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Michigan Head & Neck Institute

TMJ Blog

09. 29. 2017

TMJ

Peripheral Nerve Field Stimulation

We have all had headaches before, but what about migraines? Chronic migraine (CM) is characterized by having more than 15 migraine episodes per month, lasting for a minimum of 3 months in a row. CM is 3 times more prevalent in women than men, and typically more severe. Women report greater disability, longer duration, greater frequency, and increased recovery time.

peripheral nerve field stimulation

This disabling condition can be partially managed with conservative treatments, but when those conservative treatments fail, another option is Occipital Nerve Stimulation (ONS). ONS is an innovative treatment for headache disorders, as it reduces muscle tension. Originally, ONS was used in the treatment of occipital neuralgia (chronic pain in the upper neck, back of the head and behind the eyes, corresponding to the locations of the lesser and greater occipital nerves). ONS can also be used to treat facial pain, cluster headaches, and Cephalgia related to TMD. It is still considered somewhat experimental for the treatment of CM, but there are more and more studies being performed with good results.

The pain of occipital neuralgia usually arises from trauma to or entrapment of the occipital nerve, but the pain may also arise from the spine.

At Michigan Head & Neck Institute, Dr. Klein uses masticatory cervical muscle therapy and injections to reduce pressure on the entrapped greater occipital nerve, which then significantly reduces  jaw clenching due to Cervicogenic Cephalgia (headache/pain). Cervicogenic headache is often a sequela of head or neck injury, but may also occur in the absence of trauma. Symptoms are similar to tension-type headache or migraine, diagnosing these can be challenging.

Predominantly in women, migraine (with aura, specifically) has been identified as a risk factor for vascular disorders. Additionally, some comorbidities of migraine include asthma, depression, anxiety and other chronic pain conditions.

“Migraine is not just a headache. Migraine is a common, complex neurovascular disorder that likely involves neuronal hyperexcitability with a cascade effect of cellular depolarization called cortical spreading depression and associated vascular changes. Several previous studies have demonstrated an increased risk of ischemic stroke with migraine.” -Tricia C Elliott MD, FAAFP

Dr. Robert Weiner and Dr. Kenneth Reed first introduced ONS for the treatment of headache in 1999, performed with equipment that is normally used for Spinal Cord Stimulation (SCS). Dr. Weiner is internationally recognized for pioneering surgical procedures in the treatment of various chronic pain syndromes, and specializes in treating chronic pain syndrome, headaches and trigeminal neuralgia. Dr. Reed specializes in Peripheral Nerve Stimulation and is board certified in pain management treatment, anesthesiology and internal medicine.

The ONS procedure involves inserting electrodes and leads (secured to connective tissue with anchors) into the epidural space and powering them (externally) via an implantable pulse generator (IPG) linked to a remote. The IPG can be located at the buttock, thoracic region, or lower abdomen. Patients control the ONS (turn on/off) and adjust the stimulation with a handheld remote control.

occipital nerve stimulation

This procedure is typically performed in two stages. The first stage, carried out under local anesthesia with sedation, is used to test the stimulation and determine optimal placement of electrodes. The second part, which involves insertion of the rest of the ONS system, is carried out under general anesthesia.

Patients who would be excluded from this kind of therapy meet the following criteria:

• Confirmed pregnancy, or the desire to get pregnant soon
• Significant psychological problems
• Pervious surgeries in the occipital region
• Recent or current drug/alcohol abuse
• Frequent need for MRI
• Received nerve block injections in the last 3 months
• Participation in other clinical trials

Recent studies:

For patients with chronic migraine (CM), peripheral nerve stimulation of the occipital nerves reduces the number of headache days, according to a study published online October 25, 2016 in Pain Practice. HealthDay News article (10/28/16)

Nagy A. Mekhail, M.D., Ph.D., from the Cleveland Clinic, and colleagues implanted 20 patients at a single center with a neurostimulation system, and overall, the researchers observed a reduction in the number of headache days per month. All patients had reductions in Migraine Disability Assessment and Zung Pain and Distress scores. “Our results support the 12-month efficacy of 20 CM patients receiving peripheral nerve stimulation of the occipital nerves in this single-center trial,” the authors write. (7/8/16)

References

Lambru G, Matharu MS. Occipital nerve stimulation in primary headache syndromes. Therapeutic Advances in Neurological Disorders. 2012;5(1): 57-67.

Saper JR, Dodick DW, Silberstein SD, McCarville S, Sun M. Occipital nerve stimulation for the treatment of intractable chronic migraine headache: ONSTIM feasibility study. Cephalgia. 2011;31(3):271-285.

Paemeleire K, Bartsch T. Occipital nerve stimulation for headache disorders. Neurotherapeutics. 2010; 7(2):213-219.

Jasper JF, Hayek SM. Implanted occipital nerve stimulators. Pain Physician. 2008;11:187-200.
Schwedt TJ. Occipital nerve stimulation for medically intractable headache. Curr Pain Headache Rep. 2008 Jan;(1):62-6.

Marchioretto F, Serra G. Nerve Stimulation for Chronic Migraine: A Randomized Trial. Pain Physician. 2012;15:245-253.

Vetvik, KG et al. Sex differences in the epidemiology, clinical features, and pathophysiology of migraine. The Lancet Neurology. 2016 Nov; 16(1):76-87.

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The contents of this website, such as text, graphics, images, and other materials are for informational purposes only. While there are many commonalities among multiple TMD and sleep apnea cases, each patient is unique. Information on this website should be used to educate the reader about what they should discuss with their doctor if they are suffering from the listed symptoms. The information is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Seek the advice of your physician or you may call our office with any questions you may have regarding TMD or sleep apnea. If you think you may have a medical emergency, call your doctor or 911 immediately.


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