Abstract Details

Title Deep Brain Stimulation of Posterior Hypothalamus in Treatment of Chronic Medically Refractory Cluster Headache: A Case for Preferential Action on Autonomic Symptoms

Topic Headache

Presentation(s) P01 - (-)

Poster/Presentation
Number 071

Objective

Background CH is the most severe of the primary headache disorders with approximately 20% of the CH patients being medically refractory. The findings of focal increase in cerebral blood flow in the ipsilateral posterior hypothalamic region during a CH attack during PET scan has led to use of neurostimulation for treatment of medically refractory CH.

Design/Methods Case report.

Results We present the case of a 40 year old male who underwent DBS for management of chronic medically refractory left sided chronic CH. He had failed multiple state of the art cluster headache preventive medications prior to DBS targeting the left posterior hypothalamus in 2008. After initial DBS titration (voltage=1.5 V), an attempt to reduce high prednisone dosage (60[rarr]18 mg/day) led to recurrence of CH attacks which were more responsive to sumatriptan treatment, a change from previous pattern. CH headaches persisted after optimization of DBS (4.3V) and he subsequently underwent left trigeminal nerve rhizotomy which dramatically improved CH pain. Assuming DBS to be a largely ineffective treatment, he turned off DBS stimulator which led to emergence of cranial autonomic symptoms (nasal stuffiness, lacrimation) two days later but without the headache. These autonomic symptoms improved instantly with re-initiation of DBS treatment.

Conclusions The pathophysiological mechanisms (central vs peripheral) leading to pain and autonomic symptoms in CH are still debated. Our case emphasizes the dichotomy in origins of pain and autonomic symptoms with central hypothalamic involvement leading to autonomic symptoms and trigeminal nerve involvement leading to pain.

Authors/Disclosures
PRESENTER	No disclosure on file
Bryan T. Klassen, MD (Mayo Clinic)	The institution of Dr. Klassen has received research support from Insightec.
Douglas L. Arnold, MD, FAAN (Montreal Neurological Institute, McGill Univ)	Dr. Arnold has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Biogen. Dr. Arnold has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for BMS. Dr. Arnold has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Frequency Therapeutics. Dr. Arnold has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Merck. Dr. Arnold has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Novartis. Dr. Arnold has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Roche. Dr. Arnold has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Sanofi. Dr. Arnold has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Shionogi. Dr. Arnold has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Xfacto communications. Dr. Arnold has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Eli Lilly. Dr. Arnold has received personal compensation in the range of $500-$4,999 for serving as a Consultant for EMD Serono. Dr. Arnold has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Biohaven. Dr. Arnold has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Find therapeutics. Dr. Arnold has received personal compensation in the range of $500-$4,999 for serving as a Consultant for GSK. Dr. Arnold has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Idorsia. Dr. Arnold has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Kiniksa. Dr. Arnold has received personal compensation in the range of $100,000-$499,999 for serving as a Consultant for Clario.
Christopher J. Boes, MD, FAAN (Mayo Clinic)	Dr. Boes has a non-compensated relationship as a Review Committee for Neurology member with ACGME that is relevant to AAN interests or activities.
	No disclosure on file
	No disclosure on file

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