Cluster Headache—Acute and Prophylactic Therapy

Avi Ashkenazi, MD; Todd Schwedt, MD

Disclosures

Headache. 2011;51(2):272-286. 

In This Article

Deep Brain (Hypothalamic) Stimulation

Leone et al reported in 2001 on a 39-year-old man with intractable CH whose attacks improved significantly after implantation of a stimulating electrode to the posterior hypothalamus, ipsilateral to the pain.[72] Since this first report, several studies have been published on the efficacy and tolerability of hypothalamic stimulation (HS) for CH.[73–75] Schoenen et al examined the effect of unilateral HS in 6 refractory CCH patients.[73] Three patients had "excellent" results, while another had only a transient remission. In 1 patient treatment had to be stopped because of AEs (autonomic disturbances and panic attacks), and 1 died of intracerebral hemorrhage shortly after the procedure. Leone et al reported on the long-term results of 16 previously refractory CCH patients who had HS.[74] At a mean follow-up of 23 months, major improvement in pain, or complete pain elimination, was obtained in 13 (81%) patients. The mean time to headache benefit was 42 days. Overall, the procedure was well tolerated. No hormonal, affective or sleep-related abnormalities were observed. One patient had an asymptomatic intracerebral hemorrhage that subsequently resolved. Transient diplopia was a common AE with high amplitude stimulation. Bartsch et al reported on 6 CCH patients who underwent HS.[75] At a mean follow-up of 17 months, 3 patients responded well to treatment, being almost attack free, while 3 patients failed to respond. The procedure was well tolerated. The authors concluded that HS is effective in a subset of refractory CCH patients. Interestingly, in another study, HS was not effective in the majority of patients when used as an acute CH treatment, suggesting that this treatment affects CH through more complex pain modulating mechanisms.[76,77]

In summary, HS is an emerging viable treatment for refractory CCH. It appears to be effective in some, but not all, patients. Although the treatment is generally well tolerated, the risk of intraceberal hemorrhage, and even death, should be kept in mind when considering this treatment option.

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