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SYMPOSIUM
Year : 2020  |  Volume : 68  |  Issue : 8  |  Page : 231-234

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


Department of Neurology, The Ohio State University Wexner Medical Center, The Ohio State University, Columbus, USA

Date of Web Publication5-Dec-2020

Correspondence Address:
Dr. Kiran F Rajneesh
Department of Neurology, The Ohio State University Wexner Medical Center, The Ohio State University, 410 W 12th Ave, Columbus, OH – 43210
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.302477

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 » Abstract 


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.


Keywords: Cluster headaches, field stimulation, intractable headache syndromes, occipital nerve stimulation, occipital neuralgia, percutaneous leads, sphenopalatine ganglion stimulation, trigeminal neuralgia
Key Message:: Intractable headaches are a leading cause of disability, especially in younger populations. Patients with headaches refractory to lifestyle modifications, conservative therapies and medication management, neurostimulation is a reasonable option to trial. Diagnostic blocks are usually performed prior to implantation of trial leads. We recommend a staged approach for implantation of permanent leads. Fluoroscopy and/or ultrasound guidance of percutaneous leads can improve safety and improve efficacy. Annual monitoring and reprogramming can optimize coverage and efficacy of neuromodulation.


How to cite this article:
Rajneesh KF. Occipital Nerve Stimulation and Sphenopalatine Ganglion Stimulation for Treatment of Intractable Headache Syndromes. Neurol India 2020;68, Suppl S2:231-4

How to cite this URL:
Rajneesh KF. Occipital Nerve Stimulation and Sphenopalatine Ganglion Stimulation for Treatment of Intractable Headache Syndromes. Neurol India [serial online] 2020 [cited 2021 Feb 25];68, Suppl S2:231-4. Available from: https://www.neurologyindia.com/text.asp?2020/68/8/231/302477




Intractable headache syndromes are a leading cause of disability in the world.[1] Headache syndromes affect all age groups, men and women. Most chronic pain syndromes including headaches generally affect women more than men.[2] Cluster headaches affect men more than women.[3] Cluster headache consists of attacks of severe, strictly unilateral pain, which is orbital, supraorbital, temporal, or in any combination of these sites, lasting 15–180 min and occurring from once every other day to eight times a day. The attacks are associated with one or more of the following, all of which are ipsilateral: conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead and facial sweating, miosis, ptosis, and eyelid edema.[4] Cluster headaches can be episodic or become chronic, associated with triggers such as smoking.[5] Trigeminal neuralgia can coexist in patients with cluster headaches resulting in cluster-tic syndrome.[6] Occipital neuralgia is another prevalent headache syndrome and usually coexists with migraine headaches. The vast majority of occipital neuralgia involves the greater occipital nerves. Other comorbidities such as cervical spinal osteoarthritis, fibromyalgia, autoimmune disorders can coexist with occipital neuralgia.

Occipital nerve stimulation using percutaneous leads

This is the preferred method of occipital nerve stimulation (ONS) by authors. The percutaneous leads are less invasive and provide ease of use even in elderly population. These leads to decrease the long-term incidence of patient discomfort due to being more pliable leads than the rigid surgical leads. Favourable response to diagnostic occipital nerve blocks is helpful in the workup. However, diagnostic occipital nerve blocks are unable to substitute for percutaneous trial leads due to coverage as well as programming advantages of the trial leads.[7],[8] If the diagnostic occipital nerve blocks do not provide adequate pain relief for extended period of time, neuromodulation could extend the time coverage. Hence short lived, diagnostic blocks are not a contraindication for trial leads but rather an indication to ascertain adequate pain relief. The techniques described below are similar for both trial and permanent leads. Trial leads can be placed with local and conscious sedation; permanent leads more likely with monitored anesthesia care or general anesthesia due to concurrent implantable generator (IPG) placement.


 » Technique Top


Fluoroscopy guidance is the more popular modality for both trial and permanent leads for occipital nerve stimulation. Patients are usually placed prone since most ONS involves both sides. However, in case of unilateral lead placement, lateral decubitus position is preferred for easier airway management. The original method involved placed the leads at C1 level, which has been supplanted by leads placed at the nuchal ridge [Figure 1].[9] The nuchal ridge is superior due to closer proximity of the leads to the greater occipital nerve.[10] Another advantage is the probability of capturing less and lesser occipital nerve fields is higher with the nuchal ridge placement. The entry point for lead insertion can be lateral to medial in unilateral leads. Most operators prefer medial to lateral insertion with bilateral leads. Optimal depth placement of the leads is critical. Superficial leads can lead to dysesthesias of the scalp during stimulation in both trial and permanent leads. In case of permanent leads, superficial leads are more prone to skin erosion, ulceration, infection, etc. Conversely, deep leads can lead to flowover stimulation - muscle contraction and spasms that may lead to discomfort and worsening of headaches in the patient. In smaller patients, consideration should be given to programming appropriate contacts on the leads. The lateral most contacts can lead to noxious stimulation of the mastoid process and ears.
Figure 1: Illustration showing ONS bilateral leads placed at the nuchal ridge level in AP view (left) and Lateral view (right) inserted from medial to lateral direction. Note the strain relief loops in view

