Does occipital nerve stimulation work?

B Burns, L Watkins & PJ Goadsby (2009). “Treatment of intractable chronic cluster headache by occipital nerve stimulation in 14 patients”, Neurology, 72: 341-345 (click author to see paper)

AUTHORS’ ABSTRACT:

Background: Cluster headache is a primary headache involving repeated attacks of excruciatingly severe headache usually occurring several times a day. Most patients with chronic cluster head- ache (CCH) have an unremitting illness requiring daily preventive therapy for years.

Objective: To describe the clinical outcome of occipital nerve stimulation (ONS) for 14 patients with intractable CCH.

Methods: Fourteen patients with medically intractable CCH were implanted with bilateral elec- trodes in the suboccipital region for ONS and a retrospective assessment of their clinical outcome obtained.

Results: At a median follow-up of 17.5 months (range 4–35 months), 10 of 14 patients reported improvement and 9 of these recommend ONS. Three patients noticed a marked improvement of 90% or better (90%, 90%, and 95%), 3 a moderate improvement of 40% or better (40%, 50%, and 60%), and 4 a mild improvement of 20 –30% (20%, 20%, 25%, and 30%). Improvement occurred within days to weeks for those who responded most and patients consistently reported their attacks returned within hours to days when the device was off. One patient found that ONS helped abort acute attacks. Adverse events of concern were lead migrations and battery depletion.

Conclusion: Intractable chronic cluster headache (CCH) is a devastating, disabling condition that has traditionally been treated with cranially invasive or neurally destructive procedures. ONS offers a safe, effective option for some patients with CCH. More work is required to evaluate and understand this novel therapy.

Dr. Sewell’s comment:

Occipital nerve stimulation appears to be the latest “hot treatment” in cluster headache therapy. The greater and lesser occipital nerves are in the neck, or more specifically, they emerge from between the first and second cervical vertebrae, and travel up to carry sensation from the back of the head (see diagram).

Occipital nerve blockOccipital nerve block is a procedure where anesthetic agents (lidocaine and bupivacaine) are injected near the occipital nerve on the back of the head near the base of the skull on the side of the headache. A steroid is often added for anti-inflammatory effects. An occipital nerve block may provide permanent relief or provide a period of pain relief for several months while the cause of the pain is healing. It was first tried for “back-of-the-head” headaches such as migraine and tension headaches and found to be effective. It was first reported to be effective for cluster headache as well as far back as 1985 by Dr. Anthony. The downside, of course, is that once the injection wears off, the cluster attacks return—it’s not a permanent solution—and repeated steroid injections aren’t good for the joints.

Occipital nerve stimulation (ONS) is a little different. This involves implanting a neurostimulator under the skin at the base of the head that delivers electrical impulses near the occipital nerves through insulated lead wires tunneled under the skin. The first two chronic cluster headache patients were successfully treated with ONS in 2003, and a couple of larger case series followed in 2007. The question Burns tried to answer in this study was whether the effect of ONS persists or whether it wears off like occipital nerve block does. He implanted an ONS in 14 patients with medically intractable chronic cluster headache and followed them for times ranging from four to 35 months, and found that 10 improved. Four were practically cured, three were about 50% better, and the last three of the ten noticed a mild improvement.

There are a couple of catches to using an ONS. For one thing, the back of your head goes numb. For another, it can actually take weeks to months to reach maximal effect. Sometimes the battery can run out, or leads can shift and need to be surgically replaced. Nevertheless, only one of the 14 patients in the trial would recommend against ONS, and it these inconveniences seem minor when weighed against the pain of chronic cluster headache.

Why does it work? After all, cluster headache is a problem with the trigeminal nerve, which carries sensation from the front of the head, not the greater or lesser occipital nerves, which come from the back of the head, and the two nerves don’t cross or even come close to each other. I posed this question to Dr. Goadsby, the last author (and thus the supervisor) on this study at the 2008 meeting of the American Headache Society. I can’t remember exactly what he said, but I remember leaving feeling that he didn’t really know why any more than I did. Which just goes to show you, there is much about this disease that we still have yet to understand. But hey, if ONS works, then it works!

