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Der Nervenarzt

, Volume 82, Issue 6, pp 743–752 | Cite as

Therapeutische Neuromodulation bei primären Kopfschmerzsyndromen

  • A. MayEmail author
  • T.P. Jürgens
Übersichten

Zusammenfassung

Kaum ein anderes Feld in der Behandlung von therapierefraktären Kopfschmerzen hat innerhalb der letzen 10 Jahre eine ähnlich rasante Entwicklung genommen wie die neuromodulierenden Verfahren. Die invasiven Verfahren umfassen die periphere Nervenstimulation (hier vor allem die Okzipitalisstimulation), die Vagusstimulation, die hochzervikale Rückenmarksstimulation und die hypothalamische Tiefenhirnstimulation. Nichtinvasiv sind die transkutane elektrische Nervenstimulation, die repetitive transkranielle Magnetstimulation und die transkranielle Gleichstromstimulation. Auf Basis der bisherigen bildgebenden, neurophysiologischen und klinischen Studien empfehlen sich vor allem die Okzipitalisstimulation und die hypothalamische Tiefenhirnstimulation für Patienten mit chronischem Clusterkopfschmerz. Nur wenige Studien liegen zur Wirksamkeit dieser beiden Verfahren bei anderen Kopfschmerzen wie der therapierefraktären chronischen Migräne vor. Auch über die Wirksamkeit der übrigen Verfahren lassen aktuelle Studien keine eindeutige Aussage zu. Vielversprechend ist das Konzept der intermittierenden Stimulation des Ganglion sphenopalatinum. Für alle Verfahren gilt jedoch, dass weitere methodisch robuste multizentrische randomisierte und Sham-kontrollierte Studien nötig sind, bevor diese Verfahren eine breite Anwendung finden. Aufgrund des bislang noch experimentellen Status sollten möglichst alle Patienten im Rahmen von Studien behandelt werden. Bevor ein invasives neuromodulierendes Verfahren erwogen wird, sollte die Diagnose gesichert und die Kriterien für einen refraktären Verlauf erfüllt werden. Grundsätzlich sollten diese Patienten in eine entsprechende Spezialambulanz für Kopfschmerzen überwiesen werden, die interdisziplinär mit Neurochirurgen mit entsprechender Expertise in neuromodulierenden Verfahren zusammenarbeitet. Entscheidend ist zudem die kompetente postoperative Betreuung mit Optimierung der Stimulationsparameter und weiterer Anpassung der Medikation.

Schlüsselwörter

Neuromodulation Kopfschmerz Nervenstimulation Migräne Clusterkopfschmerz 

Therapeutic neuromodulation in primary headaches

Summary

Neuromodulatory techniques have developed rapidly in the therapeutic management of refractory headaches. Invasive procedures comprise peripheral nerve stimulation (particularly occipital nerve stimulation), vagus nerve stimulation, cervical spinal cord stimulation and hypothalamic deep brain stimulation. Transcutaneous electrical nerve stimulation, repetitive transcranial magnetic stimulation and transcranial direct current stimulation are noninvasive variants. Based on current neuroimaging, neurophysiological and clinical studies occipital nerve stimulation and hypothalamic deep brain stimulation are recommended for patients with chronic cluster headache. Less convincing evidence can be found for their use in other refractory headaches such as chronic migraine. No clear recommendation can be given for the other neuromodulatory techniques. The emerging concept of intermittent stimulation of the sphenopalatine ganglion is nonetheless promising. Robust randomized and sham-controlled multicenter studies are needed before these therapeutic approaches are widely implemented. Due to the experimental nature all patients should be treated in clinical studies.

It is essential to confirm the correct headache diagnosis and the refractory nature before an invasive approach is considered. Patients should generally be referred to specialized interdisciplinary outpatient departments which closely collaborate with neurosurgeons who are experienced in the implantation of neuromodulatory devices. It is crucial to ensure a competent postoperative follow-up with optimization of stimulation parameters and adjustment of medication.

Keywords

Neuromodulation Headache Nerve stimulation Migraine Cluster headache 

Notes

Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehung hin: Diese Arbeit wurde von der Deutschen Forschungsgemeinschaft unterstützt (MA 1862/4–1). Die Autoren haben keinen conflict of interest. Insbesondere erhalten oder erhielten sie keine Gelder, weder persönlich noch für Forschungszwecke mit Bezug auf Neuromodulation bei Kopfschmerzen.

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

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Authors and Affiliations

  1. 1.Institut für Systemische Neurowissenschaften und Kopfschmerzambulanz der Neurologischen KlinikUniversitätsklinikum Hamburg-Eppendorf (UKE)HamburgDeutschland

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