Feasibility of simultaneous vagal nerve and deep brain stimulation in chronic cluster headache: case report and considerations

Deep brain stimulation (DBS) of the posterior hypothalamus was found to be effective in the treatment of drug-resistant chronic cluster headache. We report the results of a multicentre case series of six patients with chronic cluster headache in whom a DBS in the posterior hypothalamus was performed. Electrodes were implanted stereotactically in the ipsilateral posterior hypothalamus according to published coordinates 2 mm lateral, 3 mm posterior and 5 mm inferior referenced to the mid-AC-PC line. Microelectrode recordings at the target revealed single unit activity with a mean discharge rate of 17 Hz (range 13-35 Hz, n = 4). Out of six patients, four showed a profound decrease of their attack frequency and pain intensity on the visual analogue scale during the first 6 months. Of these, one patient was attack free for 6 months under neurostimulation before returning to the baseline which led to abortion of the DBS. Two patients had experienced only a marginal, non-significant decrease within the first weeks under neurostimulation before returning to their former attack frequency. After a mean follow-up of 17 months, three patients are almost completely attack free, whereas three patients can be considered as treatment failures. The stimulation was well tolerated and stimulation-related side-effects were not observed on long term. DBS of the posterior inferior hypothalamus is an effective therapeutic option in a subset of patients. Future controlled multi-centre trials will need to confirm this open-label experience and should help to better define predictive factors for non-responders.

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Secondary chronic cluster headache treated by posterior hypothalamic deep brain stimulation: First reported case

Cephalalgia ◽

10.1177/0333102412468675 ◽

2012 ◽

Vol 33 (2) ◽

pp. 136-138 ◽

Cited By ~ 15

Author(s):

Giuseppe Messina ◽

Michele Rizzi ◽

Roberto Cordella ◽

Augusto Caraceni ◽

Ernesto Zecca ◽

...

Keyword(s):

Deep Brain Stimulation ◽

Cluster Headache ◽

Brain Stimulation ◽

Soft Tissues ◽

Chronic Cluster Headache ◽

Successful Outcome ◽

The Right ◽

Fondazione Irccs ◽

Deep Brain

Introduction Deep brain stimulation (DBS) of the posterior hypothalamus (pHyp) has been reported as an effective treatment for primary, drug-refractory and chronic cluster headache (CCH). We here describe the use of such a procedure for the treatment of secondary CCH due to a neoplasm affecting the soft tissues of the right hemiface. Methods A 27-year-old man affected by infiltrating angiomyolipoma of the right hemiface who subsequently developed drug refractory homolateral CCH underwent DBS of the right pHyp region at the Fondazione IRCCS Istituto Nazionale Neurologico Carlo Besta. Results After surgery, the patient presented a significant reduction in frequency of pain bouts. However, because of a subsequent infection, the entire system was removed. After re-implantation of the system, successful outcome was observed at 2 years follow-up. Discussion This brief report shows the feasibility of pHyp DBS in secondary drug-refractory CCH syndromes; future reports are needed in order to confirm our positive result.

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Ventral tegmental area deep brain stimulation for chronic cluster headache: Effects on cognition, mood, pain report behaviour and quality of life

Cephalalgia ◽

10.1177/0333102419839957 ◽

2019 ◽

Vol 39 (9) ◽

pp. 1099-1110 ◽

Cited By ~ 5

Author(s):

Davide Cappon ◽

Agata Ryterska ◽

Susie Lagrata ◽

Sarah Miller ◽

Harith Akram ◽

...

