Outcomes of Occipital Nerve Stimulation for Craniofacial Pain Syndromes.

OBJECTIVES: Occipital nerve regional stimulation (ONS) is reported to improve pain in several studies. We examined long-term pain and functional outcomes of ONS in an open-label prospective study. METHODS: Patients with medically refractory and disabling craniofacial pain were prospectively selected for ONS. Primary outcome was a change in mean daily pain intensity on the numeric pain rating scale (NPRS) at 6 months. Secondary outcomes included changes in NPRS, Headache Impact Test-6 (HIT-6), Migraine Disability Assessment (MIDAS), Pain Disability Index (PDI), Center for Epidemiologic Studies Depression Scale - Revised (CESD-R), and Short Form-36 version 2 (SF36) at last follow-up. RESULTS: Thirteen patients (mean age 49.7 ± 8.4) diagnosed with occipital neuralgia (6), hemicrania continua (2), persistent idiopathic facial pain (2), post-traumatic facial pain (1), cluster headache (1), and chronic migraine (1) were enrolled. Mean NPRS improved by 2.1 ± 2.1 at 6 months and 2.1 ± 1.9 at last follow-up (23.5 ± 18.1 months). HIT-6 decreased by 8.7 ± 8.8, MIDAS decreased by 61.3 ± 71.6, and PDI decreased by 17.9 ± 18. SF36 physical functioning, bodily pain, and social functioning improved by 16.4 ± 19.6, 18.0 ± 31.6, and 26.1 ± 37.3, respectively. Moderate to severe headache days (defined as ≥50% of baseline mean NPRS) were reduced by 8.9 ± 10.2 days per month with ONS. CONCLUSION: ONS reduced the long-term NPRS and moderate-severe monthly headache days by 30% and improved functional outcomes and quality of life. A prospective registry for ONS would be helpful in accumulating a larger cohort with longer follow-up in order to improve the use of ONS.

Effect of Atlas Vertebrae Realignment in Subjects with Migraine: An Observational Pilot Study.

Introduction. In a migraine case study, headache symptoms significantly decreased with an accompanying increase in intracranial compliance index following atlas vertebrae realignment. This observational pilot study followed eleven neurologist diagnosed migraine subjects to determine if the case findings were repeatable at baseline, week four, and week eight, following a National Upper Cervical Chiropractic Association intervention. Secondary outcomes consisted of migraine-specific quality of life measures. Methods. After examination by a neurologist, volunteers signed consent forms and completed baseline migraine-specific outcomes. Presence of atlas misalignment allowed study inclusion, permitting baseline MRI data collection. Chiropractic care continued for eight weeks. Postintervention reimaging occurred at week four and week eight concomitant with migraine-specific outcomes measurement. Results. Five of eleven subjects exhibited an increase in the primary outcome, intracranial compliance; however, mean overall change showed no statistical significance. End of study mean changes in migraine-specific outcome assessments, the secondary outcome, revealed clinically significant improvement in symptoms with a decrease in headache days. Discussion. The lack of robust increase in compliance may be understood by the logarithmic and dynamic nature of intracranial hemodynamic and hydrodynamic flow, allowing individual components comprising compliance to change while overall it did not. Study results suggest that the atlas realignment intervention may be associated with a reduction in migraine frequency and marked improvement in quality of life yielding significant reduction in headache-related disability as observed in this cohort. Future study with controls is necessary, however, to confirm these findings. Clinicaltrials.gov registration number is NCT01980927.

Occipital stimulation for chronic migraine: patient selection and complications.

BACKGROUND: Chronic migraine is a significant cause of disability world-wide and occipital region stimulation (OS) has been proposed to treat it. While participating in an industry-sponsored pilot trial of OS, we aimed to collect data regarding our surgical complications and long term usage of OS in our chronic migraine patients. METHODS: Ten patients (8 female, median age 46.5 years) were enrolled based on criteria established by the sponsoring company, screened in the headache clinic, and followed for a median of 33 months. We did not access data collected by industry for this report and instead collected our own data prospectively, including predominant location of headache, location of paresthesia evoked by OS, and complications. RESULTS: Adverse events included three possible early infections requiring antibiotics but not hardware removal, one late implantable pulse generator erosion requiring removal, one generator malfunction requiring revision, and loss of paresthetic coverage requiring four revisions in four patients. Two patients experienced new symptoms requiring psychiatric intervention. Five patients had no benefit and have been explanted. Of those who remain using their device, the proportion of their pre-operative pain located in the occipital region was 0.62 ± 0.14, whereas in those patients who have been explanted, the proportion was 0.31 ± 0.18 (t = 3.15, p=0.01). CONCLUSIONS: Complication rates with OS are higher than those seen with other stimulation techniques, despite identical hardware and similar surgery. The location of migraine pain did predict outcome, and suggests that only those with primarily occipital region headache are candidates for this therapy.

Multidisciplinary treatment for headache in the Canadian healthcare setting.

BACKGROUND/OBJECTIVES: Multidisciplinary treatment programs are seen as an effective way to treat patients with chronic illness. The purpose of this study was to describe a multidisciplinary headache program which was developed in the Canadian public healthcare setting, and to report on patient perceptions of the program and patient treatment outcomes. METHODS: The Calgary Headache Assessment and Management Program (CHAMP) was developed with initial funding from Alberta Health, and continued with function from the Calgary Health Region. Patient perceptions of the program were obtained with questionnaires. Outcome measures for a cohort of patients who completed the Self-Management Workshop were obtained using standard headache related disability measures. RESULTS: Patient perceptions of the education session, the Lifestyle Assessment, and the Self-Management Workshop were very positive. Headache Disability Inventory scores fell from 56.2 to 46.3 from baseline to three months post Self-Management Workshop (p < .001). Corresponding scores for the HIT-6 were 63.6 and 58.2 (p < .001). CONCLUSIONS: Multidisciplinary headache treatment programs can be developed in the Canadian public healthcare system. The program described here was well accepted by many patients and perceived to be useful by them. Headache related disability as measured by standard measures was significantly reduced after participation in the program.