Occipital Nerve Stimulation Effectively Controls Refractory Seizures: A Case Report
We report a novel treatment for refractory seizures with occipital nerve stimulation (ONS). A 37-year-old right-handed woman was referred by her neurologist for interventional management of intractable chronic migraine headaches that she had experienced for the past 15 years. The migraine headaches were usually bitemporal and typically without aura. She described her headaches as “sharp, pulsating pains in the head.” They were accompanied by photophobia, phonophobia, and nausea. The headaches were present nearly daily, despite use of multiple prophylactic medications, and typically lasted more than 4 hours. They were resistant to conventional preventive treatment with multiple membrane stabilizers, β-blockers, serotonin norepinephrine reuptake inhibitors, tricyclic antidepressants, monoamine oxidase inhibitors, onabotulinumtoxinA injections, and abortive treatment, including nonsteroidal anti-inflammatory drugs and a variety of triptans.
The patient also had a history of adolescent-onset grand mal epilepsy. Generalized tonic-clonic seizures were documented with electroencephalogram. Her seizure disorder was diagnosed when she was 16 years old, few years prior to the onset of her migraine. She denied a family history of epilepsy. The intensity and frequency of seizure attacks decreased with administration of antiepileptic drugs, but she still experienced at least 1 seizure episode per week.
The patient reported acceptable but temporary relief of her migraine headaches following greater occipital nerve blocks. Following a successful ONS trial, she received a permanent ONS implant with percutaneous placement of bilateral occipital neuroelectrodes and implantable pulse generator.
After placement of the ONS, the patient experienced a marked reduction of both frequency and severity of migraine headaches. Unexpectedly, her enduring seizure disorder, which had been resistant to medical management, became adequately controlled, and attacks eventually completely stopped.
Following the implant, the patient experienced a 2-year seizure-free period. She then began to develop seizures again without worsening of her migraine headaches. She requested reevaluation of the leads especially, as she felt the stimulation in the lower neck rather than in the occipital area. Lead migration is a relatively common concern with ONS.1 Head radiography showed that both ONS leads had migrated. Several weeks later, the patient noted the return of her migraine headaches. The patient underwent revision of ONS leads, with immediate and complete resolution of seizures.
Two and one-half years later, the patient was assaulted, at which time she was dragged to the ground and punched in the back of her head repeatedly. She developed a seizure episode, for the first time in 2½ years. A few days after this incident, her migraines worsened. She stated that initially she could not feel any ONS and subsequently began to feel stimulation solely in the low neck. Radiographs documented migration of leads down in the neck area.
The patient reported excellent relief from the ONS before this incident and repeated that she never had seizures while she felt the occipital stimulation. The stimulation was producing approximately 95% relief of intensity and frequency of her headaches before the assault. The patient continued to complain of frequent seizure episodes and started using more sumatriptan to control her headaches and continuing to use topiramate and extended-release propranolol for headache prevention.
The patient noted again that the return of migraine headaches was not as immediate as that of seizures. She underwent a second ONS revision with restoration of the original occipital placement. The revision again led to immediate and complete resolution of seizures. At the 16-month follow-up evaluation of the second ONS revision, the patient reported no seizures and only 1 to 2 migraines per month.
The relationship between migraine headaches and seizure disorder has long been a subject of debate. Particular relationships have been noted between migraines, especially basilar type, and occipital seizures.