Phenotype of patients responsive to occipital nerve stimulation for refractory head pain

Occipital nerve stimulation (ONS) has been employed off-label for medically refractory head pain. Identification of specific headache diagnoses responding to this modality of treatment is required. Forty-four patients with medically refractory head pain and treated with ONS were invited to participate in a retrospective study including a clinical interview and, if necessary, an indomethacin test to establish the headache phenotype according to the International Classification of Headache Disorders, 2nd edn (ICHD-II). We gathered data from questionnaires before implantation, at 1 month after implantation, and at long-term follow-up. Twenty-six patients consented and were phenotyped. At 1 month follow-up and at long-term follow-up a significant decrease in all pain parameters was noted, as well as in analgesic use. Quality of sleep and quality of life improved. Patient satisfaction was generally high as 80% of patients had ≥ 50% pain relief at long-term follow-up. The overall complication rate was low, but revisions were frequent. After phenotyping, two main groups emerged: eight patients had 'Migraine without aura' (ICHD-II 1.1) and eight patients 'Constant pain caused by compression, irritation or distortion of cranial nerves or upper cervical roots by structural lesions' (ICHD-II 13.12). Overuse of symptomatic acute headache treatments was associated with less favourable long-term outcome in migraine patients. We conclude that careful clinical phenotyping may help in defining subgroups of patients with medically refractory headache that are more likely to respond to ONS. The data suggest medication overuse should be managed appropriately when considering ONS in migraine. A controlled prospective study for ONS in ICHD-II 13.12 is warranted.