Posterior Hypothalamic and Brainstem Activation in Hemicrania Continua

Matharu, Manjit; Cohen, Anna; McGonigle, David J.; Ward, Nick; Frackowiak, R. S. J.; Goadsby, Peter J.

doi:10.1111/j.1526-4610.2004.04141.x

Cited by 234 publications

(176 citation statements)

References 75 publications

(172 reference statements)

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“…There are few reports that point to brainstem structures, such as ventrolateral midbrain, rostral-dorso part of pons and bulb-pons junction, involved in the pathophysiopathy of hemicrania continua. 5 MRI and positron emission tomography (PET) studies have shown that the grayish substance in the posteriorinferior hypothalamus is activated during trigemino autonomic cephalalgias 6 . On the other hand, clinical, PET and deep cerebral stimulation studies suggest that the rostral portion of the brainstem is essential to migraine pathophysiology, with emphasis on the role of periaqueductal gray substance contralateral to the pain episode 7 .…”

Section: Discussionmentioning

confidence: 99%

Headache secondary to haemorrhagic stroke resembling paroxysmal hemicrania

Bazan

Almeida

Rocha

et al. 2008

Arq. Neuro-Psiquiatr.

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The association between hemicrania and autonomic phenomena is the main aspect shared by a group of headaches called trigemino autonomic cephalalgias (TAC's) 1 . Their pathophysiology is not entirely known. Trigeminal and intermediary nerves of Wrisburg are involved as well as structures and brainstem connections and posterior hypothalamus 2 . Belonging to TAC's, paroxysmal hemicrania (PH) was described by Sjaastad and Dale 3 , in 1974, as a variant of cluster headaches, characterized by similar crises with a lower duration, higher frequency and dramatic response to indomethacin. Associations of structural lesions with paroxysmal hemicranias, other trigemino autonomic cephalalgias and migraine-like headaches have been described. Such reports corroborate the view according to which posterior hypothalamus and brainstem play a major role in the pathophysiology of these groups of headaches 4 . We report a case of a patient with a headache resembling TAC's but secondary to intraparenchymatous hematoma in brainstem, with an expressive response to indomethacin. CASEMale, 51 years old, caucasian, reported having shown three to four attacks a week for three months of strictly high intensity right hemicrania, mostly around the ocular globe, with sharp pains and average duration of 20 minutes. The crises of headache occurred four to six times a day, predominantly at night, but rarely awakening because of pain. The headache was associated with lacrimation, conjunctival hyperemia, palpebral edema and nasal congestion, ipsilateral to hemicrania. In his personal history he had severe artery hypertension, smoking, and haemorrhagic stroke (HCVA), clinically treated, occurring ten days before the onset of headache. He denied having previous headaches or familial history of headache.Neurological examination showed right hypertonic and hyper-reflex hemiparesia. Magnetic scanning (MRI) was compatible to intraparenchymatous hematoma in brainstem, in pons topography, mostly in anterior and left regions, and midbrain (Figs 1, 2 and 3).The patient was first treated with amitriptyline, 50 mg/day, and reevaluated a month later. No clinical improvement was obtained. At that occasion, indomethacin was administered orally

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Section: Discussionmentioning

confidence: 99%

Headache secondary to haemorrhagic stroke resembling paroxysmal hemicrania

Bazan

Almeida

Rocha

et al. 2008

Arq. Neuro-Psiquiatr.

View full text Add to dashboard Cite

show abstract

“…These headache syndromes are compared with other short-lasting headache disorders, such as hypnic headache, and a chronic headache syndrome with milder autonomic features such as hemicrania continua. Recent imaging data, however, place hemicrania continua nearer to the TACs [28] and future work will probably do the same with hypnic headache. Idiopathic stabbing headache, cough headache, exertional headache, sexual headache and trigeminal neuralgia are not part of these syndromes as these short-lasting disorders have no autonomic component [16,38].…”

Section: Arne Maymentioning

confidence: 94%

“…Melatonin in particular is a marker of the circadian system and a blunted nocturnal peak melatonin level and complete loss of circadian rhythm have been reported in cluster headache patients [51]. Recently, using functional and structural imaging, a significant structural difference in grey matter density, a Ôlesion' coinciding with the inferior posterior hypothalamus, was found in cluster headache [33,45] and Hemicrania continua [28], but not in migraine patients [30] when compared to healthy controls. Given that many of the basic features of SUNCT are shared by cluster headache and paroxysmal hemicrania, the question arises whether a shared pathophysiological basis exists, which could possibly be visualized through similar cerebral activation patterns.…”

