Neurostimulators for the Treatment of Primary Headaches

Massimo Leone; Alberto Proietti Cecchini; Angelo Franzini; Gennaro Bussone

Future Neurology. 2013;8(4):457-467.

Conclusion

Response rates reported in neurostimulation studies do not seem superior to those of the most effective prophylactic medications. Selection criteria for neurostimulation in headache patients are not uniform, and with few exceptions follow-up is too short to provide firm conclusions on long-term efficacy and safety, as well as costs. Notwithstanding these limitations, occipital nerve stimulation does seem to produce satisfactory improvement in chronic drug-resistant cluster headache and when it does not produce benefit, hypothalamic stimulation can be considered. Occipital nerve stimulation has been extensively investigated as a treatment of chronic migraine, but there is still some skepticism about its efficacy.^[88]

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Table 1. Summary of results of hypothalamic stimulation studies in drug-resistant chronic cluster headache.
Study (year)	Implanted patients (n)	Mean follow-up (years)	Improved patients (n)^†	Improved (%)	Ref.
Leone et al. (2001, 2006 and 2013)	19	8.7	12	71^‡	[7,9,20]
Schoenen et al. (2005)	4	4	2	50	[8]
Starr et al. (2007)	4	1	2	50	[12]
Owen et al. (2007)	1	0.7	1	100	[13]
Bartsch et al. (2008)	6	1.4	3	50	[16]
Fontaine et al. (2010)	11	1	6	55	[17]
Seijo et al. (2011)	5	2.8	3	60	[19]
Hidding and May (2011)	1	NR	0	0	[18]
D'Andrea et al. (2006)	3	2.5	2	67	[10]
Benabid et al. (2006)	1	1	1	100	[11]
Mateos et al. (2007)	2	1	2	100	[15]
Black et al. (2007)	2	2.6	2	100	[14]
Nikka et al. (2005)^§	2	2	0	0
Total	61	2.4	36	61

^†At least 50% improvement in headache frequency and/or intensity.
^‡Percentage calculated from 17 of out 19 patients: one patient died for reasons other than the neurostimulator and in another patient the electrode was removed owing to infection.
^§[Nikka et al., Pers. Comm.].
NR: Not reported

Table 2. Summary of results of occipital nerve stimulation studies in drug-resistant chronic cluster headache.
Study (year)	Implanted patients (n)	Follow-up (months)	Improved patients (n)^†	Improved (%)	Ref.
Magis et al. (2007 and 2011)	15	36.8	12	80	[43,52]
Burns et al. (2009)	14	17.5	5	36	[44]
Proietti Cecchini et al. (2009)	13	21	8	62	[45]
Lara Lara et al. (2009)	6	6–15	4	67	[46]
de Quintana-Schmidt et al. (2010)	4	6	4	100	[47]
Salom and Lainez (2010)	14	NR	7	50	[48]
Müller et al. (2011)	10	12	9	90	[49]
Fontaine et al. (2011)	13	14.6	10	77	[50]
Strand et al. (2011)	3	12	2	67	[51]
Total	92	17.1	61	66

^†At least 50% improvement in headache frequency or intensity.
NR: Not reported.

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Executive Summary

Occipital Nerve Stimulation

Occipital nerve stimulation has achieved good results in drug-resistant chronic cluster headache, but less favorable results are achieved in chronic migraine. Occipital nerve stimulation is widely considered to be the first choice neurostimulation procedure for chronic cluster headache.

Hypothalamic Stimulation

Hypothalamic stimulation is an invasive procedure for drug-resistant chronic cluster headache and other trigeminal autonomic cephalalgias (short-lasting neuralgiform headache attacks with conjunctival injection and tearing, and paroxysmal hemicrania). This technique is tolerable and effective in approximately 60% of treated patients many years after implantation.

Transcranial Magnetic Stimulation

Transcranial magnetic stimulation efficacy has been investigated in migraine, both chronic and episodic, and with and without aura. Results are less favorable than with other neurostimulation procedures.

Transcranial Direct Current Stimulation

Transcranial direct current stimulation seems to have a certain efficacy in reducing migraine intensity rather than frequency.

Cervical Spinal Cord Stimulation

Cervical spinal cord stimulation is a rather invasive procedure that in one study reduced both frequency and intensity of chronic cluster headache.

Sphenopalatine Ganglion Stimulation

Preliminary findings suggest that stimulation can rapidly control ongoing cluster headaches. Surgery-related local adverse events are claimed to be as frequent as with other maxillofacial surgical procedures.

Other Types of Nerve Stimulation

Vagal nerve stimulation to treat drug-resistant chronic migraine and cluster headache may be justifiable when other conditions, such as epilepsy or depression, are also present.

Conclusion

Interest in neurostimulation techniques to treat intractable headache conditions has burgeoned in recent years, but enthusiasm should be tempered as most studies have been open. Although many of these techniques show effectiveness, they should be used with caution: rigorous selection criteria are necessary, and the advantages and disadvantages, including costs, should be extensively evaluated on an individual basis, implying more than usual attention to the patient by the physician.

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Neurostimulators for the Treatment of Primary Headaches

Conclusion

Tables

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Authors and Disclosures

Authors and Disclosures

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