Effect of deep brain stimulation of the posterior hypothalamic area on the cardiovascular system in chronic cluster headache patients

The objective of this study was to determine the cardiovascular effects of chronic stimulation of the posterior hypothalamic area (PHA) in cluster headache (CH) patients. Systolic and diastolic blood pressure (SBP, DBP), cardiac output, total peripheral resistance (TPR), heart rate (HR) and breathing were monitored at supine rest and during head-up tilt test (HUTT), Valsalva manoeuvre, deep breathing, cold face test and isometric handgrip in eight drug-resistant chronic CH patients who underwent monolateral electrode implantation in the PHA for therapeutic purposes. Autoregressive power spectral analysis (PSA) of HR variability (HRV) was calculated at rest and during HUTT. Each subject was studied before surgery (condition A) and after chronic deep brain stimulation (DBS) of PHA (condition B). Baseline SBP, DBP, HR and cardiovascular reflexes were normal and similar in both conditions. With respect to condition A, DBP, TPR and the LF/HF obtained from the PSA of HRV were significantly ( P  < 0.05) increased during HUTT in condition B. In conclusion, chronic DBS of the PHA in chronic CH patients is associated with an enhanced sympathoexcitatory drive on the cardiovascular system during HUTT.     

Heritability of cluster headache

We conducted a pedigree analysis in 222 patients with cluster headaches (CHs) in order to assess a familial predisposition to the disease. Heritability was determined by Falconer's index (from the incidence of CH among first degree relatives of probands compared with a control population), which varies between 0 and 1 (none or full genetic causation). A positive family history (I/II degree relatives) was found in 2.3% of our CH patients. Three generations were affected in one family and two generations in another two families. The calculated Falconer's heritability index was, however, only 0.26 ± 0.25 SD. Our study confirms a higher familial occurrence of CH, some families showing a pattern compatible with autosomal dominant inheritance with reduced penetrance. The low Falconer's index indicates, however, a large non-genetic causation in most cases of CH.     

Clinical observations on familial cluster headache

Cluster headache (CH) has traditionally been considered a sporadic disease. Recently, an Italian study pointed out a risk of developing CH in the affected patients' firstdegree relatives that was increased 39-fold compared with the general population. The aims of this study were to investigate any possible differences in mean age at onset, clinical features and lifestyle between familial and non-familial CH cases. Among all CH patients referred to the Parma Headache Centre (n=691), we considered those who reported at least a first-degree relative with a probable diagnosis of CH in their family histories (n=30). CH diagnosis in the relatives was confirmed for 19 of the 30 patients. Each one of the 19 "familial cases" was matched by sex and age at the first visit (within 2 years) to two CH patients who did not report any family history for CH. The male:female ratio was 1.4:1 in the familial cases. Mean age at onset was significantly lower in women with familial CH than in those with non-familial CH. The study did not show any significant differences in symptoms between the two CH groups, such as pain location, accompanying symptoms, duration and frequency of attacks, and active periods. Our study seems to suggest that genetic factors play a role in the female gender, affecting age at onset of headache without modifying the clinical features. Received: 15 December 2002 / Accepted: 22 February 2003 Correspondence to: P. Torelli     

Lithium and clonazepam treatment of two cases with cluster headache

Patients with cluster headache are often treated with lithium. However, there are some patients who can not be fully treated with lithium alone. Two patients with cluster headache were treated with clonazepam, one of the most potent benzodiazepines. Lithium prolonged the period of remission, and the addition of clonazepam further prolonged it in case 1. Treatment with clonazepam reduced the symptoms in case 2, and when combined with lithium, the disorder went into remission after 6 months. These findings suggest that the combination of lithium and clonazepam may be effective in patients with cluster headache.     

Calcium entry blocker: Treatment in acute pain in cluster headache patients

15 chronic cluster headache patients in whom pain was induced by nitroglycerin received acute intravenous treatment with a calcium entry blocker. At the time of peak pain we noted a sudden decrease after the Verapamil injection. The mechanism by which the calcium entry blocker afforded relief is unlikely to have been vasodilatation in patients whose blood vessels had just been dilated by nitroglycerin. A more probable mechanism is blockade of the release of the pain-inducing neurotransmitters. The vasodilatation phase is not a primary factor in the onset of pain.

