Bob Johnson
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"Only the educated are free." -Epictetus
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Curr Treat Options Neurol. 2011 Feb;13(1):56-70. MANAGEMENT OF CHRONIC CLUSTER HEADACHE. Leone M, Franzini A, Proietti Cecchini A, Mea E, Broggi G, Bussone G. SourcePain Neuromodulation Unit, Department of Neurology, Headache Center, Carlo Besta Neurological Institute Foundation, Via Celoria 11, 20133, Milano, Italy, leone@istituto-besta.it.
Abstract OPINION STATEMENT: Primary cluster headache (CH) is an excruciatingly severe pain condition. Several pharmacologic agents are available to treat chronic CH, but few double-blind, randomized clinical trials have been conducted on these agents in recent years, and the quality of the evidence supporting their use is often low, particularly for preventive agents. We recommend sumatriptan or oxygen to abort ongoing headaches; the evidence available to support their use is good (Class I). Ergotamine also appears to be an effective abortive agent, on the basis of experience rather than trials. We consider verapamil and lithium to be first-line preventives for chronic CH, although the trial evidence is at best Class II. Steroids are clearly the most effective and quick-acting preventive agents for chronic CH, but long-term steroid use carries a risk of several severe adverse effects. We therefore recommend steroids only if verapamil, lithium, and other preventive agents are ineffective. In rare cases, patients experience multiple daily cluster headaches for years and are also refractory to all medications. These patients almost always develop severe adverse effects from chronic steroid use. Such patients should be considered for neurostimulation. Occipital nerve stimulation is the newest and least invasive neurostimulation technique and should be tried first; the evidence supporting its use is encouraging. Hypothalamic stimulation is more invasive and can be performed only in specialist neurosurgical centers. Published experience suggests that about 60% of patients with chronic CH obtain long-term benefit with hypothalamic stimulation.
PMID:21107766[PubMed] ======= 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. Published by Elsevier B.V. All rights reserved.
PMID:23103434[PubMed ==== PDF file, below.
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