Monday, March 12, 2012 10:03 PM

Medically Refractory Headache
Treatment with Peripheral Nerve Stimulation (PNS)

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Erich O. Richter, MD
Member, International Neuromodulation Society

Department of Neurosurgery, Louisiana State University (LSU) Health Sciences Center, New Orleans, LA, USA
Kenneth M. Alo`, MD
Member, International Neuromodulation Society
Pain Management, The Methodist Hospital Research Institute, Houston, TX, USA
Marina V. Abramova, MD
Department of Neurosurgery, LSU Health Sciences Center, New Orleans, LA, USA


While the majority of headaches are caused by tension and do not require medical intervention, roughly 20 percent of the population experience incapacitating headaches that resist medical treatment. Migraines, cluster headaches, and occipital neuralgia are among these.

In 1999, the International Neuromodulation Society’s journal Neuromodulation: Technology at the Neural Interface published clinical observations describing use of neurostimulation to reduce the severe head pain of occipital neuralgia that generally occurs to the rear of the head, in areas supplied by the occipital nerves.1 The authors noted that, similar to treating neuropathic pain with spinal cord stimulation, using peripheral neurostimulation (PNS) on the occipital nerves induced a pleasant tingling sensation. They reported the effect relieved the lightning-like pain condition by at least half in the patients whose conditions were monitored from 18 months to 6 years.

Most medically refractory headache syndromes, including migraines, cause pain throughout the head. Thus, an understanding of the structures and physiology underlying this pain is of paramount importance for practitioners who are considering using PNS as a therapy for chronic headache that is not relieved by more conservative measures.

Recent clinical results have seemed to support the expectation of some clinicians that applying PNS to a combination of the occipital nerves and nerves that supply the face might result in a better outcome.4-6 (A partial convergence of these two systems occurs at the trigeminocervical complex.)

Indeed, the response rate for patients with intractable head-wide pain who were treated with neurostimulation to the occipital and trigeminal nerve systems is reported to be better than 90%4-6.

This is an improvement from using only stimulation to the occipital nerves for head-wide pain syndromes, which is reported to bring about just a 40% response11. (On average, patients who only have pain in the rear of the head, a posterior occipital syndrome, show improvement averaging 88% from occipital nerve stimulation, with the range running from 71 – 100%.)

Appropriate candidates for PNS for medically refractory headache syndromes should have7:

  • Pain within the occipital or trigeminal systems, or both
  • Recent neuropsychological testing
  • A positive response to the anesthetic phase of respective nerve blocks

The procedure consists of a trial with temporary electrical leads. If this is successful, it is followed by permanent implantation of electrodes that are connected to a compact pulse generator. Following the implantation procedure, the patient visits the office to program the device in order to induce the optimum degree of stimulation to relieve symptoms. Prior to the trial, the patient may undergo testing to determine the exact placement of the leads – done through careful examination, often combined with diagnostic imaging involving use of a contrast agent or ultrasound 8-10

Complications are usually minor. These include medical complications, such as infection, bleeding or fluid collection under the skin, and hardware-related complications, including movement of the electrical lead, breakage, or pulse generator failure.

Much like results of spinal cord stimulation for neuropathy, medically refractory headache pain seems to respond to PNS well only when the tingling sensation evoked, paresthesia, occurs in all the primary nerve distributions involved (occipital and/or trigeminal).

There is a growing body of literature on these techniques, although continued studies – using random sampling of subjects at multiple treatment centers – are warranted to definitively assess their long-term effectiveness.

In summary, clinical evidence shows PNS procedures for medically refractory head pain syndromes are effective, safe, and well-tolerated.

Please note:This information should not be used as a substitute for medical treatment and advice. Always consult a medical professional about any health-related questions or concerns.

More information

American Council for Headache Education

American Academy of Neurology
1080 Montreal Avenue
St. Paul, MN 55116
(651) 695-1940

American Headache Society
19 Mantua Road
Mt. Royal, NJ 08061
(609) 423-0258

National Headache Foundation
428 West St. James Place, 2nd Floor
Chicago, IL 60614-2750
(888) NHF-5552

National Institute of Neurological Disorders and Stroke
PO Box 5801
Bethesda, MD 20824
(301) 496-5751


1. Weiner RR, KL. Peripheral Neurostimulation for Control of Intractable Occipital Neuralgia. Neuromodulation: Technology at the Neural Interface. 1999;2(3):217-221.
2. Popeney CA, Alo KM. Peripheral neurostimulation for the treatment of chronic, disabling transformed migraine. Headache. Apr 2003;43(4):369-375.
3. Oh M, Ortega J, Belotte J, Whiting D, Alo` K. Peripheral nerve stimulation for the treatment of occipital neuralgia and transformed migraine using a C1-2-3 subcutaneous paddle style electrode: a technical report. Neuromodulation: Technology at the Neural Interface. 2004;7:103-112.
4. Reed KL, Black SB, Banta CJ, 2nd, Will KR. Combined occipital and supraorbital neurostimulation for the treatment of chronic migraine headaches: initial experience. Cephalalgia. Mar 2010;30(3):260-271.
5. Slavin K, Wess C. Trigeminal branch stimulation for intractable neuropathic pain: technical note. Neuromodulation: Technology at the Neural Interface. 2005;8:7-13.
6. Mammis A, Gudesblatt M, Mogilner A. Peripheral neurostimulation for the treatment of refractory cluster headache, long-term follow-up: Case Report. Neuromodulation: Technology at the Neural Interface. 2011;14(5):432-435.
7. Levin M. Nerve blocks in the treatment of headache. Neurotherapeutics. 2010;7:197-203.
8. Magown P, Garcia R, Beauprie I, Mendez IM. Occipital nerve stimulation for intractable occipital neuralgia: an open surgical technique. Clin Neurosurg. 2009;56:119-124.
9. Skaribas I, Alo` K. Ultrasound imaging and occipital nerve stimulation. Neuromodulation: Technology at the Neural Interface. 2010;13(2):126-130.
10.Slavin KV, Colpan ME, Munawar N, Wess C, Nersesyan H. Trigeminal and occipital peripheral nerve stimulation for craniofacial pain: a single-institution experience and review of the literature. Neurosurg Focus. 2006;21(6):E5.
11. Saper JR, Dodick DW, Silberstein SD, McCarville S, Sun M, Goadsby PJ. Occipital nerve stimulation for the treatment of intractable chronic migraine headache: ONSTIM feasibility study. Cephalalgia. Feb;31(3):271-285.

December 5, 2011


Last Updated on Monday, December 12, 2016 03:20 PM