Surgical Treatment Option for Chronic Cluster Headaches

Chronic cluster headache (CH) is considered to be one of the most severe facial pain syndromes. Typically, the pain first begins in, around, or above the eye or the temple; occasionally the face, the neck, or the ear may also be affected. Attacks usually start with sudden, deep, nonfluctuating pain, which then escalates in intensity. In addition, the attacks occur in clusters that often last for weeks or months, and they may be separated by remissions lasting for months or even years.

A new study, "Deep Brain Stimulation for Intractable Chronic Cluster Headache: Results, Neuroimaging and Neurovegetative Assessment," that highlights treatment for chronic cluster headaches, will be presented during the 71st Annual Meeting of the American Association of Neurological Surgeons (AANS) in San Diego. The study will be presented on Monday, April 28 from 5:00 to 5:15 p.m. The study's authors include Angelo Franzini, MD; Paolo Ferroli, MD; Massimo Leone, MD; Gennaro Bussone, MD and Giovanni Broggi, MD.

The common symptoms of CH (other than pain) include lacrimation (eye watering), nasal congestion, ptosis (lowered upper eyelid), miosis (smaller pupil), redness of the eye, and facial sweating. These are often accompanied by an increase in heart rate at the onset of attacks. Each attack may last from 30 minutes to up to two hours. Attacks range in frequency from eight per day to one per week, with a mean of five to 10 per day in the chronic form. The attacks may persist for an average of four to five years, without significant remissions.

"The management of CH should be primarily medical and nonsurgical," said Giovanni Broggi, a co-author of the study and an AANS member. "Since the results of surgery for the treatment of medically intractable CH remain, to this day, very disappointing, alternative strategies for this devastating problem are needed."

The objective of the study was to introduce a new surgical treatment option for intractable chronic cluster headaches. The authors have researched the therapeutic effectiveness of chronic high-frequency stimulation of the posterior hypothalamus region of the brain for the treatment of CH. A multidisciplinary team that included neurologists and neurosurgeons was involved in both the evaluation and the selection of patients for the study. The neurologist made the initial diagnosis of CH according to the criteria for the diagnosis of chronic CH, as defined under the classification of "headache," by the International Headache Society.

Nine electrodes were surgically implanted in the posterior hypothalamus in eight patients suffering from intractable chronic CH. The conservative management of these patients consisted of a regimen of the following drugs, alone or in combination: corticosteroids, lithium, methysergide, ergotamine, calcium channel blockers, beta-blocking agents, tryciclic antidepressants, melatonin and nonsteroidal anti-inflammatory drugs.

As a result of the long-term high-frequency hypothalamic stimulation, all of the patients experienced complete pain relief that continued throughout the course of the study and through the follow-up evaluation. Over an average time period of more than four weeks, there was a progressive reduction in the number of daily attacks until the symptoms completely disappeared.

All of the patients were pain-free at follow-up intervals of two to 26 months. A reported three of the eight patients remained pain-free without any medication, while five of the eight required low doses of medication. In addition, the authors noted that there were no side effects from chronic high-frequency hypothalamic stimulation and no complications from the implanted procedure.

"The hypothalamic stimulation treatment is a safe and effective alternative for treatment of drug-resistant chronic cluster headaches," said Angelo Franzini, MD, co-author of the study and an AANS member. "The procedure does not cause any of the unwanted side effects associated with surgical procedures."

This study is perhaps the first involving the successful treatment of a series of patients with chronic CH using long-term, high-frequency hypothalamic stimulation.

Founded in 1931 as the Harvey Cushing Society, the American Association of Neurological Surgeons (AANS) is a scientific and educational association with more than 6,500 members worldwide. The AANS is dedicated to advancing the specialty of neurological surgery in order to provide the highest quality of neurosurgical care to the public. All active members of the AANS are certified by the American Board of Neurological Surgery, the Royal College of Physicians and Surgeons (Neurosurgery) of Canada or the Mexican Council of Neurological Surgery, AC. Neurological surgery is the medical specialty concerned with the prevention, diagnosis, treatment and rehabilitation of disorders that affect the entire nervous system including the spinal column, spinal cord, brain and peripheral nerves.