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Peripheral nerve stimulation for treatment of chronic headache: a case report.

Introduction

Chronic headaches are vast and varied. They describe a syndrome that includes other primary and secondary headaches such as chronic tension type headaches, chronic migraine headaches, hemicrania continua and chronic cluster headaches. These headaches can affect daily activities. There are multiple treatment strategies with varying efficacies. Currently, limited options exist when headaches prove intractable to analgesic and conventional treatments. In this article, we describe a patient with greater than ten years of chronic headaches resistant to multiple treatment strategies who underwent a trial of peripheral nerve field stimulation. In our discussion and literature review, we discuss neuromodulation and how it is used commonly for chronic pain, intractable to analgesics and conventional treatments for various conditions.

Case Report

A 27 year old female with greater than 10 years of chronic daily headaches was referred for evaluation and treatment by the headache clinic in the Department of Neurology. The patient began experiencing regular headaches in her early teens. The patient was initially diagnosed and treated for migraines. Unfortunately, her symptoms were not well controlled. With time, the headaches increased in severity and frequency. The headaches became a daily occurrence, lasting from hours to days, debilitating her from participating in daily activities. The patient noted symptoms that began in the bilateral occipital and temporal regions, with radiation to the top of her head, which eventually lead to a global headache. She described the pain as throbbing with nausea, vomiting, photophobia and phonophobia. The headaches occurred during the day and also at night, frequently waking her from sleep. Prior to evaluation and treatment at the headache clinic, she had tried multiple regimens including, over-the-counter medications, combination acetaminophen, butalbital, and caffeine, oral contraceptive pills, amitriptyline, propranolol, verapamil, gabapentin, sumpatriptan, frovatriptan, rizatriptan and eletriptan, without significant relief. At the time of evaluation with the headache clinic, she was on topiramate, magnesium, combination of isometheptene mucate, dichloralphenazone, and acetaminophen and as needed oxycodone, which she used 2-3 tablets per week. On multiple occasions, the patient was treated in the emergency room with intravenous morphine, toradol, fluids and anti-emetics. Neuroimaging and diagnostic work ups, including computed tomography and magnetic resonance imaging of the brain and lumbar puncture were all unremarkable.

The headache clinic initially placed the patient on almotriptan, co-enzyme Q10 and quetiapine as needed to her regimen. She was diagnosed with complex migraine with components of occipital neuralgia. Due to continued headache, she was trialed on dexamethasone and venlafexine without significant benefit. She underwent bilateral occipital blocks alone and with trigger point injections of various muscles including the semispinalis capitis with varying results, all with limited duration of benefit. She was then also tried on levetiracetam and underwent onabotulinumtoxinA injections, without benefit.

Due to her refractory response to medical therapy, the patient presented for evaluation. Based on her history of symptoms, exam and responses to previous treatments, we discussed several options, including cryo-analgesia for the occipital neuralgia treatment and peripheral nerve stimulation. The patient elected to try cryo-analgesia of the bilateral greater and lesser occipital nerves, unfortunately without significant benefit. Patient continued to experience pain in the bilateral temporal regions daily, with escalation to a global headache.

Subsequently, the patient underwent a 7 day trial of peripheral nerve stimulation with 3 wire leads (Medtronic Inc., Minneapolis, MN). With the patient in a prone position, the trial leads were placed with the aid of fluoroscopy, via a single needle technique per lead. A 15 gauge curved beveled tuohy needle bent to conform to the patients anatomy, was advanced after minimal subcutaneous local anesthetic infiltration at the C2 vertebral level. The needle was advanced subcutaneously, below the dermis via palpation and with the aid of fluoroscopy. After confirmation of the needle placement, the stylet was removed and the lead was advanced. Then after verification of the lead placement, the tuohy needle was removed. This was repeated at the temporal region bilaterally. Bilateral Quad electrode leads were subcutaneously placed in the posterior temporal region along with a single Octad electrode lead placed subcutaneously around the C2 vertebral level (Figure 1). At follow-up, the patient reported greater than 85% pain relief on a visual analog scale without side effects or complications. The patient continued her topiramate but did not require any additional medications or treatments during the week. As results, she proceeded with permanent implantation. The permanent implantation was performed similarly to the trial except for an incision that is made to visualize and to anchor the lead to the fascia. Then the leads were connected to the battery, all subcutaneously. On initial follow up after the implantation, patient was found to have migration of the right temporal lead superficially requiring revision. On 12 month follow up, the patient noted improved pain relief from the trial period, stating greater than 95% pain relief. She continues to take topiramate but has not needed any breakthrough medications since the permanent implantation.

