What is the definition of a chronic headache?

Dr. Peter Goadsby: Doctors think about chronic headache problems using a term called chronic daily headache, which means that the patient has a headache on at least 15 days a month, most usually every day a month, and they’ve had it for many months. Typically, these patients have disabling, daily, awful headaches, which effectively ruin their lives.

Are there a lot of effective treatments for these types of headaches?

Dr. Goadsby: As you might imagine, the problem with chronic headaches is they can be very difficult to treat. On one side, we have the treatments for the attacks, which in some ways make things worse, like the problem of medication overuse. On the other side, we have the difficulty of finding medicines to try and stop the headaches. Many patients can’t find satisfactory medicines, and some of the medicines produce dreadful side effects.

What are the side effects of these treatments?

Dr. Goadsby: The range of side effects that people have on medicines for headache can be anything from sleepiness to weight gain to hair thinning, for example, to stomach ulcers and bleeding, and life-threatening events.

Is this study for those patients who can’t take medications?

Dr. Goadsby: In this study, we’re interested in looking for a way to treat people who otherwise had no medical option, and indeed, when they were taking their treatments, were unfortunately getting dreadful side effects, some life-threatening side effects.

Until this study, were there any other treatments that were not medications?

Dr. Goadsby: The treatment of medically intractable headache has been a real challenge over the years, and it’s only in the last five years that we’ve been able to evolve the stimulation devices as a new way forward to be able to treat people with otherwise intractable headache.

What are the new stimulation devices?

Dr. Goadsby: Stimulation devices around the occipital nerve fall into two categories. The more usual stimulation devices, which have a battery pack in and around the chest in the back, and run a wire up to the back of the head, or these new devices, the bion, which just sit under the skin and eliminate the need for all of the rest of the electronics.

What charges these devices?

Dr. Goadsby: They are charged externally through a coupling device, so to speak, so they are charged through the skin.

How do the devices work?

Dr. Goadsby: Occipital nerve stimulation works by activating nerves at the back of the head that then feed into the brain and change the way the brain behaves, in terms of responses to head pain signals.

Are the patients still having the head pains, but their brain isn’t reading it the same way?

Dr. Goadsby: It’s a really good question to try and understand how these devices work. We actually think probably that the way the brain is controlling head pain is altered. This is a very complex area.

Are there certain people who do better with this type of stimulation?

Dr. Goadsby: Occipital nerve stimulation is remarkably good at affecting a range of types of headache -- from migraine to cluster headache to hemicrania continua, which is the condition that we studied -- and typically, the stimulation is just around the occipital nerves.

What results did your study find?

Dr. Goadsby: What the study showed was that the bion device could significantly reduce the daily suffering that these patients had and eliminate the need for what were for some of them life-threatening medicines. That really quite revolutionized their lives. For four of the six patients, they had a better than 90 percent response, really quite an important difference, and were able to substantially come off their medicines. I think it’s fair to say that most of them were really very satisfied with what happened.

Is this something that stays implanted forever?

Dr. Goadsby: As far as we know, most patients with this particular type of headache, hemicrania continua, tend to have it more or less indefinitely. At the moment, these devices are going to be there more or less indefinitely. Many of these headache problems have not been well-studied. There’s quite a lot of under-investment in research in headache, and we now have an opportunity to do new things to try and understand the sort of questions that you’re asking about the natural history. It would be a shame to think that we couldn’t build on this sort of information to do better for patients in the future.

When you turned off the stimulator during the study, did the headaches come back?

Dr. Goadsby: Yes. When you turn the stimulators off, as we did deliberately for the study, the headache comes back. If the device malfunctions, then the headache comes back, so it does seem that patients, at least for the moment, will need to continue to use it for a long period of time. Typically, when the device is turned off, the headache will come back within seven to 10 days.

How invasive is the procedure to get this implanted?

Dr. Goadsby: Invasive is an interesting word in this context. There are some forms of stimulators that are being developed for the cluster headache, where the electrodes are actually placed in the brain substance by drilling a hole in the skull. I think I would call that invasive. Putting a device under the skin is invasive, but much less invasive than drilling a hole in your head.

Is it a one-day procedure?

Dr. Goadsby: I think that’s where it’s going to head. I can’t see it being done in drug stores, but I can see it being done as a day case.

Is this the start of a new generation of ways to treat chronic headache and migraine?

Dr. Goadsby: The development of nerve-stimulation procedures is the beginning of what is really an exciting future for people with intractable headache, where instead of just providing them with some medicine for relief, and providing them with not much future to think about, there is a real opportunity to change their lives. I think this is the vanguard of what is going to happen in the next five to seven years.

How long have you been treating people with headaches?

Dr. Goadsby: I’ve been treating people with difficult headache problems for more than 20 years. I’ve seen tens of thousands of patients with headaches. These people with medically intractable headaches are truly disabled, and this is an opportunity to change the lives of many, many people.

Is the nerve stimulation the most exciting thing you’ve seen come out so far for these patients?

Dr. Goadsby: Neuro-stimulation procedures are certainly the most exciting thing that really I’ve seen happen in the time that I’ve been practicing, the last 20 years or so.

Do you feel like you’re giving patients a second chance of living normally?

Dr. Goadsby: The ability to be able to take a person whose life is more or less ruined by the headache problem and make a real difference to that is one of the real excitements that drives me to work, and it’s an opportunity to do good in a world where things are sometimes a bit difficult.