DBS Cluster Headache New

8/8/2019 DBS Cluster Headache New

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Primary Headaches

Migraine

Tension-type

Cluster



Cluster headache

Severe, unilateral pain, orbitally, supraorbitally

and/or temporally, lasting 15-180 minutes,occurring from once every other day to 8 times aday.Bouts may last weeks or months (or so-called

cluster periods) and then remit for months oryears (average 1/year)80-90% are episodic (as above), 10-20% arechronic. 85% with episodic cluster headaches are

males vs F>M for chronic



IHS diagnostic criteria for episodic clusterheadache

A. At least 5 attacks fulfilling B-DB. Severe unilateral orbital, supra-orbital and/or temporal pain

lasting 15-180 minutes untreated.C. Headache associated with at least one of the following

signs: conjunctival injection; lacrimation; nasal congestion;rhinorrhea; forehead and facial sweating; miosis, ptosis,eyelid oedema.

D. Frequency once every other day to 8 per day.

Chronic refers to similar attacks but occurring for > 1 yearwithout remission or with remission lasting < 14 days.



Cluster headaches-abortive treatment

Subcutaneous sumatriptan 6mgHigh dose/high flowrate oxygen(100% oxygen)

ergotaminesIntranasal triptans- not so effective



Cluster headache- preventive treatments

Verapamil 240-960mg/day ( ECG)-bradycardia,hypotension,arrythmias,constipation,fatigue,oedema

Lithium 400-2000mg/day hypothyroidism,Diabetes insipidus, tremor,nausea, wt gainataxia drowsiness, confusion seizure

Methylsergide 3-12mg/day vascular constrictive phenomena, fibrotic reactions,muscle cramps, abdominal discomfort weight gain, mood change

Transitional treatments:

High dose corticosteroids- 1mg/kg ( up to 60mg daily for 5 daystapering over 2-3 weeks

rapid onset of action. Attack recurs once dose reduced. Initial add-on untilother preventatives are effective



Consideration of alternatives

Drugs used for prolonged period with significant side effect.Patients not responding to drugsLimitations due to prolonged use and high dosagetherapeutic approach to cluster headache was neededbecause the disorder is chronic in about 15% of patients,Given the notorious severity of cluster headache attacksand their requency (several times a day), such patients areseverely debilitated and this represents a major clinical

problem.



N on medical Alternatives

Deep Brain StimulationOccipital nerve stimulation

Occipital nerve blockage



DBS

Deep brain stimulation (DBS ) Deep brain stimulation (DBS) isa surgical treatment involving the implantation of a medicaldevice called a brain pacemaker, which sends electricalimpulses to specific parts of the brain. DBS in select brainregions has provided remarkable therapeutic benefits for otherwise treatment-resistant movement and affective disorderssuch as chronic pain, Parkinson¶s disease, tremor and dystonia,and major depression.





DBS placement

DBS leads are placed in the brain according to the type of symptoms to be addressed. For non-Parkinsonian essentialtremor the lead is placed in the ventrointermedial nucleus (VIM)of the thalamus. For dystonia and symptoms associatedwith Parkinson'sdisease (rigidity, bradykinesia/akinesia and tremor), the leadmay be placed in either the globus pallidus or subthalamicnucleus.

All three components are surgically implanted inside the body.



Surgical implantation of DBS

Under local anesthesia, a hole about 14 mm in diameter isdrilled in the skull and the electrode is inserted, with feedbackfrom the patient for optimal placement. The installation of theIPG and lead occurs under general anesthesia. The right side of the brain is stimulated to address symptoms on the left side of the body and vice versa.



DBS biochemistry

It has been shown in thalamic slices from mice that DBS causesnearby astrocytes to release adenosine triphosphate (ATP), aprecursor to adenosine (through a catabolic process). In turn,adenosine A1 receptor activation depresses excitatorytransmission in the thalamus, thus causing an inhibitory effectthat mimicks ablation or "lesioning".



DBS side effects/risks

Neuropsychiatric side effects.Apathy,hallucinations,compulsive gambling,hypersexuality,

cognitive dysfunction, and depression.However, these may be temporary and related to correct

placement and calibration of the stimulator and so arepotentially reversible



occipital nerve blockage

An occipital nerve block is an injection of localanaesthetic and steroid around the sympathetic nerveswhich supply the scalp. These nerves are located onthe back of the head Occipital nerve block is aprocedure where anesthetic agents (lidocaine andbupivacaine) are injected near the occipital nerve onthe back of the head near the base of the skull on theside of the headache.A steroid is often added for anti-inflammatory effects.An occipital nerve block may provide permanent relief or provide a period of pain relief for several monthswhile the cause of the pain is healing.



I was first tried for back-of-the-head headachessuch as migraine and tension headaches andfound to be effective.I was first reported to be effective for clusterheadache as well as far back as 1985 by Dr.Anthony.The downside, of course, is that once theinjection wears off, the cluster attacks return it snot a permanent solution and repeated steroidinjections aren t good for the joints





occipital nerve stimulation

ON S involves delivering a small electricalcharge to the occipital nerve to preventMigraines and headaches in patients whohave not responded to medications.The basic hardware of the O N S systemsconsists of a lead with electrodes and contactswhich is connected to a separatelyimplantedimpulse generator by a wire



ON S is not appropriate for all patients.Occipital nerve block injections may be a goodpredictor of whether OS N is suitable forindividual patients.patients using O N S may see a reduction inMigraine and headache frequency, but not acomplete cessation of Migraines and headaches.The first two chronic cluster headache patientswere successfully treated with O N S in 2003, and acouple of larger case series followed in 2007

DBS Cluster Headache New

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