Discussion and review of literature

Neuromodulation provides a minimally invasive and reversible treatment options for various conditions. Via a trial period, the patient has the ability to access and test the effectiveness prior to permanent implantation.

Neuromodulation, including peripheral nerve field stimulation (PNFS), generally involves selective application of programmable pulse waveform through series of electrodes within a lead to stimulate nerve fibers, subsequently reducing pain. (1) Neuromodulation is commonly used as a treatment option for chronic pain, intractable to analgesics and conventional treatments for various conditions, ranging from failed back syndrome to peripheral vascular disease. (2-7) In PNFS, the leads are subcutaneously placed to stimulate the region of affected nerves, cutaneous afferents or the dermatomal distributions. (8) The combination of PNFS with SCS has been effective in select patients in relieving lower back and leg pain refractory to conventional management.

Bernstein and colleagues presented a case series of twenty patients who were treated with a combination of both SCS and PNFS for lower back and radicular leg pain syndromes. (8) Of the twenty patients, four underwent a trial of SCS with greater than 50% relief of pain overall, but poor buttock/ lower back coverage therefore a combination approach was used at time of permanent implant. Each patient reported improved coverage and pain relief with combination compared to SCS alone. (8) Seven patients with pre-existing SCS system were subsequently given PNFS months or years later to relieve persistent or worsening lower back pain. Each patient reported greater pain relief and improved quality of life with the combination of SCS and PNFS with continued follow-up from 7 to 21 months from time of implant. (8) Nine patients were given a trial using a combination up front, prior to any permanent implant. Different stimulation parameters were programmed using the epidural or the PNFS contacts individually and in combination, patients were able to directly compare the coverage from each modality during the course of the five to seven day trial. (8) Of the combination trial three patients did not proceed with permanent implantation due to dissatisfaction with sensory of stimulation or effectiveness of stimulation in controlling their pain. Two patients identified PNFS as adequate for relieving their pain and underwent permanent implantation of PNFS alone. (8) The other four patients went ahead with permanent implants of the combination of SCS and PNFS, preferring the stimulation combination compared to either modality alone. (8)

The use of PFNS for treatment of craniofacial pain was first observed in the 1960's, when Wall and Sweet reported use of stimulation of infraorbital foramina for pain relief. (9) Since the late 1990's, studies emerged using PNFS as a promising treatment option for various conditions. (10,11)

Weiner and Reed and others have reported successful use of PFNS for treatment of occipital neuralgia (1.2,13) Weiner and Reed reported thirteen patients underwent 17 implant procedures for medically refractory occipital neuralgia using PNFS with follow-up ranging from 1-1/2 to 6 years. Twelve patients continue to report good to excellent response with greater than 50% pain control and requiring little or no additional medications. The 13th patient was subsequently explanted following symptom resolution. (12) Occipital neuralgia is a condition associated with paroxysmal jabbing pain in the distribution of the greater occipital nerves or the third occipital nerve, typically as a result of entrapment of a nerve along it course. (14)

Complex migraine, is often used interchangeably with migraine variants or complicated migraine, defined syndromes associated with episodic, transient, and reversible neurologic dysfunction. However, the term is no longer commonly used. Nevertheless, the treatment can be difficult. Currently, various PNFS, from supraorbital to auriculotemporal nerve stimulation have been reported with successful management of epicranial headaches. (15-18)

Matharu and colleagues reported eight patients with chronic migraine that underwent 12 implant procedures with bilateral suboccipital stimulators. Three patients needed revisions after initial implantation because of lead migration; one of these patients needed two revisions. (17) Of these eight patients, four had excellent response with their headaches completely suppressed with no breakthrough headaches; two patients described their response to stimulation as very good; the headaches are completely suppressed most of the time, though they have breakthrough headaches about 10 days per month, for which they either have to take analgesics or increase the stimulation amplitude. (17) The other two patients continued to have constant headaches but both reported their response to stimulation as good, with the severity of the headaches reduced by 50-75%; one of these patients had derived further benefit from implanted bilateral supraorbital stimulators. (17) All patients reported that they had managed to either completely stop or considerably reduce the headache medications they were taking. (17)

