Pain. 2012 Sep 29.
Success, failure, and putative mechanisms in hypothalamic stimulation for drug-resistant chronic cluster headache.
Leone M, Franzini A, Proietti Cecchini A, Bussone G.
SourceDepartment of Neurology, Headache Centre and Pain Neuromodulation Unit, Fondazione Istituto Nazionale Neurologico Carlo Besta, Milano, Italy. Electronic address: leone@istituto-besta.it.

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 8.7years, range 6-12years) 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 3years (range 3-4years). Five patients did not improve: 4 had bilateral CH, and 3 developed tolerance after experiencing relief for 1-2years. 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 16MONTHS. 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.

Copyright © 2012 International Association for the Study of Pain..

PMID:23103434[PubMed]