Occipital nerve stimulation (ONS) is a therapy form in which headache and craniofacial pain treats effectively.
It consists of implantable device with electrode and pulse generator therapy.
The lead is placed in subcutaneous tissues near occipital nerves, while the pulse generator is implanted in a chest pocket.
Before implantation, a trial involves placing leads under the skin connected to an external battery.
Trial conducted under sedation as patient discharged same day. Patient documents pain diary after 4 to 7 days of therapy.
Implant permanent device only after patient shows significant pain improvement.
A clinical specialist programs the device, evolving since 1993 for intractable occipital headache syndromes, with robust data support.
Neurostimulation is FDA-approved for select pain syndromes, but remains off-label for headache, chronic migraine, and craniofacial pain treatment.
Neuromodulation theory involves therapeutic electrical or chemical alterations in nervous system activity
ONS is a reversible and adjustable neuromodulation tailored to individual needs.
Gate control theory by Melzack and Wall in 1965 suggests a mechanism for ONS in treating local neuropathic pain.
Continuous firing of unmyelinated afferents maintains pain, but increased activation of large and myelinated afferents closes the gate.
Indications
Chronic Migraine
Occipital Neuralgia
Cluster Headache (Chronic & Refractory Cases)
Chronic Daily Headache
Post-Traumatic Headache
New daily persistent headache
Hemicranias continua
Cervicogenic Headache
Intractable primary and secondary headache disorder
Neuropathic pain involving the occipital or suboccipital region
Contraindications
Device not implanted if patient’s quality of life does not improve.
Patient’s headaches linked to medication or opioid use may disqualify them from implantation, despite trial period quality-of-life improvement.
Active infection
Bleeding disorders or anticoagulation therapy
Uncontrolled epilepsy or seizure disorders
Severe psychiatric disorders
Allergy to implant components
Pacemakers or other implanted electronic devices
Severe cervical spine pathology
Previous neck surgery or trauma
Pregnancy or planned pregnancy
Chronic pain disorders with psychological overlay
Outcomes
Long-term studies show that over 150 implant patients rated 75% as good or excellent for pain relief, with 15% fair and 10% poor ratings.
Studies show 40 to 70% of patients experience ≥50% headache reduction and improved quality of life.
ONS is effective for identified occipital nerve pathology about 50% of chronic cluster headache patients see improvement.
Long-term studies show benefits, but tolerance may develop in patients.
Reprogramming and adjustments ensure efficacy. Improves mood and mental health for those with chronic pain anxiety.
Equipment required
Surgical equipment
Neurostimulation equipment
Leads
Implantable pulse generator
Imaging and monitoring equipment
Patient Preparation
Local anesthesia applied at incision sites. Secure the leads to the skin using a 2-0 nylon drain stitch.
Patients mostly choose the off-label implantable pulse generator system. Battery life depends on amplitude used and daily usage hours of the device.
Primary lithium-ion batteries last 3-5 years, while rechargeable ones can last 7-9 years before replacement.
Patient positioning varies laterally or prone; head on horseshoe headrest with slight cervical spine flexion based on incision.
Percutaneous lead inserted fluoroscopically with patient sedated. Entry point should be 1 cm above mastoid tip, with trajectory directed towards odontoid process.
Place the electrode in the superficial subcutaneous fat to avoid the dermis and fascia.
Patients reported immediate stimulation in occipital nerve distribution using 1 to 4 volts settings.
Trial success requires over 50% pain improvement, fewer headache days, or enhanced quality of life.
Informed Consent:
Explain the procedure’s risks and potential complications clearly to the patient.
Patient Positioning
Patient positioning is lateral or prone based on incision.
Trial Phase
A short incision is made at the upper neck. An introducer sheath is used to insert percutaneous leads.
Electrodes are positioned parallel to the occipital nerves.
The device is activated to ensure the patient feels paresthesia in the occipital region.
Leads connect to an external stimulator for a 5-to-7-day pain relief trial.
Permanent Implantation:
Leads are tunnelled subcutaneously from the occipital region to the pulse generator site.
A subcutaneous pocket is created, and the implantable pulse generator (IPG) is placed then IPG is connected to the leads and secured.
Device offers tailored stimulation settings with adjustable options.
