Occipital Nerve Stimulation
The literature includes several case series of patients with cluster headache who received occipital nerve stimulation (ONS), an invasive neuromodulation technique. Approximately two-thirds of the patients responded to ONS, and 60% had sustained significant improvement. Cluster headache changed from chronic to episodic for five patients. A multicenter randomized controlled trial of ONS in cluster headache is ongoing in Europe. The study is comparing high- and low-amplitude ONS. For now, the level of evidence for ONS in cluster headache is U, said Dr. Tepper.
The St. Jude Genesis ONS device received a CE mark for chronic migraine in Europe, but the mark subsequently was rescinded because of problems such as electrode migration, dysesthesias, cable discomfort, muscular spasms, infection, and battery depletion. This development “suggests the degree of problems with ONS for the future,” said Dr. Tepper.
Deep Brain Stimulation
Researchers have studied deep brain stimulation (DBS), another invasive technique, in 14 case series that included 65 patients with cluster headache. At a mean follow-up of 2.8 years, 31% of patients were pain-free. Approximately one-third of patients had a reduction of headache intensity of at least 50%. In a study of 17 patients with cluster headache who were followed up for 8.7 years, 35% had sustained, significant improvement.
The adverse events of DBS can be serious, however. Increasing the voltage too quickly may result in oculomotor disturbance and vertigo. One patient receiving DBS had a fatal intracerebral hemorrhage, and others have had transient ischemic attack and stroke. The level of evidence for DBS in cluster headache is U because of a lack of randomized controlled trials, “but it does appear to work,” concluded Dr. Tepper.
—Erik Greb
