Abstract
Dear Sir I would like to make a few comments on your recent article by Schwedt et al. (1).
Even if one grants the difficulty in defining chronic headache, patients suffering from ‘head pain that involved the C2 distribution with or without pain in other regions of the head’ would seem to be suffering mostly from occipital neuralgia. To define medically intractable headache in terms of C2 pain and then to equate pain relief with paraesthesias produced in the C2 region by a neurostimulator may turn out to be a useful form of treatment. It seems to me equally likely, however, that the outcome will be: (i) patient indecision about the extent of headache pain relief, (ii) a maximum placebo effect, and/or (iii) a conditioned response, as with Pavlov's dogs.
A technical note: the authors found lead migration in 100% of their cases at 3 years. Others have addressed this problem, either by suturing down the distal ends of cylindrical electrodes (2), or by using paddle electrodes and appropriate suturing techniques (3). Either method would involve a little more surgery than the authors describe and this, in turn, would probably require endotracheal intubation for airway protection, since the operation is carried out with patients in the prone position. The slightly added risk, however, would be more than compensated for by the reduction in postoperative lead migration.