Richard S. Zimmerman

Occipital nerve stimulation for chronic headache - Long-term safety and efficacy

The aim of this study was to examine the safety and efficacy of occipital nerve stimulation for medically intractable headache. Electrical stimulation of large sensory afferents has an antinociceptive effect. Occipital nerve stimulation may be effective for the treatment of medically intractable headache. Retrospective analysis was performed of 15 patients with medically refractory headache who underwent implantation of an occipital nerve stimulator. Pre- and postimplant data regarding headache frequency, severity, disability, depression and post-stimulator complications were collected. Twelve patients were female and three male. Ages ranged from 21 to 52 years (mean 39 years). Eight patients had chronic migraine, three chronic cluster, two hemicrania continua and two had post-traumatic headache. Eight patients underwent bilateral and seven had unilateral lead placement. Patients were measured after 5-42 months (mean 19). All six mean headache measures improved significantly from baseline (P < 0.03). Headache frequency per 90 days improved by 25 days from a baseline of 89 days; headache severity (0-10) improved 2.4 points from a baseline of 7.1 points; MIDAS disability improved 70 points from a baseline of 179 points; HIT-6 scores improved 11 points from a baseline of 71 points; BDI-II improved eight points from a baseline of 20 points; and the mean subjective percent change in pain was 52%. Most patients (60%) required lead revision within 1 year. One patient required generator revision. Occipital nerve stimulation may be effective in some patients with intractable headache. Surgical revisions may be commonly required. Safety and efficacy results from prospective, randomized, sham-controlled studies in patients with medically refractory headache are needed.

Two‐year seizure reduction in adults with medically intractable partial onset epilepsy treated with responsive neurostimulation: Final results of the RNS System Pivotal trial

To demonstrate the safety and effectiveness of responsive stimulation at the seizure focus as an adjunctive therapy to reduce the frequency of seizures in adults with medically intractable partial onset seizures arising from one or two seizure foci.

Seizure Prophylaxis in Patients With Brain Tumors: A Meta-analysis

OBJECTIVE To assess whether antiepileptic drugs (AEDs) should be prescribed to patients with brain tumors who have no history of seizures. METHODS We performed a meta-analysis of randomized controlled trials (1966-2004) that evaluated the efficacy of AED prophylaxis vs no treatment or placebo to prevent seizures in patients with brain tumors who had no history of epilepsy. Summary odds ratios (ORs) were calculated using a random-effects model. Three subanalyses were performed to assess pooled ORs of seizures in patients with primary glial tumors, cerebral metastases, and meningiomas. RESULTS Of 474 articles found in the initial search, 17 were identified as primary studies. Five trials met inclusion criteria: patients with a neoplasm (primary glial tumors, cerebral metastases, and meningiomas) but no history of epilepsy who were randomized to either an AED or placebo. The 3 AEDs studied were phenobarbital, phenytoin, and valproic acid. Of the 5 trials, 4 showed no statistical benefit of seizure prophylaxis with an AED. Meta-analysis confirmed the lack of AED benefit at 1 week (OR, 0.91; 95% confidence interval [CI], 0.45-1.83) and at 6 months (OR, 1.01; 95% CI, 0.51-1.98) of follow-up. The AEDs had no effect on seizure prevention for specific tumor pathology, including primary glial tumors (OR, 3.46; 95% CI, 0.32-37.47), cerebral metastases (OR, 2.50; 95% CI, 0.25-24.72), and meningiomas (OR, 0.62; 95% CI, 0.10-3.85). CONCLUSIONS No evidence supports AED prophylaxis with phenobarbital, phenytoin, or valproic acid in patients with brain tumors and no history of seizures, regardless of neoplastic type. Subspecialists who treat patients with brain tumors need more education on this issue. Future randomized controlled trials should address whether any of the newer AEDs are useful for seizure prophylaxis.

Frequency of seizures in patients with newly diagnosed brain tumors: A retrospective review

Brain tumors may lead to symptomatic epilepsy. A retrospective analysis was undertaken to evaluate the frequency of seizure as the presenting symptom leading to brain tumor diagnosis in adults. One hundred and forty-seven consecutive patients with newly diagnosed brain tumors were analyzed regarding the frequency of seizures as the initial presenting symptoms and those subsequently developing seizures. One hundred twelve patients had primary central nervous system tumors (CNS) and 35 had metastatic lesions. Statistical evaluation was carried out using the Chi-square test with p values of <0.05 considered to be statistically significant. Astrocytomas and meningiomas were the most common primary CNS tumors in this study. Of these, oligodendrogliomas and grade 2 astrocytomas were significantly more likely to present with seizures (p<0.001). Seizures were a frequent presenting symptom, occurring in over 38% of those with primary brain neoplasms and 20% of those with cerebral metastases. Primary location of tumor also correlated amongst primary CNS tumors and was associated with a trend in seizure risk: parietal (80%); temporal (74%); frontal (62%); and occipital (0%) (p<0.5). The findings highlight the importance of obtaining appropriate evaluation for underlying malignancy in adults with new-onset seizures as well as provide more information to the patient for prognosis and counseling.

