Electrical Stimulation of the Sphenopalatine Ganglion for the Treatment of Migraine Headaches
Electrical Stimulation of the Sphenopalatine Ganglion for the Treatment of Migraine Headaches
This investigation will gather information about a procedure called sphenopalatine ganglion
 (SPG) stimulation, and its appropriateness, safety, and efficacy as a treatment for those who
 suffer migraine headaches which may result in chronic severe disability. The SPG is a small
 collection of nerve cells in the head, and is located near the base of the nose on either
 side. Participation involves the surgical implantation of an electrode (small electrical
 conductor) over the sphenopalatine ganglion. The electrode is connected to a stimulator which
 will enable treatment for migraine headaches. Tiny electrical current is delivered to the
 stimulator device by an internal pulse generator implanted in the area at the top of the
 chest, to stop the migraine headaches. The implant system will be controlled with a wireless
 remote provided after the implant procedure.

 Participation will record headache diaries throughout the study, which will last
 approximately 8½ months, and a yearly visit annually for five years.
This application proposes a clinical study of electrical stimulation of the sphenopalatine
 ganglia (SPG) as a treatment for up to three individuals with episodic migraine headache. The
 present study is aimed at obtaining pilot data to guide a future controlled trial of this
 treatment modality. The study population will include individuals suffering from episodic
 migraine headaches with chronic severe disability, as demonstrated by the Migraine Disability
 Assessment Questionnaire (Lipton, 2000) and Headache Impact Test short form (HIT-6™)
 (Kosinski, 2003).

 The treatment involves implantation of an electrode into the SPG. The electrode is connected
 subcutaneously to an infraclavicular stimulator (PrimeAdvanced™ 37702 Multi-program
 Neurostimulator System, Medtronic Inc., Minneapolis MN). Proper electrode placement will be
 verified using anatomic and physiologic techniques. Participants will receive the Medtronic
 Model 3389 or 3387 lead, or Medtronic subcompact lead Model 3776-45, 3776-60, or 3776-75.
 Stimulation will be delivered in a range of frequencies from 20 to 130 Hz, and pulse width
 from 60 to 450 μsec, and a titrated voltage. The voltages used for chronic stimulation may
 range up to the pulse generator maximum of 10.5 volts but are anticipated to generally be
 below 3 volts, keeping below the 30 µcoulomb/cm² charge density safety limit, and below the
 threshold for adverse stimulation-related effects. The minimum number of contacts on the
 quadripolar leads will be activated as necessary to produce a response.

 The Prime Advanced neurostimulator to be used in this study allows the clinician to set all
 stimulation parameters including the maximum allowable amplitude. It is our responsibility to
 assure that appropriate stimulation parameters are used to result in appropriate electrical
 exposure charge density) below a 30 µC/cm2/phase limit. As is done with commercially
 available neurostimulators, during this study, we will utilize the charts presented in
 Figures 1 and 2 below to assist in selection of programming parameters, and this programming
 will be maintained by software controls within the neurostimulator.

 For this exploratory study of 3 patients, the maximum electrical stimulating parameters,
 resulting electrical exposure (e.g., charge density), will be determined using the methods
 described above. It is our responsibility to assure that safe stimulation parameters are used
 at all times and that the maximum settings do not exceed the safety limits. Our plan is to
 begin with lead 3776 if possible, because it does not require an extra extension, but we
 would use 3387 or 3389 if clinically indicated.

 The proposed study is a physician-sponsored research investigation of three patients, and the
 attention to stimulation parameters will be much greater than can be expected for a
 commercially released product. It is our responsibility within this investigational study to
 insure the selected stimulation parameters do not exceed the safety limit of 30μC/cm2/phase.
 Patients participating in the study will only be able to lower stimulation amplitudes,
 thereby keeping stimulation parameters BELOW any clinician set maximum. The only programs
 available to or accessible by the patients will maintain the previously described parameter
 set limitations. Thus, the programming of the Implantable Programmable Generator (IPG) will
 keep the three patients from stimulating outside or above the set and safe parameters.

 The primary outcome measures for assessing the efficacy of migraine treatment will be a
 subject reported daily diary noting frequency and intensity of headaches. During this
 investigation we will obtain preliminary controlled data on the safety and efficacy of SPG
 stimulation for migraine treatment.
Inclusion Criteria:

 1. Age ≥18 years.

 2. Subject has onset of migraine headache occurring before age 60.

 3. Subject has been diagnosed with migraine headache with or without aura, according to
 the 2004 IHS criteria 1.1 and 1.2.

