Neurol India Home 

Year : 2015  |  Volume : 63  |  Issue : 5  |  Page : 650--651

Neuromodulation in chronic headache

Manmohan Singh 
 Department of Neurosurgery and Gamma Knife Center, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Manmohan Singh
Department of Neurosurgery and Gamma Knife Center, All India Institute of Medical Sciences, New Delhi

How to cite this article:
Singh M. Neuromodulation in chronic headache.Neurol India 2015;63:650-651

How to cite this URL:
Singh M. Neuromodulation in chronic headache. Neurol India [serial online] 2015 [cited 2020 Apr 2 ];63:650-651
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Chronic disabling headache is a common problem in clinical practice and poses a daunting challenge to both patients and physicians. Chronic daily headache is a global health problem affecting 3–5% of the population.[1] It is responsible for the loss of precious man-hours. Headache can be primary due to endogenous disorders or secondary due to factors such as a tumor, infection or occurrence of trauma. With an improved understanding of the various types of headaches, the majority of these patients can be treated effectively with medical management alone. However, a few of them remain refractory to medical management. Various treatment guidelines for the management of chronic headache have been proposed,[2] but no single protocol exists which provides an algorithm for the management of intractable headache. Therefore, there is a need for other novel treatment options to manage these patients.

Nerve blocks with local anesthetics or steroid injections may provide relief to some of the patients to a limited extent. However, relief may not be long lasting in many of them necessitating further treatment. Ablative procedures like neurectomies or neurolysis can lead to long-term complications like anesthesia in the affected area or deafferentation pain that may be very difficult to treat. In recent years, neuromodulation has emerged as one of the treatment options with promising results. In the last two decades, many implantable devices have been introduced to manage some of the difficult-to-treat headache disorders. Neuromodulation is reversible and lacks major complications. Various procedures listed under neuromodulation include transcutaneous electrical nerve stimulation (TENS), occipital nerve stimulation (ONS), vagal nerve stimulation (VNS), supraorbital nerve stimulation, spinal cord stimulation (SCS), deep brain stimulation (DBS), sphenopalatine ganglion (SPG) stimulation, repetitive transcranial magnetic stimulation, and transcranial direct current stimulation. It involves application of the electrical current to modify pain signals through various means.

A thorough knowledge of the craniocervical nociceptive system is mandatory to understand and manage chronic headache. Three divisions of the trigeminal nerve supply the face and forehead. The greater occipital nerve, lesser occipital nerve, and third occipital nerve supply posterior part of the head. Goadsby and Hoskin[3] had described connections between the trigeminal and cervical spinal nerve systems. This connection is in the brainstem and upper cervical spinal cord (trigeminocervical system). These anatomic and functional connections explain the presence of referred pain from the cervical to the frontal region. That is why stimulation of the occipital nerve not only modulates pain in its own territory but also in the distribution of the trigeminal nerve.

ONS is an important form of neuromodulation in chronic migraine (CM), cluster headache, and other headache disorders[4],[5] that are refractory to conventional medical management. However, many randomized trials of ONS did not yield encouraging results. The Medtronics study on ONS for the treatment of intractable CM demonstrated that only 39% patients had more that 50% reduction in headache intensity at a 3-month follow-up.[6] ONS is more effective in the management of trigeminal autonomic cephalgias (TAC) than in the management of CM. Chronic cluster headache treated with ONS shows a better outcome in 67% of the patients.[7] ONS has also been shown to be effective in hemicrania continua.[8] Peripheral nerve stimulation is perceived by the patient as paresthesia in the distribution of the nerve. Therefore, for research, blinding of the procedure is not possible wherein active nerve stimulation is compared with no stimulation. Under these circumstances, to carry out a controlled trial of ONS is an issue that needs to be resolved.

SPG stimulation by various means has been used in clinical practice to treat cluster headaches. The benefit has been reported to be variable in different studies. Newer techniques of SPG stimulation in one study have shown complete resolution of the cluster headaches in 61% attacks.[9] SPG stimulation is effective in aborting an induced migrainous attack.[10] The most common side effect of the SPG stimulation is a loss of sensation in the maxillary division of the fifth nerve, which is of concern on a long term basis. Various studies are underway at the moment to further validate its efficacy.

Efficacy of VNS in intractable epilepsy has been well documented in carefully selected cases. A favorable response of VNS in CM and cluster headache has been seen. Despite the encouraging results, the morbidity of VNS implants (due to scarring and adhesions of the vagus nerve) has limited its usage. The development of noninvasive transcutaneous vagus nerve stimulation has shown good results. The device utilized is known as gammaCore. It transcutaneously stimulates the cervical branch of the vagus nerve. In a pilot study of gammaCore involving 30 patients of CM, it was found that 22% patients were pain-free and 42% patients had pain relief after 2 hours. There were no significant side effects.[11]

A central approach like DBS of the posterior hypothalamus has been found to be effective in the management of cluster headache. The first such case was reported in 2001.[12] The posterior hypothalamus has become the target for electrical stimulation ever since positron emission tomography studies have shown increased blood flow in that region during the attack of cluster headache.[13] Till date, the data of more than 60 hypothalamic DBS performed for cluster headache or TAC is available in the literature, revealing a good outcome in 50–60% of patients.[14]

High cervical SCS has been shown to reduce the frequency of chronic cluster headaches with the response rate being 86%.[15] However, the hardware complications at this location have resulted in a very high revision rate, considerably nullifying its successes. Cervical SCS still remains a promising treatment in a carefully selected group of patients.

In today's practice, neuromodulation devices provide a ray of hope for the patients of chronic headache syndromes. In future, improvement in the hardware devices will yield better clinical results with less adverse effects. The need of the hour is to have well-planned, large volume trials to validate the efficacy of neuromodulation.


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