In cluster headache, neuromodulation is offered when patients are refractory to pharmacological prophylaxis. Non-invasive peripheral neuromodulatory approaches are of interest. We will focus on these and particularly on nociception specific, transcutaneous supraorbital nerve stimulation.
In a study using the nociception specific blink reflex, we made a serendipitous discovery, notably the potential prophylactic effect of bilateral, time contingent, nociception specific, transcutaneous stimulation of the supraorbital nerve.
We report on a case series of seven cluster headache patients, in whom attacks seemed to disappear during repeated stimulation of the supraorbital nerves. Three patients stopped experiencing attacks since study participation.
Bilateral, time contingent, nociception specific, transcutaneous supraorbital nerve stimulation may have a prophylactic effect in episodic and chronic cluster headache. Given its limited side effects and its non-invasive nature, further studies to investigate this potential peripheral neuromodulatory approach for both episodic and chronic cluster headache are warranted.
“The ‘gate-control theory’ of Melzack and Wall deals with the influence of a competition between nociceptive and innocuous signals on second-order neurons (10-11), the latter signals transmitted by A-beta fibers. One may question the applicability of this theory to NSTS of the supraorbital nerve, in which nociception specific stimulation of trigeminal A-delta afferents seem to suppress the transmission of the other nociceptive (i.e. headache) signal on a segmental level.”
The parameters used were monophasic 200 Hz train of three 0.5 ms pulses, working up to 2.1 mA given on average 6 times at 2 hour intervals. They were using a type of electrical current they wanted to be painful and testing for a blink response. It was serendipity that they found the cluster headaches went away. Cluster headaches are a particularly painful and problematic variety, so it is good to see potential here from a treatment that is non-invasive and at least in this small sample seems to have worked quite well.
I generally favor alternating current to the monophasic current used in this study, largely because it feels better. However, it certainly is an interesting finding and should perhaps be compared to alternating currents being applied transcutaneously to the supraorbital nerve. I would like to see how it compares to suboccipital stimulation, as well as to the combination of the two for cluster headaches, migraines, tension, and cervicogenic headaches. I have been noticing a very good effect with the latter three. It is also interesting that the headache prevention may not be due to gate-control theory.
As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.
Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.