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Headache Medicine: 2021

Credits: None available.

Headache Medicine: 2021


According to the Centers for Disease Control and Prevention:

  • 14% of adults suffer from migraine or severe headache
  • 14% of adults suffer from neck pain
  • 5% of adults suffer from face pain

Up to 20% of patients don't respond to, or cannot tolerate, medications to treat these conditions. 

Learning Objectives

As a result of participating in this activity, learners will be able/better able to:

  • Employ new strategies to manage and treat patients with chronic cluster headaches
  • Manage and treat patients with migraine headaches


  • Refractory headaches
  • Neurostimulation techniques
    • Stimulation of the sphenopalatine ganglion
    • Occipital nerve stimulation
    • Transcutaneous Supraorbital Neurostimulation (tSNS)
    • Non-invasive Vagal Neurostimulation (nVNS)
    • Transcranial Magnetic Stimulation
    • Remote Electric Neurostimulation
  • OnabotulinumtoxinA for the treatment of intractable chronic migraine 
  • Involvement of the calcitonin gene-related peptide (CGRP) pathway

Desirable Physician Attributes

  • Patient Care [ACGME/ABMS] Provide care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health
  • Medical Knowledge [ACGME/ABMS] about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
  • Employ Evidenced-based Practice [IOM] Integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible

Accreditation & Designation

Release date: This activity was released 8/27/2021.

Termination date: The content of this activity remains eligible for CME Credit until 8/26/2024, unless reviewed or amended prior to this date.

Neurovations Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Neurovations Education designates this other activity (blended learning) for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity includes discussions of unlabeled or investigational uses of commercial and/or developmental products.

This activity includes discussions and explorations of new and evolving topics. Such inclusion includes adequate justifications of statements based upon current science, evidence and clinical reasoning.

Disclosure of Financial Relationships & Measures to Resolve of Conflicts of Interest

[Presenter] Samer Narouze discloses the following financial relationships within the past 24 months: Consulting: Vertex Pharma [Past relationship]

No other person with control of, or responsibility for, the planning, delivery, or evaluation of accredited continuing education has, or has had within the past 24 months, financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships have been mitigated. Materials were reviewed in advance of the activity by person(s) that do not have conflicts of interest related to the content. In some cases, content may have been modified as part of the review and mitigation process. All clinical recommendations are evidence-based and free of commercial bias (e.g., peer-reviewed literature, adhering to evidence-based practice guidelines).

