title: Success, failure, and putative mechanisms in hypothalamic stimulation for drug-resistant chronic cluster headache.
abstract: Drug-resistant chronic cluster headache (CH) is an unremitting illness with excruciatingly severe headaches that occur several times daily. Starting in 2000, a total of 19 patients with long-lasting chronic CH, with multiple daily attacks unresponsive to all known prophylactics, received stimulation of the posterior inferior hypothalamic area ipsilateral to the pain as treatment. We report long-term follow-up (median 8.7 years, range 6-12 years) in 17 patients. Long-lasting improvement occurred in 70% (12 of 17): 6 are persistently almost pain-free; another 6 no longer experience daily attacks but rather episodic CH interspersed with long-lasting remissions. In 5 of 6 almost pain-free patients, the stimulators have been off for a median of 3 years (range 3-4 years). Five patients did not improve: 4 had bilateral CH, and 3 developed tolerance after experiencing relief for 1-2 years. Adverse events are electrode displacement (n=2), infection (electrode n=3; generator n=1), electrode malpositioning (n=1), transient nonsymptomatic third ventricle hemorrhage (n=1), persistent slight muscle weakness on one side (n=1), and seizure (n=1). This exceptionally long follow-up shows that hypothalamic stimulation for intractable chronic CH produces long-lasting improvement in many patients. Previous experience was limited to a median of 16 months. Important new findings are as follows: stimulation is well tolerated for many years after implantation; after several years during which stimulation was necessary for relief, a persistent almost pain-free condition can be maintained when stimulation is off, suggesting that hypothalamic stimulation can change disease course; tolerance can occur after marked long-lasting improvement; and bilateral chronic CH seems to predict poor response to hypothalamic stimulation.
authors.affiliation: Department of Neurology, Headache Centre and Pain Neuromodulation Unit, Fondazione Istituto Nazionale Neurologico Carlo Besta, Milano, Italy Department of Neurosurgery, Fondazione Istituto Nazionale Neurologico Carlo Besta, Milano, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Leone
authors.forename: Angelo
authors.initials: A
authors.lastname: Franzini
authors.forename: Alberto Proietti
authors.initials: AP
authors.lastname: Cecchini
authors.forename: Gennaro
authors.initials: G
authors.lastname: Bussone
mesh_terms: D000328:Adult; D000368:Aged; D002908:Chronic Disease; D003027:Cluster Headache / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*; D046690:Deep Brain Stimulation / Q000009:adverse effects* / Q000379:methods*; D004351:Drug Resistance; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007031:Hypothalamus / Q000502:physiology* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012074:Remission Induction; D019233:Retreatment; D013995:Time; D017211:Treatment Failure; D016896:Treatment Outcome; D055815:Young Adult