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Mao Q, Xu S, Wang Y, Wu D, Huang G, Li Z, Zhang X, Chi Z. Research hotspots and frontiers of cluster headaches: a bibliometric analysis. Front Neurol 2024; 15:1395770. [PMID: 38725643 PMCID: PMC11079126 DOI: 10.3389/fneur.2024.1395770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/10/2024] [Indexed: 05/12/2024] Open
Abstract
Background Extensive research on cluster headaches (CHs) has been conducted worldwide; however, there is currently no bibliometric research on CHs. Therefore, this study aimed to analyze the current research hotspots and frontiers of CHs over the past decade. Methods Raw data on CHs was obtained from the Web of Science Core Collection database from 2014 to 2023. CiteSpace V6.2 R7 (64 bit) and Microsoft Excel were used to assess the annual publication volume, authors, countries, and references. VOSviewer 1.6.19 software was used to assess the institutions, cited authors, and keywords, and co-occurrence and clustering functions were applied to draw a visual knowledge map. Results In the past decade, the overall annual publication volume of articles related to CHs has increased year by year, showing promising development prospects. The total 1909 articles contained six types of literature, among which the proportion of original research articles was the highest (1,270 articles, 66.53%), published in 201 journals. Cephalalgia (439 articles, 23.00%) had the highest publication volume, and the Lancet was the journal with the highest impact factor (IF = 168.9). Furthermore, the United States of America was the country with the most published papers (584 articles, 30.60%), University of London was the research institution with the most published papers (142 articles, 7.44%), and Goodsby, Peter J was found to be the most prolific author (38 articles, 1.99%). Conclusion This study may provide some direction for subsequent researcher on CHs. The hotspots and frontiers of future research on CHs are suggested as follows: in basic medicine, more attention should be paid to pathophysiology, especially on increasing research on the pathogenesis mediated by CGRP; in clinical medicine, more attention should be paid to the design of evidence-based medicine methodology, especially the strict design, including double-blind, questionnaire, and follow-up, in randomized controlled trials, using high-quality articles for meta-analyses, and recommending high-level evidence; therapeutic techniques need to be further explored, suggesting the implementation of transcranial magnetic stimulation of the cortex, and stimulation of the sphinopalatine ganglia and occipital nerve to achieve peripheral neuromodulation. Furthermore, chronic migraine and insomnia are inextricably linked to CHs.
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Affiliation(s)
- Qiangjian Mao
- Department of Acupuncture and Moxibustion, Affiliated Hospital of Jiangxi University of Chinese Medicine, Nanchang, Jiangxi, China
| | - Shiqi Xu
- Acupuncture and Moxibustion Massage College, Jiangxi University of Chinese Medicine, Nanchang, Jiangxi, China
| | - Yuqing Wang
- Acupuncture and Moxibustion Massage College, Jiangxi University of Chinese Medicine, Nanchang, Jiangxi, China
| | - Desheng Wu
- Department of Acupuncture and Moxibustion, Affiliated Hospital of Jiangxi University of Chinese Medicine, Nanchang, Jiangxi, China
| | - Guomin Huang
- Department of Acupuncture and Moxibustion, Affiliated Hospital of Jiangxi University of Chinese Medicine, Nanchang, Jiangxi, China
| | - Ziru Li
- Department of Acupuncture and Moxibustion, Affiliated Hospital of Jiangxi University of Chinese Medicine, Nanchang, Jiangxi, China
| | - Xiaoming Zhang
- Department of Acupuncture and Moxibustion, Affiliated Hospital of Jiangxi University of Chinese Medicine, Nanchang, Jiangxi, China
| | - Zhenhai Chi
- Department of Acupuncture and Moxibustion, Affiliated Hospital of Jiangxi University of Chinese Medicine, Nanchang, Jiangxi, China
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Hamani C, Davidson B, Lipsman N, Abrahao A, Nestor SM, Rabin JS, Giacobbe P, Pagano RL, Campos ACP. Insertional effect following electrode implantation: an underreported but important phenomenon. Brain Commun 2024; 6:fcae093. [PMID: 38707711 PMCID: PMC11069120 DOI: 10.1093/braincomms/fcae093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/08/2023] [Accepted: 03/26/2024] [Indexed: 05/07/2024] Open
Abstract
Deep brain stimulation has revolutionized the treatment of movement disorders and is gaining momentum in the treatment of several other neuropsychiatric disorders. In almost all applications of this therapy, the insertion of electrodes into the target has been shown to induce some degree of clinical improvement prior to stimulation onset. Disregarding this phenomenon, commonly referred to as 'insertional effect', can lead to biased results in clinical trials, as patients receiving sham stimulation may still experience some degree of symptom amelioration. Similar to the clinical scenario, an improvement in behavioural performance following electrode implantation has also been reported in preclinical models. From a neurohistopathologic perspective, the insertion of electrodes into the brain causes an initial trauma and inflammatory response, the activation of astrocytes, a focal release of gliotransmitters, the hyperexcitability of neurons in the vicinity of the implants, as well as neuroplastic and circuitry changes at a distance from the target. Taken together, it would appear that electrode insertion is not an inert process, but rather triggers a cascade of biological processes, and, as such, should be considered alongside the active delivery of stimulation as an active part of the deep brain stimulation therapy.
