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Trigeminal Autonomic Cephalgias – From Pathophysiology to Neurostimulation
the trigeminocervical complex. However, occipital nerve stimulation has Spontaneous attack regression is known to occur in chronic cluster
also shown a certain efficacy against drug-resistant migraine, suggesting headache. In order to distinguish spontaneous from stimulation-
a non-specific pain-relief mechanism.
induced improvement, the stimulator should be switched off,
preferably unknown to the patient (placebo can improve pain in over
Two recent studies addressed the efficacy of GON stimulation in 40% of cluster headache cases
), in order to determine whether and
cluster headache. In one,
five of eight operated patients became how promptly attacks reappear.
pain-free or had headache frequency reduced by over 90%. Outset
headache frequency was not homogeneous – although three had In the second report on GON stimulation in chronic cluster headache
multiple daily attacks, two had one attack per day and three had one only three of eight (38%) operated patients improved. Nevertheless,
to two attacks per week – and overall frequency was in fact much when asked, all patients said they would recommend the operation to
lower than reported in other surgical series, making efficacy others with cluster headache. Factors other than pain relief per se might
comparisons difficult. It is unclear whether patients with just one to lead patients to express such positive judgements, and the discrepancy
two attacks a week should undergo invasive surgical procedures. between their opinions and established headache severity measures
Furthermore, follow-up was short in three patients (two had four suggest the former may not be the most appropriate way to report on
months of follow-up and one had two months of follow-up), and only the efficacy of a surgical procedure in primary headaches.
four patients had sufficiently long follow-up (over one year) to provide
a useful indication of outcome. In these four cases, four to 10 months Acknowledgement
were required for the improvements to become manifest. The author thanks Don Ward for help with the English.
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