Deep Brain Stimulation of the Posterior Hypothalamus in Chronic Cluster Headache

This chapter focuses on the use of deep brain stimulation (DBS) of the posterior hypothalamus for treating chronic cluster headache (CCH). Physiopathological data on the etiology of cluster headaches point to the hypothalamus as a crucial site for the development of the disease. The diagnosis of CCH must be precise and supported by the headache classification criteria stated by the Headache Classification Committee of the International Headache Society in 2004. To avoid bias in patient selection, a multidisciplinary team approach including headache neurologists, psychiatrists, and headache dedicated Operative Units is recommended. About 30% of CCH patients may have significant improvement after peripheral neuromodulation procedures (GON), suggesting the existence of different subtypes of patients in the same diagnostic category. In some CCH patients, the peripheral component may contribute more to the genesis of the pain than the central components. The application of DBS in CCH patients is well tolerated and results in significant reduction of pain bouts. Transient, reversible diplopia is the main stimulation-related side effect, which limits the use of higher amplitudes for chronic stimulation. Currently, the collective experience from the literature suggests that 50-60% of patients respond to DBS. As a result of stimulation, most patients' lives gradually returns to normal and most resumes work. Further refinement of targeting and patient selection is expected to improve the success rate of pHyp stimulation in CCH patients. The cost of the procedure is largely compensated by one year of pain remission even if the disease cannot be cured by DBS.