Keyword(s):

Quality Of Life ◽

Deep Brain Stimulation ◽

Cluster Headache ◽

Ventral Tegmental Area ◽

Brain Stimulation ◽

Rating Scale ◽

Chronic Cluster Headache ◽

Headache Frequency ◽

Deep Brain

Background Deep brain stimulation in the ventral tegmental area (VTA-DBS) has provided remarkable therapeutic benefits in decreasing headache frequency and severity in patients with medically refractory chronic cluster headache (CH). However, to date the effects of VTA-DBS on cognition, mood and quality of life have not been examined in detail. Methods The aim of the present study was to do so in a case series of 18 consecutive patients with cluster headache who underwent implantation of deep brain stimulation electrodes in the ventral tegmental area. The patients were evaluated preoperatively and after a mean of 14 months of VTA-DBS on tests of global cognition (Mini Mental State Examination), intelligence (Wechsler Abbreviated Scale of Intelligence), verbal memory (California Verbal Learning Test-II), executive function (Delis–Kaplan Executive Function System), and attention (Paced Auditory Serial Addition Test). Depression (Beck Depression Inventory and Hospital Anxiety and Depression Rating Scale-D), anxiety (Hospital Anxiety and Depression Rating Scale-A), apathy (Starkstein Apathy Scale), and hopelessness (Beck Hopelessness Scale) were also assessed. Subjective pain experience (McGill Pain Questionnaire), behaviour (Pain Behaviour Checklist) and quality of life (Short Form-36) were also evaluated at the same time points. Results VTA-DBS resulted in significant improvement of headache frequency (from a mean of five to two attacks daily, p < .001) and severity (from mean Verbal Rating Scale [VRS] of 10 to 7, p < .001) which was associated with significant reduction of anxiety (from mean HADS-A of 11.94 to 8.00, p < .001) and help-seeking behaviours (from mean PBC of 4.00 to 2.61, p < .001). VTA-DBS did not produce any significant change to any tests of cognitive function and any other outcome measures (BDI, HADS-D, SAS, BHS, McGill Pain Questionnaire, Short Form-36). Conclusion We confirm the efficacy of VTA-DBS in the treatment of medically refractory chronic cluster headache. The reduction of headache frequency and severity was associated with a significant reduction of anxiety. Furthermore, the result suggests that VTA-DBS for chronic cluster headache improves pain-related help-seeking behaviours and does not produce any change in cognition.

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Deep Brain Stimulation for Chronic Cluster Headache: Meta‐Analysis of Individual Patient Data

Annals of Neurology ◽

10.1002/ana.25887 ◽

2020 ◽

Vol 88 (5) ◽

pp. 956-969

Author(s):

Andreas Nowacki ◽

Martin Schober ◽

Lydia Nader ◽

Assel Saryyeva ◽

Thuy‐Anh Khoa Nguyen ◽

...

Keyword(s):

Deep Brain Stimulation ◽

Cluster Headache ◽

Brain Stimulation ◽

Individual Patient Data ◽

Meta Analysis ◽

Chronic Cluster Headache ◽

Patient Data ◽

Deep Brain

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Deep Brain Stimulation for Intractable Chronic Cluster Headache: Proposals for Patient Selection

Cephalalgia ◽

10.1111/j.1468-2982.2004.00742.x ◽

2004 ◽

Vol 24 (11) ◽

pp. 934-937 ◽

Cited By ~ 133

Author(s):

M Leone ◽

A May ◽

A Franzini ◽

G Broggi ◽

D Dodick ◽

...

Keyword(s):

Electrical Stimulation ◽

Deep Brain Stimulation ◽

Cluster Headache ◽

Brain Stimulation ◽

Brain Area ◽

Chronic Cluster Headache ◽

Primary Headaches ◽

Positron Emission ◽

Academic Medical ◽

Deep Brain

Cluster headache is the most severe of the primary headaches. Positron emission tomography and functional MRI studies have shown that the ipsilateral posterior hypothalamus is activated during cluster headache attacks and is structurally asymmetric in these patients. These changes are highly specific for the condition and suggest that the cluster headache generator may be located in that brain area; they further suggest that electrical stimulation of that region might produce clinical improvement in chronic cluster headache sufferers refractory to medical therapy. In five patients with severe intractable chronic cluster headache, hypothalamic electrical stimulation produced complete and long-term pain relief with no relevant side-effects. We therefore consider it essential to propose criteria for selecting chronic cluster headache patients for hypothalamic deep brain stimulation before this procedure is undertaken at other academic medical centres.