Section: The Pathophysiological Puzzlementioning

confidence: 95%

Update on the diagnosis and management of Trigemino-Autonomic Headaches

May

2006

J Neurol

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Severe shortlasting headaches are rare but very disabling conditions with a major impact on the patients' quality of life. Following the IHS criteria, these headaches broadly divide themselves into those associated with autonomic symptoms, so called trigeminal autonomic cephalgias (TACs), and those with few autonomic symptoms. The trigeminal-autonomic cephalgias include cluster headache, paroxysmal hemicranias, and a syndrome called SUNCT (short lasting unilateral neuralgic cephalgias with conjunctival injection and tearing). In all of these syndromes, hemispheric head pain and cranial autonomic symptoms are prominent. The paroxysmal hemicranias have, unlike cluster headaches, a very robust response to indomethacin, leading to a notion of indomethacin-sensitive headaches. Although TACs are, in comparison with migraine, quite rare, it is nevertheless very important to consider the clinical factor that they are easy to diagnose and the treatment is very effective in most patients.

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“…Subsequently, it was shown that this hypothalamic area is also activated during short-lasting, unilateral, neuralgiform headache attacks with conjunctival injection and tearing (SUNCT), 43,44 paroxysmal hemicrania 45 and hemicrania continua. 46 Despite this, a second study found no activation in the hypothalamus in hemicrania continua in a single patient without cranial autonomic features. 47 For DBS the electrode is usually implanted stereotactically in the left posterior hypothalamus/anterior periventricular region of the triangle of Sano, according to the co-ordinates published.…”

Section: Defining the Target Pointmentioning

confidence: 99%

Neuromodulatory Approaches to the Management of Medically Refractory Cluster Headache

May¹,

Goadsby²

2010

European Neurological Review

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Cluster headache (CH) is, by neurological standards, a relatively common condition that affects about one in 1,000 people, 1 although compared with other more common primary headaches such as migraine 2 it remains rare in practice. CH has been defined in the second edition of the International Classification of Headache Disorders 3 as involving recurrent attacks of severe pain on one side of the head for between 15 and 180 minutes, associated with cranial autonomic features such as lacrimation, conjunctival injection, nasal congestion or rhinnorhoea (see Table 1). This condition can be divided into episodic (ECH) and chronic (CCH) forms. A diagnosis of ECH requires at least two cluster periods lasting from seven days to one year separated by painfree periods lasting one month or longer, while a diagnosis of CCH requires attacks to occur for more than one year without remission or with remission lasting less than one month. CCH affects about 10% of CH patients. General aspects of therapy of the disorder are covered elsewhere. 4,5 While it is not directly germane to neuromodulatiuon approaches, an understanding of the broad issues in medical treatment serves as a useful backdrop against which to discuss newer approaches. CH is one of the trigeminal autonomic cephalalgias, 6 and their therapies are usefully considered to be background 7 as they also can be considered for these newer approaches. Who Is Suitable for Neuromodulation Approaches?It seems reasonable to suggest that neuromodulation approaches to the management of CH be employed in patients with medically intractable forms of the condition. While this is currently true, it reflects the relatively primitive state of current interventions. One should observe that as devices become less invasive, the threshold for their use will become lower. For the moment there is a proposed working definition of medically intractable CH. 8 The essential components are disabling headache that fails at least four preventative drugs, including two from the first three of verapamil, lithium, methysergide, melatonin, topiramate and gabapentin (see Table 2). These considerations are particular to CH and, naturally, generic considerations related to requirements for the devices -such as fitness for anesthesia -are part of the overall assessment of patient suitability. What Approaches Have Been Tried?In essence, two classes of neuromodulation have been explored in CH:peripheral and central. Prior to moving to stimulation approaches, the dreadful pain and disability of medically intractable CH lead to a number of destructive procedures. In principle, these seem unlikely to work if one considers CH as fundamentally being a brain condition. Moreover, they may cause both mortality and significant morbidity, and can induce further pain problems such as anaesthesia dolorosa. Neuromodulatory Approaches to the Management of Medically Refractory Cluster Headache AbstractThe trigeminal autonomic cephalalgias are a group of primary headache disorders characterised by unilateral trigeminal d...

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Posterior Hypothalamic and Brainstem Activation in Hemicrania Continua

Cited by 234 publications

References 75 publications

Headache secondary to haemorrhagic stroke resembling paroxysmal hemicrania

Headache secondary to haemorrhagic stroke resembling paroxysmal hemicrania

Update on the diagnosis and management of Trigemino-Autonomic Headaches

Neuromodulatory Approaches to the Management of Medically Refractory Cluster Headache

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