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Sommario Sono stati studiati 15 soggetti affetti da Cluster cronica inducendo loro la crisi dolorosa con Trinitrina, trattandoli poi con calcio antagonista (Verapamil) per via endovenosa. Al momento dell'apice del dolore, valutato dal paziente con un analogo visivo, la somministrazione di Verapamil endovena, determina una rapida estinzione del dolore. L'azione efficace del Ca-antagonista non può sicuramente essere rapportata alla vasodilatazione poiché la crisi dolorosa insorge già in una fase di vasodilatazione per l'azione della Trinitina. Il meccanismo d'azione più probabile è il blocco del release di neurotrasmettitori inducenti l'attacco doloroso. Si sottolinea che la vasodilatazione non è il fattore primario dell'induzione del dolore.

     

急性脑梗死后血管性认知障碍的磁共振波谱研究

目的应用质子磁共振波谱(1 H-MRS)技术,探讨急性脑梗死后血管性认知障碍(VCI)患者的颅内物质代谢变化与认知损害的关系。方法对86例脑梗死患者(脑梗死组)及21名健康对照者(对照组)进行简易精神状态检查量表(MMSE)和蒙特利尔认知评分量表(MoCA)评分,并计算其视空间及执行功能评分。根据认知评分结果,将脑梗死组分为脑梗死后认知功能正常组(NCI)、脑梗死后VCI非痴呆组(VCIND)、脑梗死后痴呆组。对脑梗死组及健康对照进行1 H-MRS检查,测定右额叶、左颞叶、左丘脑及顶枕叶交界处N-乙酰天冬氨酸(NAA)/肌酸(Cr)、肌醇(mI)/Cr及胆碱复合物(Cho)/Cr比值,并分析脑梗死组物质代谢比值与认知评分(MoCA评分、视空间及执行功能)间的相关性。结果 (1)与对照组(左颞叶及左丘脑NAA/Cr 1.53±0.08、1.52±0.10)相比,VCIND组左颞叶及左丘脑NAA/Cr(1.46±0.07、1.47±0.07)降低(P=0.001、P=0.006);与VCIND组右额叶1.46±0.10比较,梗死后痴呆组右额叶、左颞叶及左丘脑NAA/Cr(1.38±0.14、1.39±0.06、1.42±0.09)降低(分别P<0.001、P<0.001、P=0.003)。对照组及NCI组间的各区域物质代谢比值无统计学差异(均P>0.05)。(2)所有脑梗死患者中,除右额叶Cho/Cr外,余各感兴趣区物质代谢比值与MoCA评分间均相关,其中以左颞叶、左丘脑NAA/Cr值与MoCA评分的相关性为著(分别r=0.566,P<0.001;r=0.485,P<0.001);除右额叶、丘脑及顶枕叶交界处Cho/Cr外,余各物质代谢比值与视空间及执行功能评分间相关,其中亦以左颞叶及左丘脑NAA/Cr值的相关性为著(分别NAA/Cr为r=0.591,P<0.001;r=0.491,P<0.001)。结论左丘脑及左颞叶代谢异常可能为VCI患者认知损害的早期关键环节之一,随着VCI病变进展可能整个皮质及皮质下环路区域都将出现代谢异常。     

Diagnostic delays and mis-management in cluster headache

OBJECTIVES: Cluster headache is a stereotyped form of primary headache that while common in terms of neurologic illnesses is much less common as a cause of disabling headache than migraine. MATERIALS AND METHODS: We directly interviewed 230 patients with cluster headache. National support groups contributed 76% and 24% came from the National Hospital for Neurology and Neurosurgery Headache Clinic. RESULTS: Seventy-two percent were men and 28% women, giving a male to female (M:F) ratio of 2.5:1. Episodic cluster headache (ECH) was recorded in 79% while 21% had chronic cluster headache (CCH). The mean time to diagnosis has dropped from 22 years in the 1960s to 2.6 years in the 1990s, although the mean number of GPs seen before a diagnosis was made remains at three. CONCLUSIONS: While there has been improvement in the time to diagnosis for cluster headache, a number of physicians will be consulted, and better education is likely to reduce the overall patient suffering.     