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Usually the trial period can last from 3 to 5 days depending on operator preference. Usually trial leads are completely removed at the end of trial period. Permanent leads have additional considerations for IPG placement. IPG implantation can done over anterior or posterior chest wall; patient preference and cosmetic/aesthetic considerations should be made as shared decision-making with the patient. Furthermore, if patient has a preferred side of sleeping that must be considered as well. Since neck is a mobile location with constant flexion, extension, rotation and lateral flexion; adequate strain relieving loops must be provided. Anchors to tether IPG and leads also need to consider pivotal points in the neck and avoid those locations to prevent scarring, fibrosis and the consequent discomfort to patients. Lead migration and lead erosion are two long term complications of ONS.[11]

Ultrasound guidance of percutaneous leads during occipital nerve stimulation.

Ultrasonography can provide valuable information with depth perspective as well as location of the greater occipital nerve.[12] Furthermore, in patients with previous history of cranial surgeries, ultrasonography can demonstrate scar tissue, mesh implants as well as aberrant vasculature, which can be helpful. In revision surgeries of ONS and in the elderly population, ultrasonography can help ascertain optimal depth placement when anatomical considerations may have been altered. Optimal lead placement can reduce lead erosion, dysesthesias, noxious muscle stimulation as detailed above. In addition, optimal lead placement can not only prolong battery life of IPG but also improve efficacy of lead programming including subthreshold stimulation.

Occipital nerve stimulation with surgical leads

Surgical leads tend to be flat and consequently can capture a larger width of coverage. Also, they are more amenable to being anchored firmly and can be useful in revision surgeries especially in the presence of scar tissue. Some operators trial with percutaneous leads and implant surgical leads. Surgical leads being larger in surface area may lead to patient discomfort over longer periods of time. Lead migration is less likely with surgical leads. However, they are subject to increased wear and tear and metal fatigue lead to loss of efficacy. While both percutaneous as well as surgical leads have their unique advantages, patient selection and patient education is crucial for their long term retention and efficacy.

Sphenopalatine ganglion stimulation

Sphenopalatine ganglion (SPG) is an autonomic ganglion located in pterygopalatine fossa. Classically, it has been considered as a predominantly parasympathetic ganglion; however, recent advances in neuroimaging as well as neuro-immunochemistry demonstrate that it has sympathetic as well as sensory components. It has vast set of functions including sensory fibers to adjacent meninges, vascular control and autonomic control of secretory functions in the lacrimal and nasal glands. Patients with refractory cluster headaches as well as trigeminal autonomic cephalgias (TACs) can derive pain relief from Sphenopalatine ganglion stimulation.[13] Some operators prefer fluoroscopy guided SPG block as a diagnostic test before trialing leads. Office-based transnasal as well as transoral SPG blocks are alternatives as well.

Percutaneous infrazygomatic approach

This is preferred method due to the location and access to pterygopalatine fossa. Fluoroscopy is the preferred imaging guidance modality followed by computed tomography (CT). The entry point is inferior to infrazygomatic process and usually anterior to the mandible. Some operators may prefer an entry point inferior to infrazygomatic process but through the coronoid notch. The needle is advanced on the pterygoid plate into the pterygopalatine fossa with imaging guidance. The percutaneous lead advanced through needle cannula and sensory stimulation performed.[14] Paraesthesia over the base of the nose confirms ideal placement. During permanent placement of the percutaneous leads, the lead is tethered at the infrazygomatic location and the IPG is usually positioned in the infraclavicular region. Attention should be directed towards providing strain relief loops to prevent lead migration and patient discomfort due to strain during neck movements. An alternative technique is the transoral infrazygomatic approach where an incision is made over the gingival mucosa and the implant is placed over cheekbone with lead in the pterygopalatine fossa. The unit is driven by an external inductive current generator [Figure 2].
Figure 2: Illustration showing SPG stimulator implant showing bone fixation plate, body, and lead with electrodes for transoral infrazygomatic technique

Click here to view



 » Advances in Neuromodulation Top


With the advent of newer technologies, neurostimulation of occipital nerves and sphenopalatine ganglion outlook is optimistic with possibility of improved pain control with lesser adverse effects. Burst stimulation which is proposed to modulate pain perception at cortical level in addition to traditional neurostimulation mechanisms may confer additional pain control and compliance in these intractable headache syndromes. Preliminary small studies appear promising.[15] Furthermore, burst stimulation is usually sub perception and maybe more comfortable for patients in these relatively periosteal and subcutaneous locations. High-frequency stimulation provides paraesthesia free stimulation with improved patient comfort and is an option for these locations.[16] Recently closed-loop spinal cord stimulation studies have been published and potentially show promise for uses for intractable headache syndromes in the future.[17]


