Long-Term Results of Deep Brain Stimulation of the Mamillotegmental Fasciculus in Chronic Cluster Headache

Abstract

Background: Deep brain stimulation (DBS) and the proper target for chronic cluster headache (CCH) are still subjects of controversy. Objectives: We present our long-term results of analysis of the target and its structural connectivity. Methods: Fifteen patients with drug-resistant CCH underwent DBS in coordinates 4 mm lateral to the III ventricular wall and 2 mm behind and 5 mm below the intercommissural point. The clinical parameters recorded were the number of weekly attacks, pain intensity, and duration of the headache. Structural connectivity was studied using 3-T MR diffusion tensor imaging (DTI). Results: All of our patients improved from a mean of 39 attacks/week to 2; pain intensity decreased from 9 to 3 out of 10, and the mean cephalalgia duration decreased from 53 to 8 min. The mean stereotactic coordinates of the effective contact location were 6.1 mm lateral to the midcommissural point and 1.2 mm behind and 4.0 mm below the intercommissural point. DTI analysis showed that this target was connected to tracts and nuclei of the posterior mesencephalic tegmentum, specifically the dorsal longitudinal and mamillotegmental fasciculi. Conclusions: Our data showed DBS to be a safe and useful procedure for the treatment of drug-resistant CCH; the rate of improvement was higher than those found in other series. Although these are promising results, larger series targeting those fasciculi with a longer follow-up are needed.

Hypothalamic regulation of headache and migraine

“…These findings prompted the use of deep brain stimulation in the posterior hypothalamic grey matter in a patient with intractable CH, and led to a complete relief of attacks (59). To date, nearly 50 operated intractable CH patients, some with a follow-up of more than 4 years, have been reported and showed a significant effect of hypothalamic DBS in about 50-60% of CH patients (60)(61)(62)(63). To understand how hypothalamic DBS may exert its effect, a PET study was applied in hypothalamic deep brain-stimulated patients.…”

Understanding Cluster Headache Using Magnetic Resonance Imaging

“…These studies confirmed the relevance, in CH pathophysiology, of the target-brainstem projections. Notably, different DBS targets were considered: inferior–posterior hypothalamus ( 21 ), midbrain tegmentum ( 28 , 33 ), and ventral tegmental area ( 35 , 52 ). In chronic CH patients, the structural connectivity of these regions also showed extended and relevant connections to pain-related areas, supporting the hypothesis of large pain matrix modulating CH attacks.…”

“…In particular, important anatomical connections were highlighted between the hypothalamus and the midbrain tegmentum, including the medial lemniscus, the dorsal longitudinal and mamillo-tegmental fasciculi, the fronto-orbital cortex, the reticular shape, and the cerebellar cortex ( 21 , 28 , 33 , 35 ).…”

Deep Brain Stimulation for Chronic Cluster Headache: Meta‐Analysis of Individual Patient Data

“…4 So far, >100 cases of DBS for CCH worldwide have been published, with reports of significant headache reduction in 50 to 100% depending on the chosen outcome measures and selected target. [5][6][7] Despite a growing number of positive case series and prospective trials, the effectiveness of this treatment is still a matter of debate, and the American Headache Society Guideline classified DBS for CCH as level B negative evidence (possibly ineffective). 8 Another area of controversy regarding DBS for CCH refers to the anatomical target for stimulation.…”