帕金森病丘脑和纹状体质子磁共振波谱研究

目的　探索帕金森病 (Parkinson sdisease ,PD)病人丘脑和纹状体质子磁共振波谱变化 ,评价质子磁共振波谱技术用于帕金森病的诊断和病理生理研究的价值。方法　采用质子磁共振波谱技术检测 2 2例帕金森病人与 12例年龄匹配的健康对照者双侧丘脑、纹状体NAA、Cho、Cr含量 ,分析比较NAA/Cr、Cho/Cr、NAA/Cho比值的变化。结果　PD患者丘脑NAA/Cr比值较正常组明显降低 (P <0 0 5 ) ,NAA/Cho、Cho/Cr无明显变化 ;患者纹状体NAA/Cho、NAA/Cr、Cho/Cr与正常对照组没有明显区别。结论　NAA/Cr降低是评价PD患者神经元功能损害的重要指标 ,质子磁共振波谱技术可以作为进一步研究帕金森病病理生理过程和诊断的无创性检测方法。     

The use of gabapentin in chronic cluster headache patients refractory to first-line therapy

Chronic cluster headache (CCH) is a rare but challenging condition. About 20% of CCH patients get refractory to treatment. Gabapentin has recently been reported to be efficacious in the treatment of CCH. To test the potential of gabapentin as second-line drug, we prospectively studied the efficacy of gabapentin as add-on drug in eight patients suffering from CCH refractory to first-line treatment. Six of eight CCH patients responded to treatment. After the end of the study phase, the patients' clinical course was further followed up until January 2006. The longest period of being continuously pain-free under gabapentin treatment was 18 months. In some individuals, increasing doses were needed with time. We conclude that gabapentin may be offered as treatment trial in patients refractory to first-line treatment. However, patients may fail to respond to treatment and drug tolerance may occur with time.     

Secondary chronic cluster headache due to trigeminal nerve root compression

Mjåset C, Russell MB * 1 [Correction added on 2 November 2010 after first online publication on 5 July 2010. The author name, “M. Bjørn Russell”, was amended to “M. B. Russell”.]
;. Secondary chronic cluster headache due to trigeminal nerve root compression.
Acta Neurol Scand: 2010: 122: 373–376.
© 2010 The Authors Journal compilation © 2010 Blackwell Munksgaard. A 50‐year‐old woman had a gradual onset of chronic headache located in the right temporal region and a burning sensation in the root of the tongue which over a year evolved into chronic cluster headache with a milder chronic headache in‐between the severe cluster headache attacks. A cerebral magnetic resonance imaging (MRI) showed vascular compression of the trigeminal nerve root on the pain side. Neurosurgery microvascular decompression relieved the patient?s chronic cluster headache, the chronic intermittent headache and the burning tongue sensation. The effect was persistent at a 1 year follow‐up. Patients with atypical symptoms of cluster headache should be examined with cerebral MRI angiography of arteries and veins to exclude symptomatic causes.     

慢性精神分裂症患者双侧海马质子磁共振波谱成像研究

目的 利用质子磁共振波谱(~1H-MRS)研究慢性精神分裂症患者双侧海马生化物质的变化.方法 选择武警广东总队医院神经外科自2007年1月至2009年6月收治的慢性精神分裂症患者25例做为患者组,门诊体检正常志愿者25例为对照组,利用~1H-MRS测量2组成员双侧海马N-乙酰天门冬氨酸(NAA),胆碱复合物(Cho)和肌酸--磷酸肌酸复合物(Cr)含量,计算NAA/Cr和Cho/Cr的比值.结果 慢性精神分裂症患者双侧海马NAA/Cr的比值(左侧2.05±0.14,右侧1.98±0.17)低于正常对照组(左侧2.19±0.13,右侧2.17±0.14),差异有统计学意义(P<0.05);Cho/Cr比值(左侧1.30±0.12,右侧1.25±0.18)高于正常对照组(左侧1.04±0.15,右侧0.95±0.13),差异有统计学意义(P<0.05).结论 慢性精神分裂症患者双侧海马可能存在神经元的缺失或功能损伤,并且伴有膜磷脂代谢紊乱.     

Anterior ischaemic optic neuropathy secondary to cluster headache

This report describes a patient with cluster headache who developed anterior ischaemic optic neuropathy during an attack of headache, an association not previously described. A possible pathophysiologic mechanism based upon the understanding of optic disc physiology and ocular vascular pathology in headache syndromes is proposed.     

