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Headache
ipsilateral anterior cingulate cortex (Brodmann areas 24 and 32) and mode.
37
In many cases, the crises returned when the stimulator was
bilateral cerebellum, but not to the hypothalamus.
28
switched off (unknown to the patient).
Deep Brain Stimulation in Trigeminal Similar results were obtained at another centre.
38
After a mean
Autonomic Cephalgias follow-up of 14.5 months, the authors concluded that the technique
was effective for intractable chronic cluster headache, although the
Deep Brain Stimulation in Cluster Headache benefit was not immediate and frequent adjustment of stimulation
As noted, hypothalamic grey matter activation appears to be specific parameters was required. However, one of the six patients died soon
to TAC attacks, and does not occur in migraine
20,21
or in experimentally after the operation due to implantation-induced intra-cerebral
induced trigeminal pain.
29
Furthermore, voxel-based morphometry
22
haemorrhage, and implantation had to be stopped intra-operatively in
has identified an anatomical anomaly (increased neuronal density) in another patient due to panic attack.
the posterior inferior hypothalamic grey matter of cluster patients
in remission that is plausibly responsible for the headache. These
findings suggested a new therapeutic approach to cluster headache.
In comparison with the use of deep brain stimulation (DBS) to treat
…it appears that specific occipital nerve
intractable movement disorders, stereotactic stimulation of the
block is not more effective than simple
hypothalamus appeared attractive as a means of interfering with
the supposed cluster generator to relieve intractable cluster headache subcutaneous infiltration.
pain.
31
A new therapeutic approach to cluster headache was necessary
because the condition is chronic in about 15% of cases, and a
proportion of these do not respond to any drugs.
Other authors have encouraging results. Starr et al.
39
and Bartsch et
Destructive surgery that interrupts the trigeminal sensory or cranial al.
40
reported that at least 50% of their patients were pain-free with
parasympathetic pathways is an option, but lasting benefit is obtained in no serious side effects after over one year of follow-up. Two other
few cases.
32–35
Trigeminal sensory rhizotomy, percutaneous radio- patients with intractable chronic cluster headache received
frequency trigeminal gangliorhizolysis and microvascular trigeminal nerve hypothalamic stimulation elsewhere and have a mean follow-up of
decompression are procedures sometimes reported as successful.
32–34
two years.
41
Both became pain-free after about one month
However, complications may be severe and include diplopia, hyperacusia, of stimulation. One relapsed, but improved again after the stimulation
jaw deviation, corneal ulcers, corneal anaesthesia and anaesthesia voltage was increased.
41
dolorosa.
32–35
When cluster headaches alternate sides, the risk of a
contralateral recurrence after surgery is high.
32
No significant alterations in hypothalamus-controlled functions have
been observed during continuous hypothalamic stimulation.
42,43
Our group first tried hypothalamic stimulation in a patient with chronic However, since the hypothalamus has not previously been chronically
intractable cluster headache who suffered alternating side attacks.
31,36
stimulated in humans, autonomic function, hormone levels,
Hypothalamic stimulation on the left greatly improved the left-side cardiovascular function, behaviour, mood and sleep–waking cycle must
attacks, but the right-side attacks persisted, despite four previous be monitored in all patients, particularly when the stimulator is on.
42,43
destructive operations on the right trigeminal nerve. Implant and
continuous hypothalamic stimulation on the right completely resolved Deep Brain Stimulation in Short-lasting Unilateral
the right-side pain.
36
Neuralgiform Headache Attacks with Conjuctival
Injection and Tearing
Increased blood flow through the ipsilateral posterior inferior
hypothalamus, compatible with activation, has been demonstrated by
Electrode implantation to the brain
functional MRI during SUNCT attacks.
25
This finding led us to propose
hypothalamic stimulation to a 66-year-old woman with a two-year history
carries a small risk of mortality due to
of daily drug-refractory SUNCT attacks. She obtained marked benefit from
intra-cerebral haemorrhage. the procedure and had no adverse events, reinforcing the hypothesis of
crucial hypothalamic involvement in TAC pathophysiology.
44
Greater Occipital Nerve Stimulation in Cluster Headache
Eighteen hypothalamic implants in 16 cluster headache patients have Although it now seems clear that the hypothalamus is involved in the
since been performed at our centre. All had suffered drug-resistant pathophysiology of TACs, the role, if any, of the GON is obscure. Some
daily attacks for years and were unable to work. After a mean studies report transient improvement of episodic and chronic cluster
follow-up of over two years, 11 (61%) are completely pain-free and headache after steroid infiltration of the ‘occipital area’,
45,46
and it appears
over 70% of post-operative days are crisis-free.
37
Most patients that specific occipital nerve block is not more effective than simple
resumed work. The benefit developed over a variable period (mean six subcutaneous infiltration.
47
Sensory fibres of the GON travel the occipital
weeks) and required frequent adjustment of stimulation amplitude. nerve to flow into the trigeminocervical complex – as do all sensory nerves
Stimulation parameters are amplitude 1–3.3V (typical range), of the head and upper cervical regions. It may be, therefore, that occipital
frequency 180Hz and pulse-width 60µsec in continuous unipolar nerve manipulation can improve cluster headache by neuromodulation of
30 EUROPEAN NEUROLOGICAL DISEASE 2007
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