Medical Hypothesis: Deep Brain Stimulation for Intractable Migraine

Abstract

Deep Brain Stimulation (DBS) has been introduced as an innovative treatment for several neurological disorders, including Parkinson’s disease, essential tremor, and dystonia and it has been proven effective in helping individuals affected by these disorders; hence, enhancing their quality of life. DBS has also been investigated for the treatment of cluster and other primary headaches. Electrodes are surgically implanted into brain structures, for example the posterior hypothalamus in case of cluster headache. Hypothalamic DBS has been successfully used to treat patients with cluster headache and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT). In these headache conditions, DBS may reduce headache frequency by half, however, some side effects have also been reported that are mainly related to infection where the electrodes are placed, syncope, and diplopia. Hypothalamic DBS is proposed to modulate neuronal structures that are directly or indirectly involved in detection or transmission of painful stimuli or in the processing of this information. Reports of the use of DBS for chronic migraine are not found in the literature. This commentary explores the medical hypothesis that DBS could be considered as a therapeutic option for intractable chronic migraine. This hypothesis is based on the commonalities between cluster headache and migraine in terms of some shared symptoms, and potential overlap of underlying mechanisms. However, due to the absence of clinical evidence supporting the use of DBS in CM, the fact that disease-specific optimization of DBS parameters must be considered carefully, and considering the optimal CNS structures to target are currently unknown, it is concluded that this interventional and invasive technique should be avoided for CM for the present time.

Case report: Migraine resolution post bilateral subthalamic deep brain stimulation

“…Given migraine has analogous features, it was hypothesized that it could be effective in chronic migraine. 1 The indirect positive effect on migraine after targeting the subthalamic nuclei with DBS can be explained by several possibilities. Functional MRI and positron emission tomography (PET) shows activation and hyper-perfusion of the hypothalamus in chronic migraine.…”

“…Neuromodulation with DBS might alleviate headache by improving these pathways (Figure 2). 1 In addition to calcitonin gene related peptide (CGRP) and serotonin 5-HT, dopamine has been suggested to play a key role in the pathogenies of migraine through activation of the trigeminocervical complex. 9 Cubo et al found that patients with Parkinson's disease and migraine show better clinical response in motor symptoms compared to those without migraine.…”

“…This can lead to wide network activation including trigeminal nuclei. 1,7,8 The hypothalamus also plays a key role in activation of the pain matrix which includes many structures such as the thalamus, cingulate cortex and insula. Neuromodulation with DBS might alleviate headache by improving these pathways (Figure 2).…”

“…2 In different populations, DBS has also been shown to be effective in conditions such as refractory epilepsy, chronic pain, severe forms of cluster headache and autonomic cephalalgias but has not been reported for the treatment of migraine. 1 Given migraine is associated with dopamine hypersensitivity and DBS has a wide neurostimulation effect including the dopaminergic network; DBS might offer a therapeutic option in refractory cases of migraine. 3 We present a case of chronic migraine that was alleviated post subthalamic DBS.…”

“…For a long time, deep brain stimulation (DBS) has been successfully used for the control of bradykinesia, rigidity, and tremors in patients with Parkinson’s disease. 1 The benefit of DBS on non-motor symptoms such as pain and autonomic functions, remains to be elucidated, although there is growing evidence of its clinical usefulness. 2 In different populations, DBS has also been shown to be effective in conditions such as refractory epilepsy, chronic pain, severe forms of cluster headache and autonomic cephalalgias but has not been reported for the treatment of migraine.…”