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Headache
Published in Anthony N. Nicholson, The Neurosciences and the Practice of Aviation Medicine, 2017
An attack of cluster headache generally lasts about 45 minutes, with the pain being felt in or around one or other eye. The pain is intense and will characteristically wake the patient from sleep. When awake, patients can rarely sit or lie still, preferring to pace around the room or press on their forehead. Some patients will describe an urge to hit their heads against the wall or on the floor to try to relieve the pain. Associated with the pain, the nose will feel congested and the patient may be aware of watering of the eye. The eyelid on the affected side may become oedematous and there may be a partial ptosis. An attack is therefore easy to distinguish from common migraine – the patient with a cluster headache appears agitated and restless in contrast with the patient with typical migraine who usually looks pale and lies quietly in a darkened room.
Recent advances in devices for vagus nerve stimulation
Published in Expert Review of Medical Devices, 2018
Ann Mertens, Robrecht Raedt, Stefanie Gadeyne, Evelien Carrette, Paul Boon, Kristl Vonck
The results from two double-blinded, sham-controlled, randomized trials (ACT1, ACT2, and pooled analysis) demonstrated the superiority of the acute use of GammaCore when added to standard optimal care for episodic cluster headache. Results showed a significantly reduced cluster headache attack intensity, duration, and adjunct medication use in the Gammacore treated group [67,70]. The PREVA study, an open-label, randomized trial, compared adjunctive prophylactic nVNS with standard of care alone for treatment of chronic cluster headache. The prophylactic nVNS consisted of three 2-min stimulations administered twice daily. This study showed significant reductions in both the frequency and duration of attacks in patients randomized to the nVNS treatment group [71].
Burst and high frequency stimulation: underlying mechanism of action
Published in Expert Review of Medical Devices, 2018
Shaheen Ahmed, Thomas Yearwood, Dirk De Ridder, Sven Vanneste
Over the past four decades, SCS has been well established as a safe and effective therapeutic tool for treating patients with chronic pain, which is difficult to treat with medications. Classic SCS is targeted at the dorsal columns with electrodes positioned in the posterior epidural space. The first SCS device was placed in the subarachnoid space; later attempts were made to stimulate the dorsal, lateral, and ventral surfaces of the spinal cord [62–64]. The dorsal epidural space exhibited a sufficiently wide therapeutic window to keep SCS clinically feasible. The dawn of SCS in treating neuropathic pain led researchers and clinicians to find new stimulation targets. One of these is the dorsal root ganglion (DRG), an intraspinal structure that can be reached via a trans-spinal approach. There are many advantages of targeting DRG with electrical stimulation. Not only has it been implicated in the development and maintenance of chronic pain in CRPS, but it is also relatively immobile owing to its anatomical location and is surrounded by a much thinner layer of cerebrospinal fluid [65]. Another stimulation target for the treatment of pain is the uppermost most of spinal for e.g. C2 nerve, the part comprising the occipital nerves known as occipital nerve stimulation. Occipital stimulation has been used for the treatment of cluster headaches, targeting the occipital and trigeminal nerves. A standard percutaneous electrode inserted at the level of C2 demonstrated significant improvement in terms of duration and intensity of cluster headache attacks, as well as other related functional and impairment metrics [66]. While other neuromodulation modalities may take up to several months to achieve improvement in symptoms, occipital stimulation achieved immediate improvement. This immediacy of effect may make occipital SCS a preferred approach for patients with intractable symptoms.