Dual occipital and supraorbital nerve stimulation for chronic migraine: a single-center experience, review of literature, and surgical considerations.

Occipital nerve stimulation (ONS) has been studied in a few clinical trials for the treatment of chronic migraine (CM) with failure to prove sufficient efficacy. To date, peripheral nerve stimulation for the treatment of primary headache is limited to off-label use only. The authors report their institutional experience in CM therapy with combined ONS and supraorbital nerve stimulation (SONS). Fourteen patients treated with dual ONS and SONS for CM were studied with follow-up ranging from 3 to 60 months. Seventy-one percent achieved successful stimulation as defined by a 50% or greater decrease in pain severity. The mean reduction in headache-related visual analog scale (VAS) score was 3.92 ± 2.4. Half of the patients also had resolution of migraine-associated neurological symptoms and returned to normal functional capacity. The main adverse events included lead migration (42.8%), supraorbital lead allodynia (21.4%), and infection (14.2%) with a resulting high reoperation rate (35.7%). The authors' stimulation efficacy was superior to the combined 33% positive response rates (≥ 50% pain reduction) in the published studies of ONS for CM. This is likely due to the fact that topographical paresthesia induced by combined ONS and SONS covers the area of migraine pain better than ONS alone. The authors also discuss effective surgical techniques to prevent patient morbidity.