Peripheral Neurostimulation for the Treatment of Medically Refractory Head Pain Syndromes

Occipital nerve stimulation (ONS) was originally described as a percutaneous peripheral neurostimulation (PNS) treatment for occipital neuralgia (ON) by Weiner and Reed1.  This description noted that, similar to spinal cord stimulation for neuropathic pain of the extremities, pleasant paresthesia induced within the occipital dermatomes could relieve occipital neuralgia (ON), a lightning-like pain condition similar to trigeminal neuralgia.  However, true ON is rare and confined only to the posterior occiput.  In contrast, medically refractory headache syndromes are more commonly holocephalic with pain in both the upper cervical root and the trigeminal distributions of the head2, 3.  Thus, an understanding of the neuroanatomy and neurophysiology of holocephalic head pain is of paramount importance in considering therapeutic percutaneous PNS. 

The C1,2,3 cervical roots include the greater occipital nerve which originates primarily from C2, and the lesser occipital nerves.  Relevant trigeminal branches include both the supraorbital and supratrochlear nerves from V1, the infraorbital branches from V2, and the superficial temporal nerves from V3. A partial convergence of these two systems occurs at the Trigemino-Cervical Complex  (TCC), and consideration of this fact led some to conclude that combined PNS of the trigeminal and occipital nerves might result in a better outcome2.  Recent clinical results have seemed to support this interpretation4-6. 

Appropriate candidates for PNS for medically refractory head pain syndromes should have pain within the anatomic distribution of the occipital, or trigeminal, systems or both; must have undergone neuropsychological testing; and should have had a positive response to the anesthetic phase of respective nerve blocks7.  As well, careful preoperative localization of anatomic landmarks by palpation, flouro or ultrasound may be helpful in assuring that appropriate subcutaneous electrode depth achieves the pre-requisite dermatomal paresthesia8-10. 

Traditionally, the procedure consists of a trial, followed by permanent implantation of electrodes with a pulse generator if the trial is successful.  Postoperative programming is directed at cathodal activation of the involved peripheral branches producing dermatomal paresthesia.  Response rate to ONS for posterior occipital pain syndromes alone ranges between 71 and 100% with average being 88%2, 3.  Response rate for ONS for holocephalic pain involving both posterior occipital and trigeminal pain distributions however, is reduced to approximately 40%11.  When ONS is combined with trigeminal PNS electrodes for holocephalic pain however, the outcomes have returned to 90+%4-6. Complications are usually minor, and can be divided into medical complications, such as infection, wound hematoma, or seroma, and hardware-related complications, including lead migration, breakage, or pulse generator failure. 

In conclusion, PNS for medically refractory head pain syndromes are effective, safe, and well-tolerated procedures.  Much like spinal cord stimulation, these pain syndromes respond well only when paresthesia is achieved in all of the primary nerve distributions involved (occipital and/or trigeminal).  Despite the growing body of literature available on these techniques, multicenter prospective randomized studies are warranted to assess their long-term efficacy.

Dr. Erich O. Richter, MD
LSU Health Sciences Center, New Orleans, LA, USA
Department of Neurosurgery

Dr. Kenneth M. Alo`, MD

The Methodist Hospital Research Institute, Houston, TX, USA

Pain Management

Dr. Marina V. Abramova, MD

LSU Health Sciences Center, New Orleans, LA, USA
Department of Neurosurgery


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.

Date: Jan. 13, 2012