Optimal deep brain stimulation site and target connectivity for chronic cluster headache

Abstract

Objective:To investigate the mechanism of action of deep brain stimulation for refractory chronic cluster headache and the optimal target within the ventral tegmental area.Methods:Seven patients with refractory chronic cluster headache underwent high spatial and angular resolution diffusion MRI preoperatively. MRI-guided and MRI-verified electrode implantation was performed unilaterally in 5 patients and bilaterally in 2. Volumes of tissue activation were generated around active lead contacts with a finite-element model. Twelve months after surgery, voxel-based morphometry was used to identify voxels associated with higher reduction in headache load. Probabilistic tractography was used to identify the brain connectivity of the activation volumes in responders, defined as patients with a reduction of ≥30% in headache load.Results:There was no surgical morbidity. Average follow-up was 34 ± 14 months. Patients showed reductions of 76 ± 33% in headache load, 46 ± 41% in attack severity, 58 ± 41% in headache frequency, and 51 ± 46% in attack duration at the last follow-up. Six patients responded to treatment. Greatest reduction in headache load was associated with activation in an area cantered at 6 mm lateral, 2 mm posterior, and 1 mm inferior to the midcommissural point of the third ventricle. Average responders' activation volume lay on the trigeminohypothalamic tract, connecting the trigeminal system and other brainstem nuclei associated with nociception and pain modulation with the hypothalamus, and the prefrontal and mesial temporal areas.Conclusions:We identify the optimal stimulation site and structural connectivity of the deep brain stimulation target for cluster headache, explicating possible mechanisms of action and disease pathophysiology.

Neurostimulation for the treatment of chronic migraine and cluster headache

“…18 Another open-label study has shown that after 5 years of follow-up, all patients had a benefit with a reduction in episode frequency from 90% to 50% associated as well with a decrease in the perception of pain intensity. 16 DBS, however, does not abort acute attacks. 21 In an open prospective study with follow-up 34 ± 14 months, seven patients with refractory CCH, a MRI-guided and MRI-verified electrode implantation was performed unilaterally in five patients and bilaterally in two.…”

“…Four patients with bilateral cluster headache showed no improvement while three patients developed tolerance after experiencing relief in the first 1-2 years. 16 Data from long-term follow-up studies indicate that long-term hypothalamic stimulation is necessary to produce sensory and nociceptive changes for a prophylactic effect to develop, which starts to show mostly after several weeks of start of stimulation. 19 A randomized prospective crossover, double-blind (with sham stimulation) study in 11 patients during 1-month periods, followed whereas three patients were considered as treatment failures.…”

“…19 A randomized prospective crossover, double-blind (with sham stimulation) study in 11 patients during 1-month periods, followed whereas three patients were considered as treatment failures. 16 Responders were defined as patients with a reduction of ≥30% in headache load (sum of severity and duration of headache in hours over a 2-week observation period).…”

“…The optimal target for DBS for refractory chronic cluster headache has shown to be within the ventral tegmental area: 6 mm lateral, 2 mm posterior, and 1 mm inferior to the midcommissural point of the third ventricle. 16…”

“…Six patients responded to treatment; there was a 76 ± 33% reduction in headache load, 46 ± 41% in attack severity, 58 ± 41% in headache frequency, and 51 ± 46% in attack duration. 16 Data from long-term follow-up studies indicate that long-term hypothalamic stimulation is necessary to produce sensory and nociceptive changes for a prophylactic effect to develop, which starts to show mostly after several weeks of start of stimulation. 16 DBS, however, does not abort acute attacks.…”