Hospital Clínic Barcelona Successfully Tests Deep Brain Stimulation to Control Cluster Headache

The Case

Cluster headache is a rare and severely disabling condition. The Clínic team performed neurostimulation on a 58-year-old patient with cluster headache refractory to standard treatments for the previous 10 years. He was experiencing between 3 and 5 extremely intense headache episodes per day, one or two of them nocturnal, lasting 30 to 60 minutes and unresponsive to any therapy.

What sets this case apart from previous procedures is that the electrodes not only stimulate but also simultaneously monitor brain activity in an attempt to detect new attacks before the patient is aware of them. Understanding the patterns that precede and predict an episode will make it possible to personalise stimulation and reduce the potential harmful effects of continuous electrical stimulation.

How the Procedure Was Performed

Electrodes were implanted in the ventral tegmental area, close to the hypothalamus. The procedure lasted three hours, followed by four hours in the ICU, with no immediate complications. Three days later the patient was discharged. Chronic stimulation began on day 21, after verifying the correct placement and function of the electrodes.

After the first weeks of stimulation, no unpleasant side effects attributable to the technique have been identified.

Three-Month Results

Three months after surgery the patient's quality of life has improved very significantly: he has gone from five headache episodes per day to none, or at most sporadic, low-intensity episodes that require no medication. He has regained sleep and the desire to engage in personal and social activities he had given up, such as riding his motorbike.

The implanted electrodes have also begun to record the patient's brain activity. It is hoped that relevant data will be obtained to allow prediction of future episodes and application of discontinuous stimulation only when the onset of an attack is detected. This will reduce potential side effects on the brain and extend the battery life of the implanted generator.

About Cluster Headache

Cluster headache is one of the most painful types of headache in existence, alongside trigeminal neuralgia. It is uncommon but ranks second among primary headaches, after migraine. Approximately 47,000 people in Spain are affected, with a higher incidence in men. Twenty per cent of cases are chronic and 10% of these do not respond to conventional treatments.

It presents as sudden episodes of very intense and disabling pain, almost always unilateral, localised around the face and eye. Episodes last between 30 minutes and 3 hours, can occur at any time of day or night and are typically accompanied by lacrimation, drooping of the eyelid and nasal congestion on the same side as the pain. A marked circadian and seasonal predisposition is characteristic.

It is known as "the suicide headache" because of its extreme impact on quality of life and its clear association with suicidal ideation.

Prior Treatments and Why DBS

Standard symptomatic treatments include triptans (preferably injectable or nasal spray), oxygen, corticosteroids and lidocaine infiltration of the greater occipital nerve. Verapamil is used as a preventive.

When patients do not respond to these or to less established treatments such as botulinum toxin, more invasive techniques are considered, including anaesthetic block or radiofrequency of the sphenopalatine ganglion. Deep brain stimulation is still under investigation, having been applied in very few cases worldwide.

Hospital Clínic Barcelona's DBS Experience

Hospital Clínic Barcelona is a national centre of excellence for deep brain stimulation, with more than 300 procedures and very good outcomes: no mortality and fewer than 0.5% infections or reoperations due to side effects. It has accumulated more than 25 years of experience in DBS for movement disorders, more than 5 years in refractory epilepsy and more than 2 years in other neuropsychiatric disorders.

Incorporating DBS for headache disorders extends the indications for this technique and, thanks to simultaneous recording of brain activity, opens the way towards increasingly precise and personalised stimulation.