Neuromodulatory Approaches to the Management of Medically Refractory Cluster Headache

The trigeminal autonomic cephalalgias are a group of primary headache disorders characterized by unilateral trigeminal distribution of pain that occurs in association with ipsilateral cranial autonomic features. The most prominent one is cluster headache, a dreadful disease with excrutiating pain attacks. These attacks last no longer than two hours but may occur several times per day. It is mandatory to find an efficient therapy for these patients, but some are unresponsive to all treatments. In these intractable cases invasive procedures are introduced, but the available evidence (while conflicting) illustrates that trigeminal denervation may not be effective in preventing the headache attacks or autonomic symptoms of chronic cluster headache. Modern neurostimulating approaches, such as stimulation of the greater occipital nerve and hypothalamic deep brain stimulation, supersede neurodestructive procedures. Both stimulation methods are exquisite and potentially life-saving treatment options in otherwise intractable patients, but they need to be better characterized and further long-term data are needed.

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Neuromodulatory Approaches to the Management of Medically Refractory Cluster Headache

European Neurological Review ◽

10.17925/enr.2010.05.01.97 ◽

2010 ◽

Vol 5 (1) ◽

pp. 97

Author(s):

Arne May ◽

Peter J Goadsby ◽

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Keyword(s):

Cluster Headache ◽

Treatment Options ◽

Primary Headache ◽

Chronic Cluster Headache ◽

Primary Headache Disorders ◽

Greater Occipital Nerve ◽

Term Data ◽

Deep Brain ◽

Stimulation Of

The trigeminal autonomic cephalalgias are a group of primary headache disorders characterised by unilateral trigeminal distribution of pain that occurs in association with ipsilateral cranial autonomic features. The most prominent one is cluster headache, a dreadful disease with excrutiating pain attacks. These attacks last no longer than two hours but may occur several times per day. It is mandatory to find an efficient therapy for these patients, but some are unresponsive to all treatments. In these intractable cases invasive procedures are introduced, but the available evidence (while conflicting) illustrates that trigeminal denervation may not be effective in preventing the headache attacks or autonomic symptoms of chronic cluster headache. Modern neurostimulating approaches, such as stimulation of the greater occipital nerve and hypothalamic deep brain stimulation, supersede neurodestructive procedures. Both stimulation methods are exquisite and potentially lifesaving treatment options in otherwise intractable patients, but they need to be better characterised and further long-term data are needed.

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Mere surgery will not cure cluster headache – implications for neurostimulation

Cephalalgia ◽

10.1177/0333102410373157 ◽

2010 ◽

Vol 31 (1) ◽

pp. 112-115 ◽

Cited By ~ 17

Author(s):

Ute Hidding ◽

Arne May

Keyword(s):

Cluster Headache ◽

Treatment Method ◽

Chronic Cluster Headache ◽

Target Area ◽

Hypothalamic Syndrome ◽

Stimulation Parameters ◽

Life Saving ◽

Greater Occipital Nerve ◽

Deep Brain

This case study concerns a patient with primary chronic cluster headache, who was unresponsive to all treatments and consecutively underwent hypothalamic deep brain stimulation (DBS). DBS had no effect on the cluster attacks, but cured an existing polydipsia as well as restlessness. However, hypothalamic DBS produced a constant, dull headache without concomitant symptoms and a high-frequent tremor. All of these effects were repeated when the stimulation was stopped and than started again. DBS had no effect on a pathological weight gain from 70 kg to 150 kg due to bulimia at night, usually during headache attacks. This case illustrates that cluster headache is, in some patients, only one symptom of a complex hypothalamic syndrome. This case also underlines that the stimulation parameters and anatomical target area for hypothalamic DBS may be too unspecific to do justice to the clinical variety of patients and concomitant symptoms. Hypothalamic DBS is an exquisite and potentially life-saving treatment method in otherwise intractable patients, but needs to be better characterised and should only be considered when other stimulation methods, such as stimulation of the greater occipital nerve, are unsuccessful.

