ONS for chronic headaches
Occipital nerve stimulation (ONS) is an effective treatment for chronic headaches that do not respond to medication, by implanting a device that sends electrical pulses to the occipital nerve.
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Some migraine patients who do not respond to medication experience improvement when Dr. Zeiad Yossry, Professor of Neurosurgery and Parkinson's Disease, stimulates a nerve at the back of the head, just above the neck. This technique, known as occipital nerve stimulation (ONS), involves surgically implanting a small device that sends electrical impulses to the occipital nerve.
What is occipital nerve stimulation (ONS)?
• Occipital nerve stimulation (ONS) aims to deliver a small electrical charge to the occipital nerve to prevent migraines and other types of headaches for patients who have not responded to drug therapy.
• The procedure involves implanting a pulse generator under the skin (in the chest or abdominal wall) and connecting it, through wires, to electrodes placed across one or both of the occipital nerves at the base of the skull.
• Stimulating this nerve interferes with pain signals and restores balance to malfunctioning nerves.
• Stimulation can be applied continuously or intermittently.
When is occipital nerve stimulation used?
Many cases of painful headaches can be effectively treated with occipital nerve stimulation. Chronic headaches are typically defined as pain occurring 15 days or more per month for over three months. Patients with resistant headaches often do not benefit from standard drugs, either due to ineffectiveness, side effects, or contraindications.
ONS is commonly considered for primary headache syndromes where medical treatments have failed, including:
• Chronic migraine, the third most common neurological disorder, affecting around a billion people worldwide.
• Cluster headaches, intense pain around one eye, usually on one side of the head.
• Chronic, refractory primary headaches (without an identifiable structural cause).
• Chronic, refractory secondary headaches (due to structural causes, such as neck injury, infection, or hypertension).
• Occipital neuralgia, a type of nerve pain causing stabbing or electric-shock-like pain in the occipital or suboccipital area, often from prolonged pressure on the second occipital nerve. It is the third most common headache syndrome after migraine and tension headaches.
• Other neck-related headaches.
• Facial and skull pain.
• Nerve injuries (from trauma or previous surgery).
How to prepare for occipital nerve stimulation surgery?
Dr. Zeiad Yossry, Professor of Neurosurgery and Parkinson's Disease, carefully selects candidates for surgery. This is an elective surgery, and patients must be in optimal medical condition (for example, well-controlled diabetes).
It is important to inform Dr. Zeiad Yossry if you experience the following:
• Blood clotting or bleeding disorders.
• Blood clots in the leg (DVT) or lungs (pulmonary embolism).
• Use of warfarin, aspirin, or herbal supplements.
• Hypertension.
• Past or present allergies.
• Any other health problems.
Trial procedure before permanent device implantation:
Under anesthesia, a temporary test is conducted in which electrodes are placed under the skin and connected to an external battery, through the following steps:
• The patient may lie on their side or back, depending on the incision site.
• The medical team positions the patient’s head on a horseshoe-shaped support and slightly bends the cervical spine.
• Dr. Zeiad Yossry inserts an electrical wire through the skin under fluorescence guidance and under anesthesia. The electrode is placed on the superficial side of the subcutaneous fat.
• Next, Dr. Zeiad Yossry inserts the wires into the test cable to begin the programming step.
• Temporary stimulation is performed using a radiofrequency (RF) transmitter, which helps the patient report the location of the stimulation, its intensity, and the type of sensation it produces.
• The patient leaves the hospital on the same day.
The trial period typically ranges from 4 to 7 days. The patient must keep a headache diary to record headaches or pain. Success of the trial is defined as at least a 50% reduction in pain, fewer headache days, or improved quality of life. Permanent implantation is only done if a significant improvement is reported.
How is occipital nerve stimulation surgery performed?
• Dr. Zeiad Yossry, professor of neurosurgery and Parkinson's disease, implants the electrodes into the base of the skull, where the occipital nerves begin. These electrodes are connected to a pulse generator.
• The pulse generator is implanted under the collarbone, buttocks, or abdominal area and generates electrical pulses to the occipital nerve.
• Dr. Zeiad Yossry adjusts and modifies the patient’s stimulation parameters through the external portable programming device.
• Full recovery takes approximately six weeks. During this period, the patient should avoid strenuous activity.
Frequently asked questions about occipital nerve stimulation:
What are the reasons for undergoing occipital nerve stimulation?
Migraines affect 12% of all men and women, with women representing 70% of sufferers. It is estimated that up to 5% of migraine sufferers experience daily or near-daily headaches. Furthermore, 1% to 2% of sufferers have a poor response to drug treatments, which can lead to serious consequences, including drug dependence, severe limitations in daily activities, failure to achieve personal and professional goals, and an overwhelming sense of despair.
Occipital nerve stimulation is a last resort for chronic headaches after medical treatment has failed. It is often recommended when medications and other treatment options are ineffective or when their side effects are severe. In these cases, surgery becomes a valuable option.
Is occipital nerve surgery effective for all types of headaches?
For some of the cases mentioned above, about 60% of patients experience complete headache relief after occipital nerve surgery. Among the remaining patients, headache frequency and intensity are reduced by approximately 50% in 80% to 90% of them.
Will the battery or electrodes need replacement later?
The lifespan of a battery or electrode depends on the total daily usage hours or the device capacity. Typically, a rechargeable battery requires replacement after about 7 to 9 years, while a lithium battery lasts 3 to 5 years without needing to be replaced.
Will I still need painkillers after getting an occipital nerve stimulator?
Patients may require occasional adjustments in programming. Their treatment plan may include pain medication for the first few months to improve pain relief. These medications can be reduced over time.
Occipital nerve stimulation is an effective treatment option for chronic headaches in patients who have failed to respond to conventional medications. Thanks to the expertise of Dr. Zeiad Yossry, Professor of Neurosurgery and Parkinson's Disease, this type of treatment has become available in safe and precise ways. It significantly improves patients’ quality of life and helps reduce daily suffering.
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