nVNS treatment instead of microvascular decompression

Abstract text (incl. figure legends and references)

Question: Non-invasive Vagal nerve stimulation (nVNS) with the GammaCore device is a safe and well tolerated treatment. Randomised sham-controlled trials have shown nVNS is efficacious for the treatment of cluster headache. There is also some evidence of the efficacy of nVNS for other trigeminal autonomic cephalalgias, namely hemicrania continua and paroxysmal hemicrania. On the other hand, patients who fail standard treatment for SUNCT/SUNA and are found to have trigeminal neurovascular conflict may be considered for microvascular decompression.

Methods: We report the case of a 58-year old woman who had a history of chronic SUNA. She had initially responded to pregabalin and then added lamotrigine, which was not sufficiently efficacious. She also failed gabapentin. Following funding the patient was started on nVNS. A previous MRI 10 years ago did not include trigeminal views. A recent brain MRI with 3D-CISS sequence showed neurovascular conflict and thinning of the of the trigeminal nerve compared to the contralateral, to the pain, side.

Results: The patient, who had been referred to neurosurgery given the new MRI findings, became attack-free after 2 months on nVNS, which she was taking at 4 treatments TDS. After 1 year of follow-up the benefit persisted and a procedure is no longer being contemplated.

Conclusions: The utility of nVNS as a treatment for refractory SUNCT/ SUNA, even in the presence of neurovascular conflict, could open the doors for its use before considering surgery, given the well-recognised risks of a procedure.