Occipital nerve stimulation showing nerve cells in brain
Occipital nerve stimulation (ONS) is a therapy form in which headache and craniofacial pain treats effectively.
It consists of implantable device with electrode and pulse generator therapy.
The lead is placed in subcutaneous tissues near occipital nerves, while the pulse generator is implanted in a chest pocket.
Before implantation, a trial involves placing leads under the skin connected to an external battery.
Trial conducted under sedation as patient discharged same day. Patient documents pain diary after 4 to 7 days of therapy.
Implant permanent device only after patient shows significant pain improvement.
A clinical specialist programs the device, evolving since 1993 for intractable occipital headache syndromes, with robust data support.
Neurostimulation is FDA-approved for select pain syndromes, but remains off-label for headache, chronic migraine, and craniofacial pain treatment.
Neuromodulation theory involves therapeutic electrical or chemical alterations in nervous system activity
ONS is a reversible and adjustable neuromodulation tailored to individual needs.
Gate control theory by Melzack and Wall in 1965 suggests a mechanism for ONS in treating local neuropathic pain.
Continuous firing of unmyelinated afferents maintains pain, but increased activation of large and myelinated afferents closes the gate.
Chronic Migraine
Occipital Neuralgia
Cluster Headache (Chronic & Refractory Cases)
Chronic Daily Headache
Post-Traumatic Headache
New daily persistent headache
Hemicranias continua
Cervicogenic Headache
Intractable primary and secondary headache disorder
Neuropathic pain involving the occipital or suboccipital region
Device not implanted if patient’s quality of life does not improve.
Patient’s headaches linked to medication or opioid use may disqualify them from implantation, despite trial period quality-of-life improvement.
Active infection
Bleeding disorders or anticoagulation therapy
Uncontrolled epilepsy or seizure disorders
Severe psychiatric disorders
Allergy to implant components
Pacemakers or other implanted electronic devices
Severe cervical spine pathology
Previous neck surgery or trauma
Pregnancy or planned pregnancy
Chronic pain disorders with psychological overlay
Long-term studies show that over 150 implant patients rated 75% as good or excellent for pain relief, with 15% fair and 10% poor ratings.
Studies show 40 to 70% of patients experience ≥50% headache reduction and improved quality of life.
ONS is effective for identified occipital nerve pathology about 50% of chronic cluster headache patients see improvement.
Long-term studies show benefits, but tolerance may develop in patients.
Reprogramming and adjustments ensure efficacy. Improves mood and mental health for those with chronic pain anxiety.
Surgical equipment
Neurostimulation equipment
Leads
Implantable pulse generator
Imaging and monitoring equipment
Local anesthesia applied at incision sites. Secure the leads to the skin using a 2-0 nylon drain stitch.
Patients mostly choose the off-label implantable pulse generator system. Battery life depends on amplitude used and daily usage hours of the device.
Primary lithium-ion batteries last 3-5 years, while rechargeable ones can last 7-9 years before replacement.
Patient positioning varies laterally or prone; head on horseshoe headrest with slight cervical spine flexion based on incision.
Percutaneous lead inserted fluoroscopically with patient sedated. Entry point should be 1 cm above mastoid tip, with trajectory directed towards odontoid process.
Place the electrode in the superficial subcutaneous fat to avoid the dermis and fascia.
Patients reported immediate stimulation in occipital nerve distribution using 1 to 4 volts settings.
Trial success requires over 50% pain improvement, fewer headache days, or enhanced quality of life.
Informed Consent:
Explain the procedure’s risks and potential complications clearly to the patient.
Patient positioning is lateral or prone based on incision.
A short incision is made at the upper neck. An introducer sheath is used to insert percutaneous leads.
Electrodes are positioned parallel to the occipital nerves.
The device is activated to ensure the patient feels paresthesia in the occipital region.
Leads connect to an external stimulator for a 5-to-7-day pain relief trial.
Permanent Implantation:
Leads are tunnelled subcutaneously from the occipital region to the pulse generator site.
A subcutaneous pocket is created, and the implantable pulse generator (IPG) is placed then IPG is connected to the leads and secured.
Device offers tailored stimulation settings with adjustable options.
Occipital nerve stimulation showing nerve cells in brain
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