory CH treated with ONS and DBS and compare preoperative to postoperative status at 6 and 12 months after the surgery and at final follow-up. Efficacy analysis using objective and subjective variables is reported, as well as medication reduction and complications. The ONS group consisted of 13 men and 4 women, with a median age of 44 years (range 31-61 years). The median number of attacks per week (NAw) before surgery was 28 (range 7-70), and the median follow-up duration was 48 months. The DBS group comprised 5 men and 2 women, with a median age of 50 years (range 29-64 years). The median NAw before surgery was 56 (range 14-140), and the median follow-up was 36 months. The NAw and visual analog scale score were significantly reduced for the ONS and DBS groups after surgery. However, while all the patients from the DBS group were considered responders at final follow-up, with more than 85% being satisfied with the treatment, approximately 29% of initial responders to ONS became resistant by the final follow-up (p = 0.0253). ONS is initially effective as a treatment for refractory CH, although a trend toward loss of efficacy was observed. No clear predictors of good clinical response were found in the present study. Conversely, DBS appears to be effective and provide a more stable clinical response over time with an acceptable rate of surgical complications.

Occipital Nerve Stimulation for Attack Prevention in Medically Intractable Chronic Cluster Headache: The Randomized, Double-Blind, Electrical Dose-Controlled ICON Study

Background: Occipital nerve stimulation (ONS) showed promising results in small uncontrolled trials in patients with medically intractable chronic cluster headache (MICCH). ONS causes paraesthesia preventing comparison versus placebo. Methods: After 12 weeks baseline observation, patients with CCH and prior failure to ≥3 standard preventive medications and ≥4 weekly attacks of CH were randomly allocated to 24 weeks double-blind 100% or 30% electrical dose ONS. These intensities were hypothesised to cause similar paraesthesia, mitigating unblinding, but differential efficacy. In weeks 25-48, participants received individually-optimised open-label ONS, which was then continued during regular patient care. Primary outcome was the weekly mean attack frequency (MAF) in weeks 21-24. Results: We enrolled 150 patients and randomized 130. At baseline, weekly MAFs were highly stable (p=0.38 for trend) but skewed (median 15.75; IQR 9.44, 24.75). In weeks 21-24, the median change from baseline across all participants was -5.2 (-11.18, -0.18; p<0.001) attacks per week, without difference between treatment arms (-2.42; 95%CI: -5.17, 3.33). The median overall relative MAF reduction was 42.56% (80.05%, 1.80%). Of all participants, 44.6% (95%CI: 36.3%, 53.2%) had ≥50% MAF reduction. Mean attack intensity (0-10) decreased from 7.58 (95%CI: 7.31, 7.85) to 5.57 (95%CI: 5.07, 6.06). Improvements were sustained throughout the entire study and a mean 5 year (range 1.5-8.5) follow up. There were no unexpected biological or hardware-related adverse events and 91% of participants would recommend ONS to other patients. Conclusions: ONS was associated with major reduction in attack frequency and intensity in patients with MICCH, without difference between 100% and 30% stimulation intensity. The intervention was well-tolerated and associated with high patients satisfaction. Large placebo responses seem unlikely, given the considerable and longterm sustained clinical improvement in patients with such a long and unremitting history of highly disabling MICCH and a stable 12 week pretreatment observation. Trial Registration: Clinical trials.gov NCT01151631 Funding Statement: The Spinoza 2009 Lifetime Scientific Research Achievement Premium from the Netherlands Organization for Scientific Research, the Dutch Ministry of Health (as part of a national provisional reimbursement program for promising new treatments), the NutsOhra Foundation from the Dutch Health Insurance Companies, and an unrestricted grant from Medtronic, all to MDF. Declaration of Interests: MDF reports grants and consultancy or industry support from Electrocore, Medtronic, Eli Lilly, Amgen, Novartis, and TEVA, and independent support from The Netherlands Organization for Scientific Research (NWO), The Netherlands Organization for Health Research and Development (ZonMW), The Dutch Brain and Heart Foundations, The Dutch Ministry of Health, and The NutsOhra Foundation from the Dutch Insurance Companies. FH reports grants and consultancy fees from ABBOTT, Saluda and Pfizer and independent support from The Netherlands Organization for Health Research and Development (ZonMW). JH reports consultancy fees from Eli Lilly and Novartis IF reports travel grants from Electrocore WMM reports consultancy fees from Eli Lilly JW reports grants and consultancy fees from ABBOTT, Saluda and Boston and independent support from The Netherlands Organization for Health Research and Development (ZonMW). FW reports grants and consultancy fees from Abbott, Medtronic, Nevro and Saluda DM reports grants and consultancy and speaker fees from Novartis NV, consultancy fees from Eli-Lilly Benelux, travel grants from electroCore LLCAbbott, Medtronic, Nevro and Allergan, speaker fees from Neurolite, Saluda LE reports consultancy fees from Medtronic and ABBOT JWK reports grants and consultancy fees from ABBOTT, Saluda and Boston, and independent support from The Netherlands Organization for Health Research and Development (ZonMW). EGMC reports grants and consultancy or industry support from Lilly, Novartis, ATI and TEVA, and independent support from the Innovatiefonds Zorgverzekeraars. The other authors report no disclosures. Ethics Approval Statement: Local ethic committees at each participating center approved the study protocol.

