Interest in neurostimulation for primary headache treatment is growing fast, partly because a proportion of patients do not improve with preventive drugs, and also because of recent advances in neurostimulator design and technology. However enthusiasm needs to be tempered, as most studies so far have been open, without a sham arm, and a placebo effect cannot be completely ruled out. There remains a need for adequately designed randomized controlled studies. In particular, several months of double-blind comparison may be necessary to reveal a supposed difference between sham and real-stimulated patients. Furthermore, uniform, carefully chosen selection criteria remain important so that studies and techniques can be compared.
In the long-term adequate access to integrated care with education, counseling, optimal treatment of acute attacks, preventive drug therapy, behavioral therapy and treatment of morbidities, may prevent the development of many chronic headache forms, and optimize the use of neurostimulation. Finally, neurostimulation should continue to be available only in tertiary headache centers, not only because of the invasive nature of many of these techniques, but because patient selection is crucial and follow-up needs to be attentive.
Future Neurology. 2013;8(4):457-467. © 2013 Future Medicine Ltd.