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1093/brain/awh245
Summary
stimulation) to the right resulted in immediate resolution
of the right side pain and the hypertensive crises. On
several occasions, both known and unknown to the patient,
the stimulators were turned off: in all cases, crises reappeared and in all instances disappeared relatively quickly
after turning stimulation back on. Pain crises have never
reappeared when ipsilateral stimulation is ongoing. The
only side effects were observed during long-term bilateral
stimulation, consisting of transient vertigo and bradycardia. After 42 months (left) and 31 months (right) of followup, the patient remains crisis free without the need for
pharmacological prophylaxis.
Keywords: cluster headache; treatment; deep brain stimulation; pathophysiology, head pain
Abbreviation: CH = cluster headache.
Received February 17, 2004. Revised May 10, 2004. Accepted May 21, 2004. Advanced Access publication August 25, 2004
Introduction
Cluster headache (CH) is a primary headache syndrome characterized by strictly unilateral head pain attacks accompanied
by ipsilateral autonomic facial phenomena (Headache Sublassification Committee of the International Headache
Society, 2004). The pain may be the most severe known to
humans. The attacks are relatively short lived and in the
episodic form occur daily for some weeks followed by a
period of remission. In the chronic form, attacks occur on
a daily basis without significant periods of remission.
When chronic CH is unresponsive to medical treatments, it
is a major problem and surgical options have to be considered
(OBrien et al., 1999). The trigeminal nerve and cranial parasympathetic nerves on the affected side have been targeted,
with inconsistent results (Ekbom and Solomon, 2000). The
most widely used surgical procedure for intractable chronic
CH is radiofrequency thermocoagulation of the trigeminal
ganglion. This procedure is often effective initially
(Jarrar et al., 2003). However, the headache may recur,
in which case a repeat procedure may be useful. Possible
sequelae are corneal analgesia with markedly increased
Brain Vol. 127 No. 10
2260
M. Leone et al.
(A)
Case history
(B)
2261
Table 1. Time relationships between switching off/on the electrodes and appearance/disappearance of pain
Mean (minmax)
Right, implanted 31 May, 2001
Mean (minmax)
Left + right
Mean (minmax)
Occasions when
stimulator was
switched off
August 2000*
September 2001
May 2002
July 2002
October 2002
January 2003
June 2003
September 2001
May 2002 +
September 2002
Days between
turning off stimulator
and attack recurrence
2 (twice)
24
45
14
24
35
120
33.2 (2120)
290
7
47
114.7 (7290)
72.8 (2290)
Stimulation
amplitude (V)
Days between
turning on stimulator
and attack cessation
2 (twice)
9
6
3
46
34
27
16.1 (246)
2
2
21
8.3 (221)
3.0
1.5
1.5
1.3
3.2
2.3
2.3
2.3 (1.33.2)
3.0
2.3
0.8
2.0 (0.83)
16.3 (246)
2.2 (0.83.2)
cautious. The following day, the right side CH crises and the
severe hypertension episodes disappeared completely. For the
first time in years, the patient started sleeping normally at night,
probably because the nocturnal CH crises had disappeared, but it
is also possible that stimulation restored normal sleepwaking
rhythms.
After 4 months of continuous bilateral hypothalamic stimulation, and freedom from all CH attacks, the patient developed vertigo and bradycardia (42 per min); before the
implants, heart rate had been 4852/min in relation to the
*Unknown to the patient; + the electrode became displaced (again unknown to the patient). Stimulator status at latest check-up
(December 2003): right side stimulator off since 1 December, 2002; left side stimulator on.
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M. Leone et al.
Discussion
Ours is the first patient to have electrodes implanted bilaterally in the posterior inferior hypothalamus. Prolonged bilateral stimulation at these sites has produced long-lasting CH
relief without the need for pharmaceutical prophylaxis and
without major side effects.
Efficacy
Adverse events
No major adverse events/side effects have been reported or
observed with ongoing stimulation on one side only. However, on one occasion, the stimulation voltage was reduced
from its highest ever value (from 3.2 to 3.0 V) when the
patient complained of short episodes of vertigo, particularly
after abruptly changing position. This reduction resolved the
vertigo with no reoccurrence of pain crises.
The stimulators have been on together for four periods:
between May and September 2001 (116 days), in July
2002 (10 days), in August and September 2002 (20 days)
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M. Leone et al.
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