7 Responses to “Does occipital nerve stimulation work?”

  1. Friedrich says:

    There were some reports about a “functional connectivity” between trigeminal and occipital nerves, e.g.:

    http://www.ncbi.nlm.nih.gov/pubmed/16396666

    http://www.ncbi.nlm.nih.gov/pubmed/17850348

    but see also:

    http://www.ncbi.nlm.nih.gov/pubmed/18513262

    Another related article, free full text:

    http://brain.oxfordjournals.org/cgi/content/full/125/7/1496

  2. asewell says:

    Thank you for the references! I may do a short series exploring the links between the occipital and trigeminal nerves, since it’s an interesting subject.

  3. Friedrich says:

    Please don’t fall of the chair again, my intention for the previous comment was just to add some information about research regarding the relationship between the neck and head pain. Joe Public knows that there is a relationship, but research hasn’t found the cause and the reason yet?

    Some comments about the paper from Burns et al.: I am glad to read, that three out of 14 patients (21%) noticed a marked improvement of 90% or better. But in total only five of the 14 patients (36%) reported an improvement of more than 50%. In some other studies placebo did have a better efficacy than 36%. Please see: http://www.ncbi.nlm.nih.gov/pubmed/12950375

    Furthermore the patients were not asked to use headache diaries for the study. In my opinion the data reported by the authors is questionable, at least regarding the “mild improvement of 20–30% (20%, 20%, 25%, and 30%).”

    – Quote:
    “Follow-up and data collection.
    Data were collected from patient records, outpatient visits, and mail and telephone by one investigator (B.B.).
    Patients retrospectively compared their attacks before and after the procedure; patient diaries were not used.”
    – End of quote.

    Source of the quote: Burns B, Watkins L, Goadsby PJ.: Treatment of intractable chronic cluster headache by occipital nerve stimulation in 14 patients. Neurology. 2009 Jan 27; 72: 341-5.

    What would a patient “retrospectively“ say about such a treatment as ONS, being asked by the Doctor?

    Btw: A data sheet with the ONS settings used and a list of the complications is available at:
    http://www.neurology.org/cgi/content/full/72/4/341/DC1

    In the paper from Burns et al. I could not find a statement about the preventive medications taken by the patients, only the sentence: “Patients who improved did so without the addition of new therapy, other than patient 8, who occasionally used intermittent dexamethasone.”

    Have all the other patients been treated with ONS only, or did they receive any additional preventive medication? All patients were intractable, according to the authors, having tried and failed or being unable to tolerate at least four of the most commonly used preventive medications. But does that mean that they didn’t take any preventive medication?

  4. Phil says:

    I would like to tell you about my understanding of the medications used by ONSI patients. ONSI patients here in the UK have openly posted about their use of medications. By their own admission they were using medications (abortive and preventative) right up to the day of their operation and continued to afterwards. So I struggle to understand the authors claims that they only operate on the intractable.

    I have yet to hear of one ONSI recipient who has stopped all other medications. I know of a handfull who continue with medications and oxygen.

    Of course my word is only anecdotal (although you can find posts by these sufferers with a few minutes searching) but then so are the claims of the authors who, it has been suggested, have not conducted any systematic post-operation research. I am told their research comprised of a phone call to each sufferer. This claim is second/third hand and I would welcome being corrected.

  5. me says:

    if the shot is givien in the wrong spot what would happen? can anthting happen?

  6. Cythia Nuara says:

    Hi there Cythia Nuara right here, wonderful article relating to Cluster Attack – Bringing Cluster Headache Researchers and Patients Together. There appear to be an issue with your web web-site while visited with ie, a few details did not load up appropriately… Internet explorer still is industry leader and a large portion of people will lose your great posting due to this problem.

  7. Oxygen Therapy is designed to greatly increase the amount of oxygen in your body— far more than breathing regular air.

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