 4. Subject reports a HIT-6 score of >56, a MIDAS score of >20 and/or a failure of
 adequate and appropriate previous migraine treatment.

 5. Subject has carried the diagnosis of migraine for at least 6 months prior to
 enrollment.

 6. Subject has had at least three migraine headache attacks per month.

 7. Subject has had at least three headache days (migraine or non-migraine) per month and
 maintains this requirement during the baseline period on diary.

 8. Subject is able to distinguish migraine headache attacks as discrete from other
 headaches (i.e., tension-type headaches).

 9. Subject has the ability to read, comprehend and legibly and reliably record
 information as required by the protocol.

 10. Subject is able to provide written informed consent prior to participation in the
 study.

 11. Subject agrees to not participate in supplemental or alternative therapy during the
 baseline or treatment phases of the clinical study. This includes: acupuncture, spinal
 manipulation, TENS, and magnetic field treatments.

 12. Subject agrees to maintain current preventative headache medication regimens (no
 change in type, frequency, or dose) from baseline screening visit to the end of the
 Phase 2 treatment phase.

 Exclusion Criteria:

 1. Subject currently has Medication Overuse Headache (MOH) in the judgment of the
 investigator or by ICHD-II criteria.

 2. Subject has a history of headaches days ≥ 15 per month.

 3. Subject has a history of trigeminal autonomic cephalalgias.

 4. Subject has any medical condition or disorder that:

 1. Is considered to be clinically significant and may pose a safety concern

 2. Could interfere with the accurate assessment of safety or efficacy

 3. Could potentially affect a subject's safety or study outcome.

 5. Subject has had a major infection or surgery in the past month.

 6. Subject has undergone facial surgery in the area of sphenopalatine ganglia for
 cosmetic, corrective, therapeutic, or traumatic reasons.

 7. Subject has been treated with radiation to the face.

 8. Subject was diagnosed with any major infectious processes, primary or secondary
 malignancies involving the face that have been active or required treatment in the
 past six (6) months.

 9. Subject currently meets criteria as defined by the Diagnostic and Statistical Manual
 of Mental Disorders (DSM-IV-TR) for an active major depressive episode or for active
 significant psychiatric disorders, including dementia, uncontrolled general anxiety
 disorder, psychotic disorders or uncontrolled bipolar disorder. Exclusion criteria
 include: suicidality, active psychosis, untreated severe depression and/ or anxiety
 disorder, litigation, addiction, homicidal ideation, significant Axis II disorders and
 untreated sleep disorder.

 10. Subject currently has clinically significant drug or alcohol abuse as defined by
 DSM-IV-TR or is unable to refrain from substance abuse throughout the study.

 11. Subject is currently participating or has participated in the last month in another
 clinical study in which the subject has, is, or will be exposed to an investigational
 or non-investigational drug or device.

 12. Subject is felt to be at risk of non-compliance (e.g. for completing the diary or
 maintaining a stable headache medicine regimen) in the investigator's opinion.

 13. Subject is woman of childbearing age who is pregnant, nursing, or not using
 contraception.

 14. Subject has had previous radio-frequency ablation of the SPG.

 15. Subject has had blocks of the SPG in last 3 months.

 16. Subject has undergone botulinum toxin injections of the head and/or neck in the last 3
 months.

 17. Subject has an implantable stimulator or any implanted devices in the head and/or
 neck.

 18. Subject has H/O bleeding disorders or coagulopathy, or is on anticoagulation,
 antiplatelet, or GP IIb IIIa inhibitor medication.

 19. Subject has H/O malignancy or any other condition that requires MRI monitoring.

 20. Subject has or requires pacemaker/defibrillator.

 21. Subject is not suitable for the study, in the judgment of the Investigators, due to
 social, co-morbid psychological, and/or medical considerations.

 22. Subject has H/O stroke, cardiovascular disease, and/or epilepsy.

 23. Subject was on antipsychotic or antidepressant medications (except for migraine
 prevention) in the past 3 months prior to the study.

 24. Subject is allergic or has shown hypersensitivity to materials of the Medtronic
 components which come in contact with the body.