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TM2-5 Percutaneous electrical nerve stimulation (PENS) therapy for refractory primary headache disorders: a pilot study

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp-2019-abn.43 ◽

2019 ◽

Vol 90 (3) ◽

pp. e14.1-e14

Author(s):

MW Weatherall ◽

D Nandi

Keyword(s):

Cluster Headache ◽

Treatment Options ◽

Primary Headache ◽

Cervicogenic Headache ◽

Chronic Cluster Headache ◽

Hemicrania Continua ◽

Single Shot ◽

Headache Disorders ◽

Trigeminal Neuropathy ◽

Primary Headache Disorders

ObjectivesPrimary headache disorders are common, but many patients are refractory to medical treatment. PENS therapy involves the stimulation of one or more individual nerves or dermatomes using needle probes. We assessed whether a ‘single shot with single probe’ strategy would benefit patients with refractory headache disorders, including chronic migraine (CM), and chronic cluster headache (CCH).DesignService evaluation of 36 patients treated with PENS therapy between September 2012 and June 2016. Follow-up data was available for 33 patients.Subjects16 patients with CM, nine with CCH, and one with hemicrania continua. Secondary headaches comprised occipital neuralgia, cervicogenic headache, and trigeminal neuropathy.MethodsPENS was given using Algotec® disposable 21 gauge PENS therapy probes (8 cm) to the occipital nerve ipsilateral to the pain (or bilaterally in cases of bilateral pain). Stimulation was delivered at 2 Hz/100 Hz, at 3 cycles/second, between 1.2–2.5 V depending on patient tolerability, for 25–28 min.Results6/9 patients with CCH improved significantly after the first session. In all patients with CCH, PENS therapy was well tolerated, with no significant adverse events reported. One patient with CCH reverted to episodic cluster. Only four patients with CM experienced any benefit.ConclusionsPENS therapy shows potential as a relatively non-invasive, low-risk, and inexpensive component of the treatment options for refractory primary headache disorders, particularly chronic cluster headache.

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Cluster Headache and Other Trigeminal Autonomic Cephalalgias

Seminars in Neurology ◽

10.1055/s-0038-1673682 ◽

2018 ◽

Vol 38 (06) ◽

pp. 603-607

Author(s):

Brian McGeeney

Keyword(s):

Cluster Headache ◽

Health Care Providers ◽

Treatment Options ◽

Primary Headache ◽

Trigeminal Autonomic Cephalalgias ◽

Care Providers ◽

Private Industry ◽

Primary Headache Disorders ◽

New Treatments ◽

Delays In Diagnosis

AbstractThe trigeminal autonomic cephalalgias are a group of distinct primary headache disorders that share common characteristics of strict unilateral headache often accompanied by unilateral cranial autonomic features. Cluster headache is the most well-known example, but other than neurologists, practitioners often have limited familiarity with these disorders and treatment options. Delays in diagnosis are typical and treatment options remain suboptimal, associated with limited scientific research into these brain disorders. Improved familiarity with core clinical features by health care providers should lead to earlier referral to specialists, and this education is the responsibility of headache medicine specialists. Optimistically, the last few years have seen lobbying for more federal research support in headache medicine and there has been renewed interest by private industry in potential new treatments for trigeminal autonomic cephalalgias.

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EHMTI-0312. Long term efficiency and tolerability of greater occipital nerve infiltrations in primary headache disorders

The Journal of Headache and Pain ◽

10.1186/1129-2377-15-s1-g44 ◽

2014 ◽

Vol 15 (S1) ◽

Author(s):

S Lim ◽

T Young

Keyword(s):

Primary Headache ◽

Headache Disorders ◽

Occipital Nerve ◽

Primary Headache Disorders ◽

Greater Occipital Nerve

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Neurostimulation Treatment in Chronic Cluster Headache—a Narrative Review

Current Pain and Headache Reports ◽

10.1007/s11916-021-00989-6 ◽

2021 ◽

Vol 25 (12) ◽

Author(s):

Stefan Evers ◽

Oliver Summ

Keyword(s):

