Occipital Nerve Stimulation Periprocedural Care

Updated: Oct 11, 2018
  • Author: Antonios Mammis, MD; Chief Editor: Jonathan P Miller, MD  more...
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Periprocedural Care

Patient Education and Consent

Elements of Informed Consent

Occipital nerve stimulation (ONS) for headache and craniofacial pain is not FDA-approved and thus represents an off-label use of this technology. Insurance companies may or may not cover the cost of occipital nerve stimulation placement, and patients are encouraged to contact their insurances to see if they qualify as candidates and if insurance will cover it.

Patients who are interested in participating in one of several clinical trials are referred to ClinicalTrials.gov.



Occipital nerve stimulation involves an implantable device composed of an electrode and pulse generator. 

In ONS programming, a wide array of electrodes is used in order to increase stimulation of the terminal branches of the occipital nerves.

A fluoroscopic images of occipital leads in the su A fluoroscopic images of occipital leads in the supraorbital (A), infraorbital (B), and occipital (C) region in a patient with intractable cluster headache
A fluoroscopic images of occipital leads showing s A fluoroscopic images of occipital leads showing stacked left-sided occipital leads in a woman with hemicrania continua.

Patient Preparation


Local anesthesia is used at the incision site only.


The patient may be positioned laterally or prone depending on the incision entry point.


Monitoring & Follow-up

The device is programmed by a clinical specialist, appointed by the manufacturer.


Device Programming and Maintenance

Most patients currently opt for the implantable pulse generator system, which is currently an off-label application for peripheral use. The life of the battery varies depending on the amplitude used and the number of hours the device is left on during the day. With the voltage settings usually required for occipital stimulation, the primary cell lithium ion battery can last 3–5 years, while the rechargeable may last 7–9 years before replacement.


Preprocedural Planning

Prior to implantation, a trial is performed in which leads are placed under the skin and are connected to an external battery. The patient may be positioned laterally or prone, based on the location of the incision. The head is placed on a horseshoe headrest and the cervical spine is slightly flexed. A percutaneous lead is introduced under fluoroscopic guidance, and with the patient under sedation. The entry point should be approximately 1 cm superior to the tip of the mastoid process, and the trajectory is towards the tip of the odontoid process. Trajectories superior to this are often times used and are well tolerated as well. The electrode should be placed in the superficial aspect of the subcutaneous fat. Care should be taken to not place the lead in the dermis, nor too close to the fascia. The leads are secured to the skin with a 2-0 nylon drain stitch.

The leads are then inserted into the trialing cable, and programming commences. Stimulation is applied using a temporary radiofrequency (RF) transmitter to various select electrode combinations; this enables the patient to report the stimulation location, intensity, and overall sensation. Most patients have reported an immediate stimulation in the selected occipital nerve distribution with 1 to 4 volts with midrange pulse widths and frequencies.

The trial period is typically 4 to 7 days, and patients are encouraged to maintain a headache or pain diary. Trial success is defined as greater than 50% improvement in pain on the visual analog scale, or significant reduction in headache days, or improvement in quality of life. A permanent device is implanted only if the patient reports significant improvements in pain and quality of life.

Alternatively, positive response to transcutaneous electric nerve stimulation has also been used as a good predictor for repsonse to ONS for treatment of occipital headache. [9]