Objective: To describe the results of deep brain stimulation of the ipsilateral posterior hypothalamus for the treatment of drug-resistant chronic cluster headaches (CHs). A technique for electrode placement is reported.

Methods: Because recent functional studies suggested hypothalamic dysfunction as the cause of CH bouts, we explored the therapeutic effectiveness of posterior hypothalamic stimulation for the treatment of CHs. Five patients with intractable chronic CHs were treated with long-term, high-frequency, electrical stimulation of the posterior hypothalamus. Electrodes were stereotactically implanted in the following position: 3 mm behind the midcommissural point, 5 mm below the midcommissural point, and 2 mm lateral to the midline.

Results: Since this treatment, all five patients continue to be pain-free after 2 to 22 months of follow-up monitoring. Two of the five patients have remained pain-free without any medication, whereas three of the five required low doses of methysergide (two patients) or verapamil (one patient). No adverse side effects of chronic, high-frequency, hypothalamic stimulation have been observed, and we have not encountered any acute complications resulting from the implant procedure. There have been no tolerance phenomena.

Conclusion: These preliminary results indicate a role for posterior hypothalamic stimulation, which was demonstrated to be safe and effective, in the treatment of drug-resistant chronic CHs. These data point to a central pathogenesis for chronic CHs.

Comment.—This study is the big kahuna, the description of the surgical treatment of cluster headache by implantation of a radiostimulator in the “hypothalamic cluster generator” first described by Dr. Peter Goadsby's group (May A, Bahra A, Buchel C, Frackowiak RS, Goadsby PJ. PET and MRA findings in cluster headache and MRA in experimental pain. Neurology. 2000; 55:1328-1335). This is an exquisite match of pathophysiologic understanding and clinical intervention. The patients operated upon by Dr. Franzini's group were severely impaired with refractory cluster headache. Additional patients have received the procedure in Belgium, and I anxiously await published results.

The standard surgical procedure for these patients in the United States has been radiofrequency trigeminogangliorhizolysis, described in great detail by Dr. Ninan Mathew in an abstract (Mathew NT, Hurt W, Kailasam J, Meadors L. Percutaneous radiofrequency trigeminal rhizolysis in intractable chronic cluster headache: 20 years experience, 125 patients [abstract]. Neurology. 2002; 58(suppl 3):A495-A496). Probably, depending on whether the Belgian physicians reproduce the Italian results, the next step will be to try this procedure in North America, because it may offer greater specificity and higher success rates for our most refractory and desperate patients with cluster headache. SJT