OCCIPITAL NEURALGIA AND HEADACHE - Health Plan of Nevada

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significant differences between the 2 treatment groups at any time during the study. Eight weeks after the initial treatment, 80% of the patients in the RF-group (Group I) and 66,7% of the patients in the local injection group (Group II) reported a successful treatment in terms of a positive global perceived effect and/or an visual analogue scale (VAS) reduction of at least 50% compared to the initial VAS. Sixteen weeks after the initial treatment, the success rate in Group I was 66,7% compared to 55,3% in Group II. After one year, there was no difference of the success rate in Group I (53,3%) compared to Group II (50%). A relatively high percentage of patients (33,3%) in both groups were not followed anymore because of several reasons. The most important reason was the disappointment in the treatment. (Haspeslagh, 2006) Stovner et al. (2004) conducted a randomized, sham-controlled study of 12 patients with cervicogenic headaches. Six patients underwent radiofrequency neurotomy and six patients received sham treatment. Patients were followed for 2 years. Patients treated with neurotomy were somewhat improved at 3 months, but later follow-up showed no significant differences between the 2 treatment groups. Vanelderen et al. (2010) reported on the results of a prospective trial with 6 months of follow-up in which pulsed radiofrequency treatment of the greater and/or lesser occipital nerve was used to treat occipital neuralgia in 19 patients. Patients presenting with clinical findings suggestive of occipital neuralgia and a positive test block of the occipital nerves with 2 mL of local anesthetic underwent a pulsed radiofrequency procedure of the culprit nerves. Approximately 52.6% of patients reported a score of 6 (pain improved substantially) or higher on the Likert scale after 6 months. No complications were reported. The investigators concluded that pulsed radiofrequency treatment of the greater and/or lesser occipital nerve is a promising treatment of occipital neuralgia. This study warrants further placebo-controlled trials. Halim et al. (2010) conducted a retrospective study that included 86 patients who had undergone lateral C1-2 joint pulsed radiofrequency application, for cervicogenic headache in a single pain center from March 2007 to December 2008. The percentage of patients who had >or=50% pain relief at 2 months, 6 months, and 1 year were 50% (43/86), 50% (43/86), and 44.2% (38/86), respectively. Longterm pain relief at 6 months and 1 year were predicted reliably by >or=50% pain relief at 2 months. Apart from 1 patient that complained of increased severity of occipital headache lasting several hours, there were no other reported complications. The lack of a control group limits the validity of the results of this study. In a clinical audit of 18 chronic cervical pain patients treated with pulsed radiofrequency, satisfactory pain relief of at least 50% was achieved in 72% of the patients at 8 weeks (Van Zundert, 2003). Thirtythree percent of the patients continued with good treatment outcome more than one year after treatment. Govind et al. (2003) studied 49 patients with occipital headaches who underwent percutaneous radiofrequency neurotomy. Eighty-eight percent of the patients achieved a successful outcome (complete relief of pain for at least 90 days). The median duration of relief in these patients was 297 days. Occipital Neuralgia & Headache Page 12 of 21
Lee et al. (2007) assessed the clinical efficacy of radiofrequency (RF) cervical zygapophyseal joint neurotomy in patients with cervicogenic headache. A total of thirty consecutive patients suffering from chronic cervicogenic headaches for longer than 6 months and showing a pain relief by greater than 50% from diagnostic/prognostic blocks were included in the study. These patients were treated with RF neurotomy of the cervical zygapophyseal joints and were subsequently assessed at 1 week, 1 month, 6 months, and at 12 months following treatment. RF neurotomy of the cervical zygapophyseal joints significantly reduced the headache severity in 22 patients (73.3%) at 12 months after the treatment. The limitations of this study were small sample size and lack of a control group. The 2008 Hayes Health Technology Brief on radiofrequency ablation for treatment of cervicogenic headache concluded that the evidence for radiofrequency ablation (RFA) for cervicogenic headache is limited and that no definitive conclusions can be drawn regarding its efficacy and safety. The results were promising in case series studies that included definitive diagnostic nerve blocks as part of the selection criteria. However, the randomized controlled trials failed to show a beneficial effect of RFA. (Hayes, 2008b) Electrical Stimulation In a systematic review, Jasper and Hayek (2008) evaluated the strength of evidence that occipital nerve stimulation (ONS) is an effective treatment of chronic headache. Ten observational studies, of which 4 were prospective, and a number of case series, case reports, and reviews were identified. No randomized controlled trials (RCT) were identified. All of the studies reported positive outcomes including improved pain relief, reduced frequency, intensity, and duration of headaches with reduced medication consumption. ONS was reportedly successful for 70 to 100% of patients. Reduction of pain in patients with occipital headaches and transformed migraine is significant and rapid; for cluster patients the improvement may be less dramatic and it may take several months of occipital stimulation to achieve relief. No long-term adverse events occurred. Several short-term adverse events occurred including infection, lead displacement, and battery depletion. The body of evidence as a whole is a level of strength of IV, limited. Johnstone and Sundaraj (2006) evaluated 8 patients with intractable occipital neuralgia. All patients were offered a trial of percutaneous stimulation and if they achieved 50% pain reduction, a permanent lead was implanted. Seven patients proceeded to a permanent stimulator. The visual analogue score was reduced in 5 of the 7 patients after permanent implantation. In a study conducted by Kapural et al. (2005), 6 patients with treatment refractive chronic headaches were treated with a midline approach for occipital nerve electrical stimulation lead implantation. During the 3-month follow-up, mean visual analog scale scores changed from 8.66 to 2.5, and pain disability index improved from 49.8 to 14.0. The authors concluded that the midline approach has advantages compared with the submastoid approach particularly regarding stability of the system. Slavin et al. (2006) analyzed the records of 14 consecutive patients with intractable occipital neuralgia treated with peripheral neurostimulation. Ten patients proceeded with system internalization after a 50% pain reduction during the trial period. Two patients had their systems explanted because of loss of stimulation effect or significant improvement of pain, and one patient had part of his hardware removed because of infection. The authors concluded that overall, the beneficial effect from chronic Occipital Neuralgia & Headache Page 13 of 21
Page 1 and 2: OCCIPITAL NEURALGIA AND HEADACHE Pr
Page 3 and 4: • Prognostic - to predict the out
Page 5 and 6: CLINICAL EVIDENCE Diagnostic Occipi
Page 7 and 8: Other Headaches Ashkenazi et al. (2
Page 9 and 10: up to 4 blocks. Visual analog scale
Page 11: microdecompression surgery for occi
Page 15 and 16: diagnoses is off-label use. Additio
Page 17 and 18: Anthony M. Headache and the greater
Page 19 and 20: Kapural L, Mekhail N, Hayek SM, et
Page 21: PROTOCOL HISTORY/REVISION INFORMATI

OCCIPITAL NEURALGIA AND HEADACHE - Health Plan of Nevada

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