Interventional Therapy: Occipital Nerve Stimulation for Treatment of Migraine
Those of us in the field of Pain Medicine know that some of the most difficult patients to help are those with intractable migraine headaches. As one by one, the accepted clinical treatments fail them, the depth of isolation these individuals experience is difficult for most of us to imagine. Many are labeled malingerers or emotionally disturbed, a slander that only augments the physical agony they feel. Finally, the most despairing of them take one last, worst action to escape the horror: suicide. For physicians who have experienced this loss, it is humbling and heartbreaking to know that the best efforts of science and compassion have failed to make a difference. Medicine desperately needs a solution for this subset of migraineurs. Drs. Hagen and Bennet are true pioneers in the field of neuroaugmentation. In this article, they provide us with a glimpse of a new technology that may offer relief for some of our patients who experience intractable migraines. Occipital nerve stimulation will not be the answer for all of them, but if it helps even a few, it could be called lifesaving.
Lynn Webster, MD, FACPM, FASAM
"If migraine patients have a common and legitimate complaint besides their migraines, it is that they have not been listened to by physicians. Looked at, investigated, drugged, charged, but not listened to."
Dr. Oliver Sacks, British Neurologist1
James E. Hagen, MSc (left) and Daniel S. Bennett, MD, DABPM (right)
Migraine is a disabling primary headache that impacts millions. This disorder has been reported by 18% of women and 6% of men in the previous year.2 In conjunction with pain, there are often other distressful symptoms such as nausea, vomiting, photophobia, phonophobia, osmophobia, and depression.3
A migraine headache can be unilateral or bilateral, often throbbing in nature, and usually aggravated by physical activity. Sometimes, when severe, the pain is expressed as, band-like, or tight. These headaches can occur at any time but seem to be most common upon arising.
The onset of migraine is usually gradual, but occasionally stabbing pain sensations that last only seconds are superimposed. Migraines can begin either with or without an aura, a transient visual or other sensory phenomenon (i.e., olfactory). Paresthesias occur with aura approximately one-third of the time. These typically start with numbness in the hands followed by symptoms in the lips, face and tongue.4
Pharmacologic treatment of migraine is currently the first-choice therapy for the majority of migraine classes; NSAIDS, triptans, ergot alkaloids, and steroids are commonly utilized. Most neurologists avoid opioids due to fear of opioid abuse, but also because of the rebound effect sometimes seen in opioid management of migraineurs. Avoiding triggers alone can prevent or diminish the severity or frequency of these headaches. Various other treatments include local nerve injections, botulinum toxin, acupuncture, physical therapy, herbal compounds, hypnosis, and dietary changes.
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