Deshpande and Wininger reported a case report of successful use of PFNS for treatment of headache with combined epicranial temporal and occipital stimulation at the 24-month follow-up. No complications or adverse side effects were reported and more than a 50% reduction in headache onset was reported, and notably, the patient had not experienced the neurologic deficits that defined her migraines. (19)

It has been proposed that the clinical benefit for temporal placement may be based on coverage of the terminal branches of the trigeminal nerves, along with the communicating branches between the auriculotemporal nerve and the lesser occipital nerve. (19-21) The occipital placement at C1 through C3 for pain relief is based on coverage of the greater and lesser occipital nerves as well as pain originating from the cervical region, such as the third occipital nerve. (22) In addition to the direct stimulation of the auriculotemporal nerve with the temporal lead placement, it has been hypothesized by Simopoulos et al that there may be stimulation of both the sphenotemporal and temporal-occipital sutures along with nociceptive fibers transversing the bony sutures of the calavera. (18)

With the growing reports, PNFS may serve as an effective treatment alternative to traditional pain management strategies in refractory headaches for reduction of pain and analgesic use.

Conclusion

This case presentation demonstrates the potential utility of neuromodulation related to chronic daily headaches. Neuromodulation, including peripheral nerve field stimulation, is a commonly used treatment option for various chronic pain conditions when other treatments have proven ineffective. Peripheral nerve field stimulation should be included as part of our armamentarium in the treatment of chronic daily headaches.

References

(1.) Keller T, Krames ES. "On the shoulder of giants": A history of the understandings of pain, leading to the understanding of neuromodulation. Neuromodulation. 2009; 12:77-84

(2.) Holsheimer J. Effectiveness of spinal cord stimulation in the management of chronic pain: analysis of technical drawbacks and solutions. Neurosurgery. 1997; 40:990-996. discussions 996-999.

(3.) Long DM, Erickson D, Campbell J, North R. Electrical stimulation of the spinal cord and peripheral nerves for pain control. A 10-year experience. Appl Neurophysiol. 1981; 44:207-217.

(4.) Shealy CN, Mortimer JT, Reswick JB. Electrical inhibition of pain by stimulation of the dorsal columns: preliminary clinical report. Anesth Analg. 1967; 46:489-491.

(5.) Kumar K, Hunter G, Demeria D. Spinal cord stimulation in treatment of chronic benign pain: challenges in treatment planning and present status, a 22-year experience. Neurosurgery. 2006; 58:481-496. discussion 481-496.

(6.) Tiede JM, Ghazi SM, Lamer TJ, Obray JB. The use of spinal cord stimulation in refractory abdominal visceral pain: case reports and literature review. Pain Pract. 2006; 6:197-202.

(7.) Kim CH, Issa MA. Spinal cord simulation for the treatment of chronic renal pain secondary to uretero-pelvic junction obstruction. Pain Physician 2011; 14:55-59.

(8.) Bernstein CA, Paicus RM, Barkow SH, Lempert-CohenC. Spinal cord stimulation in conjunction with peripheral nerve field stimulation for the treatment of low back and leg pain: A case series. Neuromodulation 2008;11:116-123.

(9.) Wall PD, Sweet WH. Temporary abolition of pain in man. Science 1967; 155:108-9.

(10.) Stanton-Hicks M, Salamon J. Stimulation of the central and peripheral nervous system for the control of pain. J Clin Neurophysio 1997; 14:46-62.

Please contact the corresponding author for a complete list of references.

Adam Green, MD

West Virginia University School of Medicine

Mohammed A. Issa, MD

Yale University School of Medicine

Chong H. Kim, MD

West Virginia University School of Medicine

Corresponding Author: Adam Green, MD, 1075 Van Voorhis Road, Suite 150, Morgantown, WV 26505; greena@wvuhealthcare.com
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Title Annotation:Scientific Article
Author:Green, Adam; Issa, Mohammed A.; Kim, Chong H.
Publication:West Virginia Medical Journal
Article Type:Report
Geographic Code:1U5WV
Date:Nov 1, 2013
Words:2174
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