[Neuromodulation in cluster headache. Clinical follow-up after deep brain stimulation in the posterior hypothalamus...

Deep brain stimulation (DBS) of the posterior hypothalamic area is a new treatment option for patients with refractory chronic cluster headache (CCH). A review of the literature reveals that studies based on large numbers of patients, long-term observations and controlled randomised trials are still lacking. In 2006 a case report of the first patient in Germany to be operated on to allow DBS was published, and we now present a report of this patient's course in the first 6 months after the operation; in addition, a current literature review is discussed. In July 2005 a DBS lead was placed in the left posterior hypothalamic area of this 39-year-old woman with CCH. Stimulation on demand achieved complete suppression of the cluster attacks, and the patient no longer needed medication. After about 8 months a decreasing effect of the stimulation, with only about 50% reduction of cluster attacks, and stimulation-induced side effects were observed. Neither reprogramming of the stimulation parameters nor pharmacological therapy with on-demand and long-term medication reduced the frequency or severity of CCH attacks to the level experienced in the early postoperative stage. Because of intolerable subjective side effects and tension-related pain at the site of the connection cable, in September 2006 the whole system was explanted at the patient's request.DBS in the posterior hypothalamic area is an invasive treatment option for use in cases with CCH that is refractory to any pharmacological therapy. As demonstrated by this case report, it is not possible to give a prognosis concerning its long-term efficacy: despite the initial excellent benefit there can be a reduction and even a loss of the effect of stimulation. The clinical results and long-term follow-up observations of the few cases published so far need to be evaluated in a larger multicentre trial with a double-blind study design.