Hypothalamic stimulation for intractable cluster headache: Long-term experience

Leone, Massimo; Franzini, Angelo; Broggi, Giovanni; Bussone, Gennaro

doi:10.1212/01.wnl.0000223319.56699.8a

Cited by 210 publications

(185 citation statements)

References 9 publications

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“…Accordingly, increased venous blood pressure in the sinus would directly cause the attack by temporarily increasing the pressure on sympathetic fibres running in the neighbourhood with the carotid artery [16]. Alternatively, evidence from PET studies [17,18], voxel-based morphometry [16] and stereotactic hypothalamic deep brain stimulation [20][21][22] suggests that there is a dysfunction of the ipsilateral posterior hypothalamus in CH, which causes a secondary activation of the trigemino-autonomic brainstem pathways [23]. This secondary activation elicits neurogenic inflammation of the large dural vessels, a mechanism that is similar to that during migraine attacks.…”

Section: Discussionmentioning

confidence: 99%

Botulinum toxin type-A therapy in cluster headache: an open study

et al. 2007

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The objective of this open single-centre study was to evaluate the efficacy and tolerability of botulinum toxin type-A (BTX-A) as add-on in the prophylactic treatment of cluster headache (CH). Twelve male patients with episodic (n=3) or chronic (n=9) CH, unresponsive to common prophylactic medications, were treated with a cumulative dose of 50 International Units (IU) BTX-A according to a standardised injection scheme into the ipsilateral pericranial muscles. One patient with chronic CH experienced a total cessation of attacks and in 2 patients attack intensity and frequency improved. In another patient with chronic CH typical attacks were not influenced, but an ipsilateral continuous occipital headache significantly improved. Patients with episodic CH did not benefit from BTX-A treatment. Tolerability was excellent. These findings provide evidence that BTX-A may be beneficial as an add-on prophylactic therapy for a limited number of patients with chronic CH.

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Section: Discussionmentioning

confidence: 99%

Botulinum toxin type-A therapy in cluster headache: an open study

et al. 2007

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“…51 However, a failure rate of up to 50% seems quite considerable for an invasive treatment with the theoretical risk of death. 52 Single case studies are possible in principle, 53 and it would be easier to define the individual target point for each patient.…”

Section: Technical Functional Imaging Considerations In Cluster Headachementioning

confidence: 99%

“…It seems clear that hypothalamic DBS is generally ineffective in ameliorating acute attacks 51 and is therefore used to reduce attack frequency with continuous stimulation. To date, 58 intractable CH patients who have been operated on have been reported, 36,54 some with a follow-up of more than four years.…”

Section: Clinical Outcomes From Current Studiesmentioning

confidence: 99%

Neuromodulatory Approaches to the Management of Medically Refractory Cluster Headache

May¹,

Goadsby²

2010

European Neurological Review

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Cluster headache (CH) is, by neurological standards, a relatively common condition that affects about one in 1,000 people, 1 although compared with other more common primary headaches such as migraine 2 it remains rare in practice. CH has been defined in the second edition of the International Classification of Headache Disorders 3 as involving recurrent attacks of severe pain on one side of the head for between 15 and 180 minutes, associated with cranial autonomic features such as lacrimation, conjunctival injection, nasal congestion or rhinnorhoea (see Table 1). This condition can be divided into episodic (ECH) and chronic (CCH) forms. A diagnosis of ECH requires at least two cluster periods lasting from seven days to one year separated by painfree periods lasting one month or longer, while a diagnosis of CCH requires attacks to occur for more than one year without remission or with remission lasting less than one month. CCH affects about 10% of CH patients. General aspects of therapy of the disorder are covered elsewhere. 4,5 While it is not directly germane to neuromodulatiuon approaches, an understanding of the broad issues in medical treatment serves as a useful backdrop against which to discuss newer approaches. CH is one of the trigeminal autonomic cephalalgias, 6 and their therapies are usefully considered to be background 7 as they also can be considered for these newer approaches. Who Is Suitable for Neuromodulation Approaches?It seems reasonable to suggest that neuromodulation approaches to the management of CH be employed in patients with medically intractable forms of the condition. While this is currently true, it reflects the relatively primitive state of current interventions. One should observe that as devices become less invasive, the threshold for their use will become lower. For the moment there is a proposed working definition of medically intractable CH. 8 The essential components are disabling headache that fails at least four preventative drugs, including two from the first three of verapamil, lithium, methysergide, melatonin, topiramate and gabapentin (see Table 2). These considerations are particular to CH and, naturally, generic considerations related to requirements for the devices -such as fitness for anesthesia -are part of the overall assessment of patient suitability. What Approaches Have Been Tried?In essence, two classes of neuromodulation have been explored in CH:peripheral and central. Prior to moving to stimulation approaches, the dreadful pain and disability of medically intractable CH lead to a number of destructive procedures. In principle, these seem unlikely to work if one considers CH as fundamentally being a brain condition. Moreover, they may cause both mortality and significant morbidity, and can induce further pain problems such as anaesthesia dolorosa. Neuromodulatory Approaches to the Management of Medically Refractory Cluster Headache AbstractThe trigeminal autonomic cephalalgias are a group of primary headache disorders characterised by unilateral trigeminal d...

