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Occipital Nerve Stimulation

  • Author: Antonios Mammis, MD; Chief Editor: Jonathan P Miller, MD  more...
 
Updated: Oct 14, 2015
 

Background

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.

Neurostimulation is FDA-approved for the treatment of certain intractable pain syndromes, although it is not approved for headache and craniofacial pain and thus occipital nerve stimulation represents an off-label use.

Mechanism of action

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[1] 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.[2] 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.

A schematic diagram of the gate control theory of A schematic diagram of the gate control theory of pain.
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Indications

Indications for occipital nerve stimulation include the following:

  • Chronic, intractable primary headache disorder [3]
  • 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:

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Contraindications

If the patient’s quality of life does not improve during the trial period (see Pre-Procedure Planning), the device is not implanted.

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Technical Considerations

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

Procedure Planning

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.

Complication Prevention

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.
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Outcomes

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.[1]

A 2011 study by Mogilner and Mammis found that 82% patients who underwent implantation reported continued significant benefit from stimulator use.[7]

Complications

Placement of an occipital nerve stimulator is a relatively safe procedure with a low complication rate. The specific complications include the following:

  • Lead migration or fracture - 5%
  • Surgical site infection - 4%
  • Wound erosion - 4%
  • Revision surgery for other reasons (primarily elective cosmetic adjustments to the leads) - 22%

No major complications have been reported, and the minor complications are easily treatable and usually do not affect the efficacy of the therapy.

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Contributor Information and Disclosures
Author

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.

Coauthor(s)

Gaurav Gupta, MD Director, Cerebrovascular and Endovascular Neurosurgery, Assistant Professor, Division of Neurological Surgery, Rutgers Robert Wood Johnson Medical School

Gaurav Gupta, MD is a member of the following medical societies: American Association of Neurological Surgeons, American College of Surgeons, American Medical Association, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Ahmed Meleis, MD Resident Physician, Department of Neurosurgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Disclosure: Nothing to disclose.

Chief Editor

Jonathan P Miller, MD Director, Functional and Restorative Neurosurgery Center, Associate Professor of Neurological Surgery, George R and Constance P Lincoln Endowed Chair, University Hospitals Case Medical 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 Medical Association, Congress of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery, North American Neuromodulation Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Medtronic Neuromodulation.

References
  1. Weiner RL, Reed KL. Peripheral neurostimulation for control of intractable occipital neuralgia. Neuromodulation. 1999 Jul. 2(3):217-21. [Medline].

  2. Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965 Nov 19. 150(3699):971-9. [Medline].

  3. 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].

  4. 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].

  5. Yang Y, Song M, Fan Y, Ma K. Occipital Nerve Stimulation for Migraine: A Systematic Review. Pain Pract. 2015 Apr 11. [Medline].

  6. 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].

  7. Mammis, A and Mogilner E. Peripheral Neuromodulation for Headache and Craniofacial Pain: Indications, Outcomes, and Complications. CNS meeting. Washington DC: 2011.

  8. Alo KM Holsheimer, J. New trends in neuromodulation for the management of neuropathic pain. Neurosurgery. 2002. 50 (4):690–704.

  9. 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.

  10. 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].

  11. 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].

  12. 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].

  13. Johnstone CS, Sundaraj R. Occipital nerve stimulation for the treatment of occipital neuralgia-eight case studies. Neuromodulation. 2006 Jan. 9(1):41-7. [Medline].

  14. Krames ES, Peckham PH, Rezai AR. Neuromodulation. 2009. Volume 1:Page 132.

  15. 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].

  16. Mammis, A and Mogilner E. Peripheral Neuromodulation for Headache and Craniofacial Pain: Indications, Outcomes, and Complications. Washington DC: CNS meeting; 2011.

  17. 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].

  18. 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].

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  20. 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.

  21. 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].

  22. 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].

  23. 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].

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  25. Weiner, RL. Occipital neurostimulation (ONS) for treatment of intractable headache disorders. Pain Med. 2006. 7:S137–S139.

 
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Image 1. A fluoroscopic images of occipital leads in the supraorbital (A), infraorbital (B), and occipital (C) region in a patient with intractable cluster headache
Image 2. A fluoroscopic images of occipital leads showing stacked left-sided occipital leads in a woman with hemicrania continua.
A schematic diagram of the gate control theory of pain.
 
 
 
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