Additional Reading

  • Schuster, N. M., & Rapoport, A. M. (2016). New strategies for the treatment and prevention of primary headache disorders. Nature Reviews Neurology, 12(11), 635-650.
  • Mathew, N. T., Frishberg, B. M., Gawel, M., Dimitrova, R., Gibson, J., Turkel, C., & Botox CDH Study Group. (2005). Botulinum toxin type A (BOTOX®) for the prophylactic treatment of chronic daily headache: A randomized, double‐blind, placebo‐controlled trial. Headache: The Journal of Head and Face Pain, 45(4), 293-307.
  • Tajti, J., Szok, D., Nyári, A., & Vécsei, L. (2019). Therapeutic strategies that act on the peripheral nervous system in primary headache disorders. Expert Review of Neurotherapeutics, 19(6), 509-533.
  • Feoktistov A, Kohan L. (2020) Refractory Headaches And The Role Of Interventional Headache Medicine. Ann Head Med. 2020; 01:05
  • Witten, A., Marotta, D., & Cohen‐Gadol, A. (2021). Developmental innervation of cranial dura mater and migraine headache: A narrative literature review. Headache: The Journal of Head and Face Pain, 61(4), 569-575.
  • Cipolla, M. J. (2009). Control of cerebral blood flow. In The cerebral circulation. Morgan & Claypool Life Sciences.
  • Saper, J. R., Dodick, D. W., Silberstein, S. D., McCarville, S., Sun, M., & Goadsby, P. J. (2011). Occipital nerve stimulation for the treatment of intractable chronic migraine headache: ONSTIM feasibility study. Cephalalgia, 31(3), 271-285.
  • Dodick, D. W., Silberstein, S. D., Reed, K. L., Deer, T. R., Slavin, K. V., Huh, B., ... & Mekhail, N. (2015). Safety and efficacy of peripheral nerve stimulation of the occipital nerves for the management of chronic migraine: long-term results from a randomized, multicenter, double-blinded, controlled study. Cephalalgia, 35(4), 344-358.
  • Sharan, A., Huh, B., Narouze, S., Trentman, T., Mogilner, A., Vaisman, J., ... & Slavin, K. (2015). Analysis of adverse events in the management of chronic migraine by peripheral nerve stimulation. Neuromodulation: Technology at the Neural Interface, 18(4), 305-312.
  • Magis, D., Allena, M., Bolla, M., De Pasqua, V., Remacle, J. M., & Schoenen, J. (2007). Occipital nerve stimulation for drug-resistant chronic cluster headache: a prospective pilot study. The Lancet Neurology, 6(4), 314-321.
  • Burns, B., Watkins, L., & Goadsby, P. J. (2007). Treatment of medically intractable cluster headache by occipital nerve stimulation: long-term follow-up of eight patients. The Lancet, 369(9567), 1099-1106.
  • Sweet, J. A., Mitchell, L. S., Narouze, S., Sharan, A. D., Falowski, S. M., Schwalb, J. M., ... & Pilitsis, J. G. (2015). Occipital nerve stimulation for the treatment of patients with medically refractory occipital neuralgia: congress of neurological surgeons systematic review and evidence-based guideline. Neurosurgery, 77(3), 332-341.
  • Eldrige, J. S., Obray, J. B., Pingree, M. J., & Hoelzer, B. C. (2010). Occipital neuromodulation: ultrasound guidance for peripheral nerve stimulator implantation. Pain Practice, 10(6), 580-585.
  • Narouze, S., Kapural, L., Casanova, J., & Mekhail, N. (2009). Sphenopalatine ganglion radiofrequency ablation for the management of chronic cluster headache. Headache: The Journal of Head and Face Pain, 49(4), 571-577.
  • Ho, K. W. D., Przkora, R., & Kumar, S. (2017). Sphenopalatine ganglion: block, radiofrequency ablation and neurostimulation-a systematic review. The Journal of Headache and Pain, 18(1), 1-27.
  • Narouze, S., Kapural, L., Casanova, J., & Mekhail, N. (2009). Sphenopalatine ganglion radiofrequency ablation for the management of chronic cluster headache. Headache: The Journal of Head and Face Pain, 49(4), 571-577.
  • Jespersen, M. S., Jaeger, P., Ægidius, K. L., Fabritius, M. L., Duch, P., Rye, I., ... & Meyhoff, C. S. (2020). Sphenopalatine ganglion block for the treatment of postdural puncture headache: a randomised, blinded, clinical trial. British Journal of Anaesthesia, 124(6), 739-747.
  • Gibelli, D., Cellina, M., Gibelli, S., Cappella, A., Panzeri, M. M., Oliva, A. G., ... & Sforza, C. (2019). Anatomy of the pterygopalatine fossa: an innovative metrical assessment based on 3D segmentation on head CT-scan. Surgical and Radiologic Anatomy, 41(5), 523-528.
  • Narouze, S. (2021). Topical intranasal lidocaine is not a sphenopalatine ganglion block. Regional Anesthesia & Pain Medicine, 46(3), 276-279.
  • Tepper, S. J., Rezai, A., Narouze, S., Steiner, C., Mohajer, P., & Ansarinia, M. (2009). Acute treatment of intractable migraine with sphenopalatine ganglion electrical stimulation. Headache: The Journal of Head and Face Pain, 49(7), 983-989.
  • Ansarinia, M., Rezai, A., Tepper, S. J., Steiner, C. P., Stump, J., Stanton‐Hicks, M., ... & Narouze, S. (2010). Electrical stimulation of sphenopalatine ganglion for acute treatment of cluster headaches. Headache: The Journal of Head and Face Pain, 50(7), 1164-1174.