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Affiliation(s)
- Clement Hamani
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Benjamin Davidson
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Nir Lipsman
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Agessandro Abrahao
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Sean M Nestor
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Jennifer S Rabin
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto M5G 1V7, Canada
| | - Peter Giacobbe
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada
| | - Rosana L Pagano
- Laboratory of Neuroscience, Hospital Sírio-Libanês, São Paulo, SP CEP 01308-060, Brazil
| | - Ana Carolina P Campos
- Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Laboratory of Neuroscience, Hospital Sírio-Libanês, São Paulo, SP CEP 01308-060, Brazil
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Zhao H, Zhang S, Wang Y, Zhang C, Gong Z, Zhang M, Dai W, Ran Y, Shi W, Dang Y, Liu A, Zhang Z, Yeh CH, Dong Z, Yu S. A pilot study on a patient with refractory headache: Personalized deep brain stimulation through stereoelectroencephalography. iScience 2024; 27:108847. [PMID: 38313047 PMCID: PMC10837616 DOI: 10.1016/j.isci.2024.108847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/23/2023] [Accepted: 01/03/2024] [Indexed: 02/06/2024] Open
Abstract
The integration of stereoelectroencephalography with therapeutic deep brain stimulation (DBS) holds immense promise as a viable approach for precise treatment of refractory disorders, yet it has not been explored in the domain of headache or pain management. Here, we implanted 14 electrodes in a patient with refractory migraine and integrated clinical assessment and electrophysiological data to investigate personalized targets for refractory headache treatment. Using statistical analyses and cross-validated machine-learning models, we identified high-frequency oscillations in the right nucleus accumbens as a critical headache-related biomarker. Through a systematic bipolar stimulation approach and blinded sham-controlled survey, combined with real-time electrophysiological data, we successfully identified the left dorsal anterior cingulate cortex as the optimal target for the best potential treatment. In this pilot study, the concept of the herein-proposed data-driven approach to optimizing precise and personalized treatment strategies for DBS may create a new frontier in the field of refractory headache and even pain disorders.