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“…57 The identification using functional imaging methods of an important role for the region of the posterior hypothalamic grey matter in cluster headache 58 lead to the use of deep brain stimulation in that region to treat medically intractable CCH. 59 While this has been an effective strategy, it is not without concerns and its application prior to occipital nerve stimulation is questionable. 60 Occipital nerve stimulation Occipital nerve stimulation (ONS) has been used in primary headache syndromes, based on the interaction between trigeminal and cer vical nociceptive inputs in the trigeminocervical complex 61 and functional imaging findings in chronic migraine patients with ONS.…”

Section: Neuromodulatory Proceduresmentioning

confidence: 99%

Prevention and treatment of cluster headache

Cohen¹,

Goadsby²

2009

Prog Neurol Psychiatry

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CCluster headache (CH) is a stereotypical primar y headache syndrome, characterised by attacks of unilateral excruciating pain usually in the eye, periorbital region and temple, with associated cranial autonomic symptoms such as conjunctival injection, lacrimation, nasal blockage, rhinorrhea, ptosis, and eyelid oedema. Restlessness and agitation also feature prominently. Attacks last for 15-180 minutes, and have a frequency of one every other day up to eight a day. 1 They can be triggered by alcohol, 2 usually in under an hour, in contrast to migraine for which alcohol typically takes longer to trigger an attack. CH attacks often occur with so-called clock-like regularity, and may be precipitated by sleep.CH has a prevalence of 0.1 to 0.3 per cent in the general population, 3 and affects slightly more men than women, with a male: female ratio of 2.5:1 in a recent study. 2 Episodic cluster headache (ECH) is defined as bouts of attacks lasting from seven days up to one year, with breaks of one month or more between bouts. In chronic cluster headache (CCH) attacks occur for more than one year without remission, or with remissions lasting less than one month. In CCH there are micro-periods, and seasonal variation is sometimes seen. Unaware of this, clinicians and patients may feel prophylactics have 'stopped working' although in fact the disorder has changed. Over years this can lead to a creeping upwards of medicine doses and eventual accrual of side-effects. If one is aware of the phenomenon of periodicity even in CCH, the physician can, after a period of increased dosing, revert to the previous dose, or preferably use other strategies for short-term care to avoid changing the baseline preventive dose.CH is probably the most severe pain known to humans, with female patients describing each attack as worse than childbirth. Health-related quality of life is significantly impaired in CH suf ferers. 4,5 Even though it is under-recognised and often suboptimally managed in primary care, 6,7 an early diagnosis and prompt treatment are essential to alleviate the devastating morbidity of these attacks. 8 DiagnosisThe diagnosis is usually clear on taking a thorough history. The presence of autonomic symptoms, restlessness, and the length of the attacks usually distinguishes this from migraine, although a proportion of migraine patients may exhibit cranial autonomic features, 9-11 and migraine can coexist with CH by chance. The differential diagnosis for CH includes the other trigeminal autonomic cephalalgias (TACs), which are paroxysmal hemicrania (PH) and SUNCT (shor t-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing), although these dif fer from CH in that the attack lengths are shorter. 1 There is considerable overlap in attack frequency, such that typical CH patients have one to two attacks a day, typical PH patients 10 and typical SUNCT/SUNA patients 50, there is a marked skew that favours lower attack frequencies. 12 Another useful clinical pointer is the lateralisation of photo...

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Hypothalamic stimulation for intractable cluster headache: Long-term experience

Cited by 210 publications

References 9 publications

Botulinum toxin type-A therapy in cluster headache: an open study

Botulinum toxin type-A therapy in cluster headache: an open study

Neuromodulatory Approaches to the Management of Medically Refractory Cluster Headache

Prevention and treatment of cluster headache

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