Acute myocardial infarction after sumatriptan administration for cluster headache

Abstract The pain of cluster headache attacks is severe, excruciating and selectively responsive to subcutaneous sumatriptan. Serious cardiovascular events attributed to sumatriptan are extremely rare and have most often been reported in patients at significant cardiovascular risk, or in overt cardiovascular disease. They also have occurred, however, in patients without evidence of cardiovascular disease. We describe a 42-year-old man with episodic cluster headache without history of coronary artery disease who was admitted to our coronary care unit for acute myocardial infarction after 3 h of subcutaneous injection of sumatriptan. During hospitalisation cluster headache attacks were successfully treated with e.v. indomethacin.     

Deficient energy metabolism is associated with low free magnesium in the brains of patients with migraine and cluster headache

We used phosphorus magnetic resonance spectroscopy to assess in vivo the brain cytosolic free magnesium concentration and the free energy released by the reaction of adenosine triphosphate (ATP) hydrolysis (DeltaG(ATPhyd)), the latter being an index of the cell's bioenergetics condition. We studied 78 patients with migraine in attack-free periods (7 with migraine stroke, 13 with migraine with prolonged aura, 37 with migraine with typical aura or basilar migraine, and 21 with migraine without aura), and 13 patients with cluster headache. In the occipital lobes of all subgroups of migraine and in cluster headache patients cytosolic free [Mg(2+)] as well as the free energy released by the reaction of ATP hydrolysis were significantly reduced. Among migraine patients, the level of free energy released by the reaction of ATP hydrolysis and the cytosolic free [Mg(2+)] showed a trend in keeping with the severity of clinical phenotype, both showing the lowest values in patients with migraine stroke and the highest in patients with migraine without aura. These results support our current hypothesis that the reduction in free [Mg(2+)] in tissues with mitochondrial dysfunction is secondary to the bioenergetics deficit, and are against a primary role of low brain cytosolic free [Mg(2+)] in causing the bioenergetics deficit in headache.     

White blood cell SPECT during active period of cluster headache and in remission

Background and purpose: Cluster headache (CH) is an episodic headache disorder characterized by recurrent, unilateral attacks of excruciating pain in the temporal/orbital region. The pathophysiology of CH is largely unknown although involvement of immunological mechanisms has been suggested. The aim of our study was to investigate whether patients with CH show signs of intracranial inflammation, when using white blood cell single‐photon emission computer tomography (WBC‐SPECT). Methods: We have examined 14 patients with CH, both in active period and in remission, and five control subjects at one occasion, with WBC‐SPECT. To be able to precisely define regions of interest (ROI:s) in the brain, all patients with CH and control subjects underwent magnetic resonance imaging (MRI) of the brain. Results: We found no significant difference in ^99mTc‐labeled WBC uptake between patients with CH in active period and controls. Furthermore, patients with CH in active period were not significantly different in uptake compared with patients with CH in remission. Conclusions: These results did not provide conclusive support for a hypothesis of a pathophysiological role of inflammation intracranially. Our conclusions are restricted to the advantages and limitations of the chosen method.     

泊尼松治疗24例丛集性头痛的疗效观察

目的探索泊尼松治疗丛集性头痛的有效性。方法采用前瞻性的方法,给予丛集性头痛患者口服泊尼松40mg/d,连服10 d,然后每周减10 mg,与既往发作的丛集期比较,观察患者的丛集发作时间、发作频率、疼痛程度。结果经泊尼松治疗后丛集性发作时间较前有缩短[(2．88±1．23) d vs (28.88±11．96)d],有显著性差异(P=0．000);头痛发作频率较前有减少[(1．04±2．42)d vs (15．50± 11．24)d],有显著性差异(P=0．000);头痛的程度较前减轻[(0．83±1．74)d vs (9．83±0．48)d],有显著性差异 (P=0．000)。结论泊尼松能非常有效治疗丛集性头痛发作。     

Hypothalamic deep brain stimulation for treatment of cluster headache

Extremely severe, unilateral, recurrent facial pain and headache, accompanied by autonomic symptoms and signs, can be identified as cluster headache attacks (CH). Despite optimal pharmacological treatment, 20% of patients will not achieve satisfactory improvement. The severity of pain is so extreme that CH has been a cause of multiple suicidal attempts among patients ineffectively treated because of CH. Hypermetabolism of ipsilateral posterior hypothalamus observed in PET studies led to multiple attempts of deep brain stimulation (DBS) utilization in CH treatment. The authors present current opinions about DBS treatment in CH. A socioeconomic analysis of neuromodulatory treatment of CH is presented.