Burst occipital nerve stimulation, which does not produce the scalp paraesthesia associated with tonic occipital nerve stimulation, produces good quality analgesia for patients with chronic migraine and chronic cluster headache, according to a study published in Neuromodulation. Larger studies are needed to determine if there are differences in efficacy between the stimulation modes.

Although tonic occipital nerve stimulation is widely used for chronic migraine and chronic cluster headache therapy, the associated scalp paraesthesia can be bothersome and limits treatment. It has been shown that effective analgesia in occipital neuralgia is possible using paraesthesia-free waveforms in spinal cord stimulation, and the current study was designed to determine if the same is possible using burst occipital nerve stimulation for chronic migraine or chronic cluster headache. The study included 12 patients with chronic migraines and 5 patients with chronic cluster headaches who were treated with bilateral burst-pattern occipital nerve stimulation, 4 of whom (1 chronic migraine and 3 chronic cluster headache) had previously had tonic occipital nerve stimulation but required revision surgery due to infection or lead displacement.

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In chronic migraine (mean headache days per month, 26.5), burst occipital nerve stimulation produced a significant mean reduction of headache days per month by 10.2 (P =.002, one-tailed sign test), but the responses were dichotomous, with 4 patients showing no reduction and the other 8 showing a mean reduction of 15 days. In chronic cluster headache (mean cluster attack frequency, 7.6 per day), a 92% reduction was seen in headache attack frequency (P =.013, one-tailed sign test) and a 42% reduction was seen in intensity of residual headaches (P =.023, one-tailed sign test).

Study limitations include the retrospective design, lack of a control group, and patients who were not systematically trialed with both stimulation models.

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Study investigators conclude, “Paraesthesia is not necessary for [occipital nerve stimulation] to be effective in [chronic migraine] and [chronic cluster headache]. The results in this study suggest that paraesthesia-free burst [occipital nerve stimulation] can perform as well as tonic [occipital nerve stimulation] or perhaps better, but larger studies will be required to provide a more accurate comparison of efficacy. Paraesthesia-free stimulation affords the opportunity to perform double-blind trials of [occipital nerve stimulation].”

AL Green and JJ FitzGerald have associations with Abbott.

Garcia-Ortega R, Edwards T, Moir L, Aziz TZ, Green AL, FitzGerald JJ. Burst occipital nerve stimulation for chronic migraine and chronic cluster headache [published online June 14, 2019]. Neuromodulation. doi:10.1111/ner.12977