ONS Implant

Summary:
Occipital nerve stimulation (ONS) involves surgically implanting a neurostimulator to deliver electrical impulses to the occipital nerves. It is considered for chronic, treatment-refractory migraine.

Biological Plausibility

ONS targets the greater and lesser occipital nerves, which converge with trigeminal afferents at the trigeminocervical complex. Modulation of this pathway can alter central pain processing involved in chronic migraine.

Evidence

Several randomized controlled trials have shown modest benefit, but high placebo response and surgical complications have limited enthusiasm. Current guidelines reserve ONS for highly selected, refractory cases.

Effect Size

About 30–40% of patients achieve ≥50% reduction in headache days. Benefits tend to accrue over months.

⚠️ Risk

High. Complications include lead migration, infection, and need for surgical revision in up to 40% of patients.

Cost

$$$$

Scores

  • Benefit: 4
  • Burden: 8
  • Ratio: 0.5

Clinical Takeaways

  • Reserved for chronic, intractable migraine unresponsive to all other therapies.
  • Requires surgical implantation and long-term follow-up.
  • Not a first- or second-line treatment due to invasiveness and risk.

Key References

  • Saper JR, et al. *Occipital nerve stimulation for the treatment of intractable chronic migraine headache: ONSTIM feasibility study.* Cephalalgia. 2011.
  • Silberstein SD, et al. *Safety and efficacy of peripheral nerve stimulation of the occipital nerves for the management of chronic migraine.* Cephalalgia. 2012.
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