Occipital Nerve Stimulation for Chronic Cluster Headache and Hemicrania Continua: Pain Relief and Persistence of Autonomic Features:

The trigeminal autonomic cephalgias (TACs) and hemicrania continua are primary headache disorders characterized by pain in a unilateral trigeminal distribution that occurs in conjunction with prominent ipsilateral cranial autonomic features (1). Cluster headache, paroxysmal hemicrania and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) are classified as TACs, while hemicrania continua is considered a separate primary headache disorder. The autonomic features and first (ophthalmic) division pain have been assumed to be interdependent. Autonomic features have been considered the result of activation of first-division nociceptive afferents, which, through a functional brainstem connection between the trigeminal nucleus caudalis and superior salivatory nucleus, leads to activation of parasympathetic efferents (2). However, this interdependence has been challenged by reports of patients with typical cluster headache without autonomic features, patients with autonomic features without cephalgia, patients with continuing autonomic features without pain after trigeminal root section and patients who report the appearance of autonomic features prior to onset of pain (3–6). Herein we report one patient with chronic cluster and one with hemicrania continua who experienced persistence of autonomic features in the absence of head pain after placement of an occipital nerve stimulator.

Occipital Nerve Stimulation: Technical and Surgical Aspects of Implantation

The objective of this article is to review the surgical aspects of occipital stimulation. Since 1999 there has been a growing interest in neuromodulation of the distal branches of C2‐3 in an effort to treat refractory headache disorders. This is accomplished via implantation of subcutaneous electrodes to stimulate peripheral nerves in the occipital region. “Occipital nerve stimulation” is a term generically used to describe the technique. Mechanisms and outcome of this modality are beyond the scope of this review, which will focus on the technical aspects of the procedure with its associated complications such as lead migration, localized pain, and infection. The history of peripheral nerve and spinal cord stimulation as pain treatment modalities will be briefly reviewed. The equipment and surgical technique for both trial and permanent implantation of occipital nerve stimulators will be described, in addition to patient selection considerations. The available literature will be summarized and a discussion of future directions will be provided. Occipital nerve stimulation may be an effective minimally invasive treatment modality for refractory headache disorders; clearly, further studies are needed.

Response to occipital nerve block is not useful in predicting efficacy of occipital nerve stimulation

Occipital nerve stimulation (ONS) may be effective for the treatment of headaches that are recalcitrant to medical therapy. The objective of this study was to determine if response to occipital nerve block (ONB) predicts response to ONS in patients with chronic, medically intractable headaches. We evaluated 15 patients who underwent placement of occipital nerve stimulators for the treatment of chronic headaches. Data were collected regarding analgesic response to ONB and to ONS. Nine of 15 patients were ONS responders (≥50% reduction in headache frequency or severity). Thirteen patients had ONB prior to stimulator implantation. Ten of 13 who had ONB had significant relief of head pain lasting at least 24 h, and three were ONB non-responders. Of the three ONB non-responders, two were ONS responders. Of the two patients who did not have ONB prior to ONS, one was an ONS responder and one was an ONS non-responder. In conclusion, analgesic response to ONB may not be predictive of the therapeutic effect from ONS in patients with medically refractory chronic headaches.

Complementary/alternative medicine for epilepsy in Arizona

The NIH defines complementary or alternative medicine (CAM) as those healthcare and medical practices not currently an integral part of conventional medicine. It is estimated that 42% of the US population regularly use some form of CAM therapies for various medical conditions, with nearly 600 million visits made to CAM practitioners at an estimated cost of

Use of Continuous Subcutaneous Insulin Infusion (Insulin Pump) Therapy in the Hospital Setting Proposed Guidelines and Outcome Measures

30 billion a year.1 Despite the commonplace nature of CAM treatments, there are few data regarding the scope of CAM use for seizures and how individuals with epilepsy (IWE), their families, and their health care professionals utilize CAM treatments. The purpose of this study is to begin to define the extent to which CAM treatments are used for epilepsy by surveying Epilepsy Foundation of Arizona (EFAZ) members, a representative sample of IWE, and health professionals that manage them to assess educational needs regarding CAM for IWE and their physicians. A 40-question survey was mailed to the EFAZ membership (n = 3,100) in September 2002, with a second mailing to those individuals who had not responded. IWE, their families, and their health professionals were questioned regarding the level of seizure control and their perceptions on the various CAM treatments for seizures. The instrument collected …

Long‐Term Outcome in Occipital Nerve Stimulation Patients With Medically Intractable Primary Headache Disorders

Purpose Individuals whose diabetes is being treated in the outpatient setting via an insulin pump often wish to maintain this therapy during hospitalization. The authors propose guidelines for management of patients on insulin pumps who require a hospital admission. Methods A collaborative interinstitutional task force reviewed current available information regarding the use of insulin pumps in the hospital. Results There was little information in the medical literature on how to manage individuals on established insulin pump therapy during a hospital stay. The task force believed that a policy that promotes patient independence through continuation of insulin pump therapy while ensuring patient safety was possible. A set of contraindications for continued use of pump therapy in the hospital are proposed. A sample patient consent form and order set are presented. Finally, measures that can be used to assess effectiveness of an inpatient insulin pump policy are outlined. Conclusions Patients on established insulin pump therapy do not necessarily have to discontinue treatment while hospitalized. However, clear policies and procedures should be established at the institutional level to guide continued use of the technology in the acute care setting.