Occipital Neurostimulation for Treatment of Intractable Headache Syndromes

This chapter focuses on the use of occipital neurostimulation for the treatment of intractable headache syndromes. Peripheral occipital subcutaneous field neurostimulation for a variety of intractable headache syndromes is a safe, reasonably effective, and uncomplicated treatment modality used while dealing with patients refractory to conventional therapy. Occipital nerve neurolysis and/or neurectomy have been used as a part of the neurosurgical armamentarium in treating intractable occipital headaches for many years. Though occasionally very effective, the not-infrequent development of delayed deafferentation pain in the distribution of the affected occipital nerve limits the longterm usefulness of the procedure. Experience with peripheral nerve electrical stimulation for painful mononeuropathies and complex regional pain syndromes involving major peripheral nerves led to the sentinel observation that subcutaneous tissue can conduct and propagate electrical impulses in a dermatomal and/or myotomal distribution of one or more peripheral nerves without direct nerve contact, producing pain relief in the region of the electrically induced local paresthesiae. This has led to the development and refinement of a percutaneous neurostimulation procedure implanted transversely into the subcutaneous space nominally at or just above the level as a minimally invasive treatment alternative for intractable occipital headache syndromes. After lead placement, stimulation is applied using a temporary RF transmitter to various select electrode combinations enabling the patient to report on the table the stimulation location, intensity, and overall sensation. The most important aspect of the procedure involves techniques to prevent electrode migration (pullback) from its transverse subcutaneous position in the highly mobile upper cervical region. These devices can be used in various scenarios, including intermittent stimulation for migraine with aura, cervicogenic headache, occipital neuralgia, postherpetic neuralgia, tension headache, and cluster headaches.