Deep Brain Stimulation ◽

Cluster Headache ◽

Brain Stimulation ◽

Nerve Stimulation ◽

Case Series ◽

Chronic Cluster Headache ◽

Narrative Review ◽

Controlled Clinical Trial ◽

Greater Occipital Nerve ◽

Deep Brain

Abstract Purpose of Review In this narrative review, the current literature on neurostimulation methods in the treatment of chronic cluster headache is evaluated. These neurostimulation methods include deep brain stimulation, vagus nerve stimulation, greater occipital nerve stimulation, sphenopalatine ganglion stimulation, transcranial magnetic stimulation, transcranial direct current stimulation, supraorbital nerve stimulation, and cervical spinal cord stimulation. Recent Findings Altogether, only nVNS and SPG stimulation are supported by at least one positive sham-controlled clinical trial for preventive and acute attack (only SPG stimulation) treatment. Other clinical trials either did not control at all or controlled by differences in the stimulation technique itself but not by a sham-control. Case series report higher responder rates. Summary The evidence for these neurostimulation methods in the treatment of chronic cluster headache is poor and in part contradictive. However, except deep brain stimulation, tolerability and safety of these methods are good so that in refractory situations application might be justified in individual cases.

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Long-Term Results of Deep Brain Stimulation of the Mamillotegmental Fasciculus in Chronic Cluster Headache

Stereotactic and Functional Neurosurgery ◽

10.1159/000489937 ◽

2018 ◽

Vol 96 (4) ◽

pp. 215-222 ◽

Cited By ~ 10

Author(s):

Fernando Seijo-Fernandez ◽

Antonio Saiz ◽

Elena Santamarta ◽

Lydia Nader ◽

Marco Antonio Alvarez-Vega ◽

...

Keyword(s):

Deep Brain Stimulation ◽

Cluster Headache ◽

Brain Stimulation ◽

Chronic Cluster Headache ◽

Long Term Results ◽

Deep Brain ◽

Stimulation Of

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Long-term use of daily sumatriptan injections in severe drug-resistant chronic cluster headache: Table

Neurology ◽

10.1212/wnl.0000000000002117 ◽

2015 ◽

Vol 86 (2) ◽

pp. 194-195 ◽

Cited By ~ 11

Author(s):

Massimo Leone ◽

Alberto Proietti Cecchini

Keyword(s):

Cluster Headache ◽

Chronic Cluster Headache ◽

Drug Resistant

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TRIGEMINAL NERVE RADIOSURGICAL TREATMENT IN INTRACTABLE CHRONIC CLUSTER HEADACHE

Neurosurgery ◽

10.1227/01.neu.0000245612.86484.7 ◽

2006 ◽

Vol 59 (6) ◽

pp. 1252-1257 ◽

Cited By ~ 22

Author(s):

Anne Donnet ◽

Manabu Tamura ◽

Dominique Valade ◽

Jean Régis

Keyword(s):

Trigeminal Neuralgia ◽

Cluster Headache ◽

Trigeminal Nerve ◽

Chronic Cluster Headache ◽

High Rate ◽

Long Term Results ◽

Complete Relief ◽

Term Evaluation ◽

The One

Abstract OBJECTIVE We have previously reported short-term results of a prospective open trial designed to evaluate trigeminal nerve radiosurgical treatment in intractable chronic cluster headache (CCH). Medium- and long-term results have not yet been reported. METHODS Ten patients presenting with a severe and drug-resistant CCH were enrolled (nine men, one woman). The radiosurgical treatment was performed according to the technique usually used for trigeminal neuralgia in our department. A single 4-mm shot was positioned at the level of the cisternal portion of the trigeminal nerve. The median distance between the center of the shot and the emergence of the nerve was 9.35 mm (range, 7.5–13.3 mm). The median of this maximum dose to the brainstem was 8.0 Gy (range, 4.0–11.1 Gy). Mean age was 49.8 years (range, 32–77 yr). Mean duration of the CCH was 9 years (range, 2–33 yr). The mean follow-up period was 36.3 months (range, 24–48 mo). RESULTS Two patients had complete relief of CCH. One patient had a good result with evolution in an episodic form. Seven patients had no improvement. Nine patients developed a new trigeminal nerve disturbance: three developed paresthesia with no hypoesthesia and six developed hypoesthesia, including two patients with deafferentation pain. Only one patient had neither paresthesia nor hypoesthesia. CONCLUSION We confirmed, with medium- and long-term evaluation, the high rate of toxicity and failure of the technique. The high toxicity, despite a methodology identical to the one used in trigeminal neuralgia, leads us to suspect an underlying specificity of the nerve in CCH. We do not recommend radiosurgery for treatment of intractable CCH.

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