Cluster headache (CH) is the most severe of the primary headache disorders. Based on the finding that regional cerebral blood flow is increased in the ipsilateral posterior hypothalamic region during a CH attack, a novel neurosurgical procedure for CH was recently introduced: hypothalamic deep brain stimulation (DBS). Two small case series have been described. Here, the authors report their technical approach, intraoperative physiological observations, and 1-year outcomes after hypothalamic DBS in four patients with medically intractable CHs.
Patients underwent unilateral magnetic resonance (MR) imaging–guided stereotactic implantation of a Medtronic DBS (model 3387) lead and Soletra pulse generator system. Intended tip coordinates were 3 mm posterior, 5 mm inferior, and 2 mm lateral to the midcommissural point. Microelectrode recording and intraoperative test stimulation were performed. Lead locations were measured on postoperative MR images. The intensity, frequency, and severity of headaches throughout a 1-week period were tracked in patient diaries immediately prior to surgery and after 1 year of continuous stimulation.
At the 1-year follow-up examination, DBS had produced a greater than 50% reduction in headache intensity or frequency in two of four cases. Active contacts were located 3 to 6 mm posterior to the mammillothalamic tract. Neurons in the target region showed low-frequency tonic discharge.
In two previously published case series, headache relief was obtained in many but not all patients. The results of these open-label studies justify a larger, prospective trial but do not yet justify widespread clinical application of this technique.
Abbreviations used in this paper:AC–PC = anterior–posterior commissure; AP = anteroposterior; CH = cluster headache; DBS = deep brain stimulation; FSE = fast spin echo; MR = magnetic resonance; MTT = mammillothalamic tract; PAGM = periaqueductal gray matter; PET = positron emission tomography; PVGM = periventricular gray matter; TIA = transient ischemic attack.
Address reprint requests to: Philip A. Starr, M.D., Ph.D., Department of Neurosurgery, University of California at San Francisco, 505 Parnassus Avenue, 779 Moffitt, San Francisco, California 94143. email:
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