  • Narouze, S. (2014). Neurostimulation at pterygopalatine fossa for cluster headaches and cerebrovascular disorders. Current Pain and Headache Reports, 18(7), 1-4.
  • Pedersen, J. L., Barloese, M., & Jensen, R. H. (2013). Neurostimulation in cluster headache: a review of current progress. Cephalalgia, 33(14), 1179-1193.
  • Schwedt, T. J., & Vargas, B. (2015). Neurostimulation for treatment of migraine and cluster headache. Pain medicine, 16(9), 1827-1834.
  • Láinez, M. J., & Guillamón, E. (2017). Cluster headache and other TACs: pathophysiology and neurostimulation options. Headache: The Journal of Head and Face Pain, 57(2), 327-335.
  • Schoenen, J., Jensen, R. H., Lanteri-Minet, M., Láinez, M. J., Gaul, C., Goodman, A. M., ... & May, A. (2013). Stimulation of the sphenopalatine ganglion (SPG) for cluster headache treatment. Pathway CH-1: a randomized, sham-controlled study. Cephalalgia, 33(10), 816-830.
  • Bratbak, D. F., Nordgård, S., Stovner, L. J., Linde, M., Folvik, M., Bugten, V., & Tronvik, E. (2016). Pilot study of sphenopalatine injection of onabotulinumtoxinA for the treatment of intractable chronic cluster headache. Cephalalgia, 36(6), 503-509.
  • Aschehoug, I., Bratbak, D. F., & Tronvik, E. A. (2018). Long‐Term Outcome of Patients With Intractable Chronic Cluster Headache Treated With Injection of Onabotulinum Toxin A Toward the Sphenopalatine Ganglion–An Observational Study. Headache: The Journal of Head and Face Pain, 58(10), 1519-1529.
  • Silberstein, S. D., Rapoport, A. M., Loupe, P. S., Aycardi, E., McDonald, M., Yang, R., & Bigal, M. E. (2019). The effect of beginning treatment with fremanezumab on headache and associated symptoms in the randomized phase 2 study of high frequency episodic migraine: Post‐hoc analyses on the first 3 weeks of treatment. Headache: The Journal of Head and Face Pain, 59(3), 383-393.
  • Rapoport, A. M., & Edvinsson, L. (2019). Some aspects on the pathophysiology of migraine and a review of device therapies for migraine and cluster headache. Neurological Sciences, 40(1), 75-80.
  • Oshinsky, M. L., Murphy, A. L., Hekierski Jr, H., Cooper, M., & Simon, B. J. (2014). Noninvasive vagus nerve stimulation as treatment for trigeminal allodynia. PAIN®, 155(5), 1037-1042.
  • Schoenen, J., Vandersmissen, B., Jeangette, S., Herroelen, L., Vandenheede, M., Gérard, P., & Magis, D. (2013). Migraine prevention with a supraorbital transcutaneous stimulator: a randomized controlled trial. Neurology, 80(8), 697-704.
  • Tepper, D. (2014). Transcutaneous supraorbital neurostimulation (tSNS). Headache: The Journal of Head and Face Pain, 54(8), 1415-1416.
  • Henssen, D. J. H. A., Derks, B., van Doorn, M., Verhoogt, N., Van Cappellen van Walsum, A. M., Staats, P., & Vissers, K. (2019). Vagus nerve stimulation for primary headache disorders: An anatomical review to explain a clinical phenomenon. Cephalalgia, 39(9), 1180-1194.
  • Lai, Y. H., Huang, Y. C., Huang, L. T., Chen, R. M., & Chen, C. (2020). Cervical Noninvasive Vagus Nerve Stimulation for Migraine and Cluster Headache: A Systematic Review and Meta‐Analysis. Neuromodulation: Technology at the Neural Interface, 23(6), 721-731.
  • Möller, M., Mehnert, J., Schroeder, C. F., & May, A. (2020). Noninvasive vagus nerve stimulation and the trigeminal autonomic reflex: an fMRI study. Neurology, 94(10), e1085-e1093.
  • Zhang, Y., Huang, Y., Li, H., Yan, Z., Zhang, Y., Liu, X., ... & Kong, J. (2021). Transcutaneous auricular vagus nerve stimulation (taVNS) for migraine: an fMRI study. Regional Anesthesia & Pain Medicine, 46(2), 145-150.
  • Burke, M. J., Joutsa, J., Cohen, A. L., Soussand, L., Cooke, D., Burstein, R., & Fox, M. D. (2020). Mapping migraine to a common brain network. Brain, 143(2), 541-553.
  • Yarnitsky, D., Volokh, L., Ironi, A., Weller, B., Shor, M., Shifrin, A., & Granovsky, Y. (2017). Nonpainful remote electrical stimulation alleviates episodic migraine pain. Neurology, 88(13), 1250-1255.
  • Moisset, X., Pereira, B., de Andrade, D. C., Fontaine, D., Lantéri-Minet, M., & Mawet, J. (2020). Neuromodulation techniques for acute and preventive migraine treatment: a systematic review and meta-analysis of randomized controlled trials. The Journal of Headache and Pain, 21(1), 1-14.
  • Anamnart, C., & Poungvarin, N. (2011). Botulinum Therapy for Chronic Migraine. Siriraj Medical Journal, 63(5), 171-173.
  • Blumenfeld, A. M., Stark, R. J., Freeman, M. C., Orejudos, A., & Manack Adams, A. (2018). Long-term study of the efficacy and safety of OnabotulinumtoxinA for the prevention of chronic migraine: COMPEL study. The Journal of Headache and Pain, 19(1), 1-12.
  • Yuan, H., Chen, A. Y., & Silberstein, S. D. (2020). CGRP Therapeutics For The Treatment Of Migraine–A Narrative Review. Ann Head Med, 1, 03.



  • 0.75 - Physician
  • 0.75 - Non-Physician

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