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| 50th Annual Meeting of the American Headache Society |
Boston, Massachusetts June 26-29, 2008 |
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Occipital Nerve Stimulation for Refractory
Primary Headache |
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BY MAURY M. BREECHER
Contributing Writer |
BOSTON — Occipital nerve stimulation and
deep brain stimulation are two promising therapies for
patients with intractable refractory headache, said Dr.
Peter J. Goadsby on June 27 at the 50th Annual Meeting
of the American Headache Society.
However, the biological rationales are distinct for
occipital nerve stimulation (ONS) for migraine or
cluster headache in contrast to deep brain stimulation
approaches for other trigeminal autonomic syndromes,
said Dr. Goadsby of the University of California, San
Francisco and editor of the journal, Cephalalgia.
Many patients with primary headache disorders often
complain of headache pain in both the front and the
backs of their heads. Consequently, researchers became
interested in the anatomical and physiological nature of
a possible connection between the front and back of the
head, believing that trigeminal-autonomic activation
must be facilitated by the brain.
This biological rationale for ONS began with research in
the brains of cats when researchers looked at Fos
activation after superior sagittal sinus simulation
(Brain Res. 1993;629:93).
Goadsby then cited research where eight human patients
with a history of episodic migraine treated successfully
with ONS were studied to determine the basis of their
response (Brain. 2004;127:220-230). While the optical
nerve stimulators were turned on, their pain was
relieved; but when the stimulus was turned off, their
pain returned.
That made them excellent subjects to determine the basis
of that response, according to Dr. Goadsby.
“We had the opportunity to give them back their pain and
see what occurred. They had the standard single cortex
activity and pain areas in the pons and in the dorsal
lateral pons,” he explained.
People with migraine basically have the same pattern of
activation. That is exactly the same area that activates
in spontaneous migraine or migraine treated with
nitroglycerine.
“Trigeminal cervical inputs on second order neurons are
the anatomical basis for that which you observe in
clinic every day,” pointed out Dr. Goadsby.
Turning to trigeminal autonomic syndromes and deep brain
stimulation, he pointed to the work of May et al.
(Lancet. 1998;351:275-278) who took patients with
cluster headache and looked at their pattern of
activation using PET. There was activation in the
singular cortex, bilateral insular activation,
non-dominant front activation and, in the hypothalamus.
“We saw activation at the back of the hypothalamus, a
structure yet be argued about, and a change in gray
matter in that area,” continued Dr. Goadsby. “It
transformed thinking about cluster headache because a
lot of people thought of cluster headache as a vascular
disorder, inflammatory or pericarotid sinus disorder.
It’s clearly not the case.”
Dr. Goadsby said that activation pattern is “relatively
unique to cluster headache.”
Dr. Goadsby added that we are starting to get some
insight as to why people would have the very distinct
behavior that is associated with the chronic headache
syndrome, and that insight might lead to a new way of
thinking about the disorder and even lead to a new
therapy.
That led to the speculation that one might expect to see
a useful effect from deep brain stimulation not only on
cluster headache, but also on the other trigeminal
autonomic syndromes, paroxysmal hemicrania, and so on,
according to Dr. Goadsby.
“This is not based on speculation that this is a good
idea,” he concluded. “It is based on functional imaging
and careful clinical characterization of these patients.
We live in exciting times. We can 100% agree that if we
are smart enough to see pictures of Mars, we have to be
smart enough to improve the lives of people with
disabling headaches.” |
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