title: A six year retrospective review of occipital nerve stimulation practice--controversies and challenges of an emerging technique for treating refractory headache syndromes.
abstract: BACKGROUND
  A retrospective review of patients treated with Occipital Nerve Stimulation (ONS) at two large tertiary referral centres has been audited in order to optimise future treatment pathways.
  
  
  METHODS
  Patient's medical records were retrospectively reviewed, and each patient was contacted by a trained headache expert to confirm clinical diagnosis and system efficacy. Results were compared to reported outcomes in current literature on ONS for primary headaches.
  
  
  RESULTS
  Twenty-five patients underwent a trial of ONS between January 2007 and December 2012, and 23 patients went on to have permanent implantation of ONS. All 23 patients reached one-year follow/up, and 14 of them (61%) exceeded two years of follow-up. Seventeen of the 23 had refractory chronic migraine (rCM), and 3 refractory occipital neuralgia (ON). 11 of the 19 rCM patients had been referred with an incorrect headache diagnosis. Nine of the rCM patients (53%) reported 50% or more reduction in headache pain intensity and or frequency at long term follow-up (11-77 months). All 3 ON patients reported more than 50% reduction in pain intensity and/or frequency at 28-31 months. Ten (43%) subjects underwent surgical revision after an average of 11 ± 7 months from permanent implantation - in 90% of cases due to lead problems. Seven patients attended a specifically designed, multi-disciplinary, two-week pre-implant programme and showed improved scores across all measured psychological and functional parameters independent of response to subsequent ONS.
  
  
  CONCLUSIONS
  Our retrospective review: 1) confirms the long-term ONS success rate in refractory chronic headaches, consistent with previously published studies; 2) suggests that some headaches types may respond better to ONS than others (ON vs CM); 3) calls into question the role of trial stimulation in ONS; 4) confirms the high rate of complications related to the equipment not originally designed for ONS; 5) emphasises the need for specialist multidisciplinary care in these patients.
authors.affiliation: Pain Management & Neuromodulation Centre, Guy's & St Thomas NHS Trust, London, UK. palmisani@gmail.com.
authors.forename: Stefano
authors.initials: S
authors.lastname: Palmisani
authors.forename: Adnan
authors.initials: A
authors.lastname: Al-Kaisy
authors.forename: Roberto
authors.initials: R
authors.lastname: Arcioni
authors.forename: Tom
authors.initials: T
authors.lastname: Smith
authors.forename: Andrea
authors.initials: A
authors.lastname: Negro
authors.forename: Giorgio
authors.initials: G
authors.lastname: Lambru
authors.forename: Vijay
authors.initials: V
authors.lastname: Bandikatla
authors.forename: Eleanor
authors.initials: E
authors.lastname: Carson
authors.forename: Paolo
authors.initials: P
authors.lastname: Martelletti
mesh_terms: D004599:Electric Stimulation Therapy / Q000009:adverse effects* / Q000379:methods*; D004567:Electrodes, Implanted / Q000009:adverse effects; D004868:Equipment Failure; D005260:Female; D020773:Headache Disorders / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012086:Reoperation; D012189:Retrospective Studies; D012886:Skull; D016896:Treatment Outcome
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