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Deep brain stimulation of posterior hypothalamic area for cluster headache

Cephalalgia Reports ◽

10.1177/2515816318771334 ◽

2018 ◽

Vol 1 ◽

pp. 251581631877133 ◽

Cited By ~ 1

Author(s):

Antti Huotarinen ◽

Mikko Kallela ◽

Ville Artto ◽

Aki Laakso ◽

Riku Kivisaari

Keyword(s):

Deep Brain Stimulation ◽

Cluster Headache ◽

Brain Stimulation ◽

Treatment Effect ◽

Chronic Cluster Headache ◽

University Hospital ◽

Hypothalamic Area ◽

Headache Patients ◽

Deep Brain ◽

Stimulation Of

Background: Deep brain stimulation of the posterior hypothalamic area is one of the neuromodulation treatments used for chronic cluster headache, but the number of published patients remains low. Aim: The aim of this article was to present the retrospective results of 12 consecutive chronic cluster headache patients treated with deep brain stimulation at Helsinki University Hospital. Materials and Methods: All chronic cluster headache patients treated with deep brain stimulation between 2004 and 2012 were included in the study. Patients were interviewed and their hospital files analyzed. Treatment effect was classified as good, partial, or no effect. Results: Of the 12 patients, four had a good treatment effect, five had partial, and three had no effect of deep brain stimulation. In contrast to previous studies, our patients reported an almost immediate benefit after the onset of stimulation. Conclusions: Deep brain stimulation provides clinically meaningful benefit to a subgroup of chronic cluster headache patients.

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Optimal deep brain stimulation site and target connectivity for chronic cluster headache

Neurology ◽

10.1212/wnl.0000000000004646 ◽

2017 ◽

Vol 89 (20) ◽

pp. 2083-2091 ◽

Cited By ~ 27

Author(s):

Harith Akram ◽

Sarah Miller ◽

Susie Lagrata ◽

Marwan Hariz ◽

John Ashburner ◽

...

Keyword(s):

Deep Brain Stimulation ◽

Cluster Headache ◽

Brain Stimulation ◽

Structural Connectivity ◽

Chronic Cluster Headache ◽

Pain Modulation ◽

Stimulation Site ◽

Surgical Morbidity ◽

Deep Brain

Objective:To investigate the mechanism of action of deep brain stimulation for refractory chronic cluster headache and the optimal target within the ventral tegmental area.Methods:Seven patients with refractory chronic cluster headache underwent high spatial and angular resolution diffusion MRI preoperatively. MRI-guided and MRI-verified electrode implantation was performed unilaterally in 5 patients and bilaterally in 2. Volumes of tissue activation were generated around active lead contacts with a finite-element model. Twelve months after surgery, voxel-based morphometry was used to identify voxels associated with higher reduction in headache load. Probabilistic tractography was used to identify the brain connectivity of the activation volumes in responders, defined as patients with a reduction of ≥30% in headache load.Results:There was no surgical morbidity. Average follow-up was 34 ± 14 months. Patients showed reductions of 76 ± 33% in headache load, 46 ± 41% in attack severity, 58 ± 41% in headache frequency, and 51 ± 46% in attack duration at the last follow-up. Six patients responded to treatment. Greatest reduction in headache load was associated with activation in an area cantered at 6 mm lateral, 2 mm posterior, and 1 mm inferior to the midcommissural point of the third ventricle. Average responders' activation volume lay on the trigeminohypothalamic tract, connecting the trigeminal system and other brainstem nuclei associated with nociception and pain modulation with the hypothalamus, and the prefrontal and mesial temporal areas.Conclusions:We identify the optimal stimulation site and structural connectivity of the deep brain stimulation target for cluster headache, explicating possible mechanisms of action and disease pathophysiology.

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