Jasper Joseph F, Hayek Salim M
Advanced Pain Medicine Physicians, Tacoma, WA, USA.
Pain Physician. 2008 Mar-Apr;11(2):187-200.
Chronic headache represents a very significant public health and economic issue. One treatment modality for chronic refractory headache involves the use of subcutaneous implanted neurostimulator leads in the occipital region. Varied types of headache etiologies including migraine, transformed migraine, chronic daily headache, cluster headache, hemicrania continua, occipital neuralgia, and cervicogenic headache have been studied with peripheral nerve field stimulation and found responsive to stimulation of the suboccipital region, known commonly as occipital nerve stimulation (ONS).
To evaluate the strength of evidence that occipital nerve stimulation is an effective treatment of benign headache.
A systematic review of occipital nerve stimulation for the treatment of chronic headache.
A systematic review of the literature through EMBASE and PubMed/Medline for clinical studies was performed. The Agency for Healthcare Research and Quality (AHRQ) criteria was utilized to assess the evidence regarding occipital nerve stimulators and arrives at conclusions as to their efficacy in the treatment of headache. Studies were also graded using AHRQ criteria. The overall body of evidence was then graded on a 5 level scale from Level I (conclusive), Level II (strong), Level III (moderate), Level IV (limited) to Level V (indeterminate).
Ten observational studies, of which 4 were prospective, and a number of case series, case reports, and reviews were identified. No randomized controlled trials (RCT) were identified. All of the articles reported positive outcomes including improved pain relief, reduced frequency, intensity, and duration of headaches with reduced medication consumption. ONS was reportedly successful for 70 - 100% of patients. Reduction of pain in patients with occipital headaches and transformed migraine is significant and rapid; for cluster patients the improvement may be less dramatic and it may take several months of occipital stimulation to achieve relief. No long-term adverse events occurred. Several short-term incidents occurred including infection, lead displacement, and battery depletion. The body of evidence as a whole is a level of strength of IV, limited.
ONS is a useful tool in the treatment of chronic severe headaches with at least Level IV (limited) evidence based on multiple positive studies.
慢性头痛是一个非常重要的公共卫生和经济问题。慢性难治性头痛的一种治疗方式是在枕部区域使用皮下植入式神经刺激器电极。多种类型的头痛病因，包括偏头痛、转化型偏头痛、慢性每日头痛、丛集性头痛、持续性偏侧头痛、枕神经痛和颈源性头痛，已通过周围神经场刺激进行研究，并发现对枕下区域的刺激有反应，通常称为枕神经刺激（ONS）。
评估枕神经刺激是治疗良性头痛的有效方法的证据强度。
对枕神经刺激治疗慢性头痛进行系统评价。
通过EMBASE和PubMed/Medline对临床研究进行文献系统评价。利用医疗保健研究与质量机构（AHRQ）的标准评估有关枕神经刺激器的证据，并得出其治疗头痛疗效的结论。研究也使用AHRQ标准进行分级。然后将整体证据从I级（结论性）、II级（强）、III级（中等）、IV级（有限）到V级（不确定）分为5个等级。
确定了10项观察性研究，其中4项为前瞻性研究，以及一些病例系列、病例报告和综述。未发现随机对照试验（RCT）。所有文章均报告了积极结果，包括疼痛缓解改善、头痛频率、强度和持续时间降低以及药物消耗减少。据报道，ONS对70%至100%的患者有效。枕部头痛和转化型偏头痛患者的疼痛减轻显著且迅速；对于丛集性头痛患者，改善可能不那么显著，可能需要数月的枕部刺激才能缓解。未发生长期不良事件。发生了几起短期事件，包括感染、电极移位和电池耗尽。整体证据强度为IV级（有限）。
基于多项阳性研究，ONS是治疗慢性重度头痛的有用工具，至少有IV级（有限）证据。
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