Neuromodulation of chronic headaches

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Neuromodulation of chronic headaches: position statement from the European Headache Federation

Authors: Paolo Martelletti, Rigmor H Jensen, Andrea Antal, Roberto Arcioni, Filippo Brighina, Marina de Tommaso, Angelo Franzini, Denys Fontaine, Max Heiland, Tim P Jürgens1, Massimo Leone, Delphine Magis, Koen Paemeleire, Stefano Palmisani, Walter Paulus and Arne May.

The Journal of Headache and Pain 2013, 14:86


To provide a consensus statement on the clinical use of neuromodulation in headache, based on theoretical background, clinical data and side effects of each method.


The various invasive and non-invasive approaches, such as hypothalamic deep brain stimulation, occipital nerve stimulation, stimulation of sphenopalatine ganglion, cervical spinal cord stimulation, vagus nerve stimulation, transcranial direct current stimulation, repetitive transcranial magnetic stimulation, and transcutaneous electrical nerve stimulation are discussed taken into account the different aspects given above.


Regarding VNS, only smaller open case series exist. In a retrospective survey, three of four patients with implanted VNS reported a substantial improvement of migraine frequency and pain scores. One of the 4 patients became migraine-free 1 month after the onset of VNS. A second patient had a reduction of >50% in both frequency and severity. A third patient reported >50% reduction in frequency. The final patient had a slight reduction in both frequency and severity. Improvement was reported to start 1 to 3 months after initiation of therapy. In another retrospective study, eight of ten patients with migraine had a 50% or more reduction in headache frequency, with five of them completely headache free in the 6 months after treatment initiation, with improvement occurring in the first 3 months following stimulator placement . A case series reported a good response to VNS in two of four patients with chronic migraine (one with a subdiagnose of basilar-type migraine (BTM) and hemiplegic migraine (HM) and the other with BTM) and in two patients with CCH [98]. Interestingly, the application of a non-invasive VNS device is recommended. The left auricular branch of the vagal nerve located medially of the tragus at the entry of the acoustic meatus can be stimulated electrically, as well as the vagal nerve itself.


This international consensus further gives recommendations for future studies on these new approaches. In spite of a growing field of stimulation devices in headaches treatment, further controlled studies to validate, strengthen and disseminate the use of neurostimulation are clearly warranted. Consequently, until these data are available any neurostimulation device should only be used in patients with medically intractable syndromes from tertiary headache centers either as part of a valid study or have shown to be effective in such controlled studies with an acceptable side effect profile.
The medical treatment of patients with chronic primary headache syndromes (chronic migraine, chronic tension-type headache, chronic cluster headache, hemicrania continua) is challenging as serious side effects frequently complicate the course of medical treatment and some patients may be even medically intractable. When a definitive lack of responsiveness to conservative treatments is ascertained and medication overuse headache is excluded, neuromodulation options can be considered in selected cases. Here, are extensively published although proper RCT-based evidence is limited. The European Headache Federation herewith provides a consensus statement on the clinical use of neuromodulation in headache, based on theoretical background, clinical data, and side effect of each method.

Comments reviewer, Prof Van Nieuwenhuizen:

In this paper, different forms of neurostimulation in the treatment of chronic headache are discussed. The results of hypothalamic stimulation, occipital nerve stimulation , stimulation of the sphenopalatine ganglion, transcranial direct current stimulation, repetitive transcranial magnetic stimulation , transcutaneous stimulation of cranial nerves, spinal cord stimulation and vagal nerve stimulation (VNS) are analysed. Regarding the latter, it is too early to draw any conclusion on the efficacy of VNS in chronic headache as randomized placebo controlled trials are lacking. So: until now, no firm conclusion on the efficacy of VNS in chronic headache can be drawn.

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