 » Complications and Adverse Effects Top


Invasive and minimally invasive procedures carry a risk potential. Minimizing risk and optimizing care starts with patient workup presurgically. This often is best accomplished with a multidisciplinary team spanning several specialities including Neurology, Neurosurgery, Radiology, Pain management, Pain Psychology and therapists.[18] Medical workup to rule out secondary causes for intractable headache syndromes is vital. Imaging studies for presurgical planning, Pain Psychology evaluation for screening as well as diagnostic blocks by Pain management are essential for final patient selection as well as realistic expectations. Furthermore, long-term compliance is attained with continued medication optimization, treatment of comorbid psychiatric disorders such as depression and anxiety and reprogramming of neurostimulation which is best implemented as a multidisciplinary team.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Steiner TJ, Birbeck GL, Jensen RH, Katsarava Z, Stovner LJ, Martelletti P. Headache disorders are third cause of disability worldwide. J Headache Pain 2015;16:58.  Back to cited text no. 1
    
2.
Steiner TJ, Stovner LJ, Birbeck GL. Migraine: The seventh disabler. J Headache Pain 2013;14:1.  Back to cited text no. 2
    
3.
Swanson JW, Yanagihara T, Stang PE, O’Fallon WM, Beard CM, Melton LJ 3rd, et al. Incidence of cluster headaches: A population-based study in Olmsted County, Minnesota. Neurology 1994;44:433-7.  Back to cited text no. 3
    
4.
Mathew NT. Cluster headache and other trigeminal autonomic cephalalgias diagnostic criteria. Handb Clin Neurol 2010;97:421-9.  Back to cited text no. 4
    
5.
Lund N, Petersen A, Snoer A, Jensen RH, Barloese M. Cluster headache is associated with unhealthy lifestyle and lifestyle-related comorbid diseases: Results from the Danish Cluster Headache Survey. Cephalalgia 2019;39:254-63.  Back to cited text no. 5
    
6.
Wilbrink LA, Weller CM, Cheung C, Haan J, Ferrari MD. Cluster-tic syndrome: A cross-sectional study of cluster headache patients. Headache 2013;53:1334-40.  Back to cited text no. 6
    
7.
Kinfe TM, Schuss P, Vatter H. Occipital nerve block prior to occipital nerve stimulation for refractory chronic migraine and chronic cluster headache: Myth or prediction? Cephalalgia 2015;35:359-62.  Back to cited text no. 7
    
8.
Schwedt TJ, Dodick DW, Trentman TL, Zimmerman RS. Response to occipital nerve block is not useful in predicting efficacy of occipital nerve stimulation. Cephalalgia 2007;27:271-4.  Back to cited text no. 8
    
9.
Weiner RL, Reed KL. Peripheral neurostimulation for control of intractable occipital neuralgia. Neuromodulation 1999;2:217-21.  Back to cited text no. 9
    
10.
Mueller O, Hagel V, Wrede K, Schlamann M, Hohn HP, Sure U, et al. Stimulation of the greater occipital nerve: Anatomical considerations and clinical implications. Pain Physician 2013;16:E181-9.  Back to cited text no. 10
    
11.
Doran J, Ward M, Ward B, Paskhover B, Umanoff M, Mammis A. Investigating complications associated with occipital nerve stimulation: A MAUDE Study. Neuromodulation 2018;21:296-301.  Back to cited text no. 11
    
12.
Skaribas I, Alo K. Ultrasound imaging and occipital nerve stimulation. Neuromodulation 2010;13:126-30.  Back to cited text no. 12
    
13.
Schoenen J. Sphenopalatine ganglion stimulation in neurovascular headaches. Prog Neurol Surg 2015;29:106-16.  Back to cited text no. 13
    
14.
Piedade GS, Vesper J, Hoyer R, Klenzner T, Slotty PJ. Accuracy of electrode position in sphenopalatine ganglion stimulation in correlation with clinical efficacy. Neuromodulation 2020. doi: 10.1111/ner.13261.  Back to cited text no. 14
    
15.
Garcia-Ortega R, Edwards T, Moir L, Aziz TZ, Green AL, FitzGerald JJ. Burst occipital nerve stimulation for chronic migraine and chronic cluster headache. Neuromodulation 2019;22:638-44.  Back to cited text no. 15
    
16.
Jurgens TP, Schoenen J, Rostgaard J, Hillerup S, Láinez MJ, Assaf AT, et al. Stimulation of the sphenopalatine ganglion in intractable cluster headache: Expert consensus on patient selection and standards of care. Cephalalgia 2014;34:1100-10.  Back to cited text no. 16
    
17.
Mekhail N, Levy RM, Deer TR, Kapural L, Li S, Amirdelfan K, et al. Long-term safety and efficacy of closed-loop spinal cord stimulation to treat chronic back and leg pain (Evoke): A double-blind, randomised, controlled trial. Lancet Neurol 2020;19:123-34.  Back to cited text no. 17
    
18.
Sahai-Srivastava S, Sigman E, Uyeshiro Simon A, Cleary L, Ginoza L. Multidisciplinary team treatment approaches to chronic daily headaches. Headache 2017;57:1482-91.  Back to cited text no. 18
    


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