Peripheral Nerve Stimulation for Facial Pain Using Conventional Devices: Technique and Complication Avoidance.

The introduction of peripheral neuromodulation to treat headache and facial pain two decades ago opened up the field to non-neurosurgical practitioners, given the relatively low risk and technical ease of the procedure. These procedures, primarily occipital nerve stimulation (ONS) and trigeminal branch stimulation such as supra- and infraorbital nerve stimulation, are now established to be effective in a number of facial pain and headache syndromes, despite their lack of approval by regulatory agencies such as the US Food and Drug Administration (FDA). For that reason and others, dedicated hardware for these procedures has not yet been developed, thus relying on hardware designed for placement in the epidural space for spinal cord stimulation (SCS). This has led to a series of technical issues and device-related complications not traditionally seen with SCS. I will review the surgical technique of ONS and peripheral nerve stimulation of the head and face utilizing this equipment, and discuss methods learned by experienced practitioners over the years to minimize device-related complications.

Occipital Nerve Stimulation and Sphenopalatine Ganglion Stimulation for Treatment of Intractable Headache Syndromes.

Headaches are an increasing cause of disability in the world. Intractable headache syndromes affect all age groups but predominantly the middle-aged, working population. Occipital neuralgia is a frequent comorbidity with intractable migraine headaches. Occipital nerve stimulation at the level of nuchal ridge is a reasonable option for these refractory patients. Ultrasound guidance of occipital nerve stimulation can optimize depth placement of leads. Revision surgeries of occipital nerve stimulation are usually performed using surgical leads. Cluster headaches and trigeminal autonomic cephalagias (TACs) are refractory headache conditions that are mediated by sphenopalatine ganglion. Sphenopalatine ganglion stimulation with infrazygomatic approach and fluoroscopic guidance of percutaneous leads can help alleviate pain from cluster headaches and TACs. Innovation in neurostimulation technologies have brought new optimism to these refractory conditions. Efficient and optimal delivery of neurostimulation for intractable headache syndromes requires a multidisciplinary team-based approach for long term compliance and efficacy.

Peripheral Nerve Stimulation for Facial Pain Using Conventional Devices: Indications and Results.

Trigeminal branch stimulation is a type of peripheral nerve stimulation (PNS) used to treat a variety of craniofacial pain disorders. Common indications include trigeminal neuralgia, trigeminal neuropathic pain, trigeminal deafferentation pain, trigeminal postherpetic neuralgia, supraorbital neuralgia, and migraine headaches. Supraorbital and infraorbital arrays are the most common electrode configurations, although preauricular, mandibular branch, and subcutaneous peripheral nerve field stimulation arrays have also been described. Trigeminal branch stimulation may be used as a stand-alone neuromodulation therapy or it may be combined with occipital nerve, sphenopalatine ganglion, or Gasserian ganglion stimulation to treat more complex pain patterns. Consistent with other forms of PNS, trigeminal branch stimulation is a minimally invasive, safe, and straightforward method of treating medically refractory neuropathic pain.