Introduction: Advances in neuromodulation have led to an increase in off-label use of occipital nerve stimulation (ONS) for treatment of headache and craniofacial pain. While various studies have demonstrated considerable long-term pain relief (1-5), there remains little understanding of how devices should be programmed to achieve rapid, optimal pain control.

Methods: A retrospective chart review of 7 patients who have undergone ONS for headache and craniofacial pain at our institution was conducted. At each follow-up appointment, ONS device settings were adjusted until patients reported optimal pain reduction. Lead configuration, pulse width, amplitude, and frequency were extracted from the patient’s ONS device at each follow-up visit.

Results: We have currently obtained data from 14 follow-up visits for 7 patients. The following parameters were adjusted during reprogramming sessions: frequency, amplitude, and pulse width. Optimal pulse width ranged from 287-600 microseconds. Amplitude ranged from 0.5-6.5V and 7.8-10.5mA. Frequency ranged from 30-110Hz. We did not find any trends over time in the mentioned parameters. Regarding lead configuration, we observed that all contacts within the array are used simultaneously, but did not notice a consistent anode/cathode configuration.

Conclusions: While we recognize that changes in device frequency, amplitude, and pulse width are paramount in optimizing ONS devices, the reasons why certain settings optimize some patients and not others remain unknown. With such large ranges in device settings, there currently does not appear to be a certain frequency, pulse width, or amplitude at which all patients experience maximum pain control. As well, programming changes among patients are dissimilar in terms of magnitude and direction. We must continue to analyze settings that report optimal pain control in this population in order to better understand how these parameters affect outcomes. Further investigation will include long-term trending of device parameters in these patients and establishment of finite ranges for optimal pain control.

Patient Care: Our research will improve patient care by objectively quantifying the occipital nerve stimulation parameters of lead configuration, pulse width, amplitude, and frequency at which patients experience optimal pain control. Such understanding will help patients with headache and craniofacial pain best utilize their stimulation devices after implantation.

Learning Objectives: 1) Identify trends in occipital nerve stimulation (ONS) device programming that lead to optimal headache and craniofacial pain control. 2) Understand how changes in lead configuration, pulse width, amplitude, and frequency affect patient pain control. 3) Evaluate how ONS device parameters can be modified to optimize pain relief.

References: 1. Brewer AC, Trentman TL, Ivancic MG, Vargas BB, Rebecca AM, Zimmerman RS, et al: Long-term outcome in occipital nerve stimulation patients with medically intractable primary headache disorders. Neuromodulation 16:557-562; discussion 563-554, 2013 2. Lambru G, Matharu MS: Occipital nerve stimulation in primary headache syndromes. Ther Adv Neurol Disord 5:57-67, 2012 3. Mammis A, Gudesblatt M, Mogilner AY: Peripheral neurostimulation for the treatment of refractory cluster headache, long-term follow-up: case report. Neuromodulation 14:432-435; discussion 435, 2011 4. Palmisani S, Al-Kaisy A, Arcioni R, Smith T, Negro A, Lambru G, et al: A six year retrospective review of occipital nerve stimulation practice--controversies and challenges of an emerging technique for treating refractory headache syndromes. J Headache Pain 14:67, 2013 5. Weiner RL, Reed KL: Peripheral neurostimulation for control of intractable occipital neuralgia. Neuromodulation 2:217-221, 1999