Headache has a large prevalence in the general population and approximately in the 4% it is present in the chronic form. It causes individual suffering and it constitutes a major global health issue, as it affects people in working-age.
Chronic headache is, by definition, incompletely responsive to currently available therapies.
Medical therapeutic options to date are limited and management of chronic headache patients results unsatisfactory due to relative efficacy and poor tolerance of pharmacological treatment with secondary hampered patient’s compliance.
Pathophysiology of Chronic headache is not exactly known, since not all chronic headache are medication overuse headache. Chronification process may include both genetic heterogeneity combined to epigenetic complex changes predisposing to headache progression and pharmacological refractoriness.
A direct consequence of repeated headache attacks in predisposed subject is the induction of sensitization process, peripheral and central, with morphological and functional changes as shown by neuroimaging studies that possibly favour and maintain the disorder, supporting the view of headache –migraine in particular- as a progressive disorder.
In the lack and latency of any innovation in the pharmacological treatments, neurostimulation techniques have been firstly applied strictly as a compassionate treatment for the treatment of drug-refractory chronic headache patients, representing a way for broader opportunity of treatment in those refractory and / or unsatisfied with pharmacological and conventional therapy.
Neurostimulation directly approach specific neural network to modulate segmental and suprasegmental activity. This can be achieved by
- Non-invasive neurostimulation options: single-pulse transcranial magnetic stimulation (TMS), non invasive vagus nerve stimulation (nVNS, gammacore®), supraorbital transcutaneous stimulation (cephaly®) and transcranial direct cortical stimulation (tDCS);
- Invasive procedures include occipital nerve stimulation, vagus nerve stimulation (VNS), sphenopalatine ganglion stimulation (SPG) and hypothalamic deep brain stimulation (DBS).
Data supporting their use derive from open-label series and small controlled trial studies.
Lack of adequate placebo hampers adequate randomized controlled trials.
Successful outcome remain a matter of combination of proper patient selection on one hand, education of the patient in dealing with headache on the other.
In time of individualized-medicine differentiated novel approaches should be pursuit to improve tailored treatment.
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