Nerve stimulation for indomethacin-intolerant hemicrania continua

Case Description:

We describe a 62-year-old woman with a history of meningitis who developed persistent left-sided headaches and was diagnosed with hemicrania continua. Her symptoms included continuous occipital and retro-orbital pain and ipsilateral cranial autonomic features. Indomethacin was initially effective but discontinued due to gastrointestinal bleeding. Multiple pharmacologic therapies and interventional strategies, including nerve blocks and botulinum toxin, failed to provide lasting relief. Persistent upper cervical pain radiating to the left skull and left supraorbital region prompted a trial of left occipital nerve stimulation. Following a successful trial, an occipital nerve stimulator was implanted, resulting in immediate symptom relief. At 1-year follow-up, the patient reported a 70% reduction in pain, improvement in quality of life, and discontinued opioid and topiramate medications. However, ongoing retro-orbital pain prompted a subsequent trial of left supraorbital nerve stimulation, resulting in an additional 70% reduction in retro-orbital pain. Combined occipital and supraorbital stimulation resulted in a sustained >70% overall pain reduction, which remained stable at 5-month follow-up.