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Affiliation(s)
- Hulin Zhao
- Department of Neurosurgery, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Shuhua Zhang
- Department of Neurology, Chinese PLA General Hospital, Beijing 100853, China
- International Headache Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Yining Wang
- School of Information and Electronics, Beijing Institute of Technology, Beijing 100081, China
| | - Chuting Zhang
- School of Information and Electronics, Beijing Institute of Technology, Beijing 100081, China
| | - Zihua Gong
- Department of Neurology, Chinese PLA General Hospital, Beijing 100853, China
- International Headache Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Mingjie Zhang
- Department of Neurology, Chinese PLA General Hospital, Beijing 100853, China
- International Headache Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Wei Dai
- Department of Neurology, Chinese PLA General Hospital, Beijing 100853, China
- International Headache Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Ye Ran
- Department of Neurology, Chinese PLA General Hospital, Beijing 100853, China
- International Headache Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Wenbin Shi
- School of Information and Electronics, Beijing Institute of Technology, Beijing 100081, China
- Key Laboratory of Brain Health Intelligent Evaluation and Intervention, Beijing Institute of Technology, Ministry of Education, Beijing 100081, China
| | - Yuanyuan Dang
- Department of Neurosurgery, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Aijun Liu
- Department of Neurosurgery, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Zhengbo Zhang
- Center for Artificial Intelligence in Medicine, Chinese PLA General Hospital, Beijing 100853, China
| | - Chien-Hung Yeh
- School of Information and Electronics, Beijing Institute of Technology, Beijing 100081, China
- Key Laboratory of Brain Health Intelligent Evaluation and Intervention, Beijing Institute of Technology, Ministry of Education, Beijing 100081, China
| | - Zhao Dong
- Department of Neurology, Chinese PLA General Hospital, Beijing 100853, China
- International Headache Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Shengyuan Yu
- Department of Neurology, Chinese PLA General Hospital, Beijing 100853, China
- International Headache Centre, Chinese PLA General Hospital, Beijing 100853, China
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Reffat N, Pusec C, Price S, Gupta M, Mavrocordatos P, Abd-Elsayed A. Neuromodulation Techniques for Headache Management. Life (Basel) 2024; 14:173. [PMID: 38398683 PMCID: PMC10890676 DOI: 10.3390/life14020173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 01/09/2024] [Accepted: 01/19/2024] [Indexed: 02/25/2024] Open
Abstract
This narrative review aims to summarize evidence regarding the current utilization and future applications of neuromodulation in patients with headaches, with special attention paid to migraine and chronic cluster headache. A search was conducted in PubMed in August of 2023 to survey the current literature on neuromodulation for the treatment of headache. In total, the search yielded 1989 results, which were further filtered to include only systematic reviews published between 2022 to 2023 to capture the most up-to-date and comprehensive research on this topic. The citation lists of these articles were reviewed to find additional research on neuromodulation and supplement the results presented in this paper with primary literature. Research on the use of neuromodulation for the treatment of headache has predominantly focused on four neuromodulation techniques: peripheral nerve stimulation (PNS), transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), and spinal cord stimulation (SCS). Outcome measures reported in this article include impact on migraine and headache frequency and/or pain intensity, adverse effects of the neuromodulation technique, and associated costs, when available. We found that neuromodulation has developed utility as an alternative treatment for both chronic cluster headaches and migraines, with a reduction in frequency and intensity of headache most elucidated from the articles mentioned in this review.
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Affiliation(s)
- Noora Reffat
- School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA; (N.R.)
| | - Carolina Pusec
- Department of Neurology, University of Wisconsin Health, Madison, WI 53705, USA
| | - Scott Price
- School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA; (N.R.)
| | - Mayank Gupta
- Kansas Pain Management & Neuroscience Research Center, Kansas City, KS 66214, USA
| | | | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin Health, Madison, WI 53705, USA
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5
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Jensen RH, Tassorelli C, Myers Oakes TM, Bardos JN, Zhou C, Dong Y, Aurora SK, Martinez JM. Baseline demographics and disease characteristics of patients with episodic or chronic cluster headache: data from two phase 3 randomized clinical trials in Europe and North America. Front Neurol 2023; 14:1293163. [PMID: 38162453 PMCID: PMC10756139 DOI: 10.3389/fneur.2023.1293163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/01/2023] [Indexed: 01/03/2024] Open
Abstract
Objective Two phase 3 galcanezumab trials were conducted in Europe and North America to analyze the reduction of weekly cluster headache (CH) attack frequency in populations with episodic and chronic CH. The current study aims to illustrate prospectively recorded baseline clinical data from these trials and to identify possible predictors of response. Methods Patients (aged 18-65 years) met The International Classification of Headache Disorders 3rd edition-beta criteria for CH. Attacks were evaluated using an electronic headache diary for 7-day (episodic) or 14-day (chronic) eligibility assessments before patients were randomized 1:1 to monthly subcutaneous galcanezumab 300 mg or placebo. Results Data were collected from 106 patients with episodic and 237 with chronic CH. Overall, the mean age [standard deviation] was 45.4 [11.0] years; patients were predominantly White (84.5%), male (75.8%), and European (77.6%). Patients with episodic CH reported 17.5 [10.0] attacks/week; patients with chronic CH reported 18.8 [10.2] attacks/week. The average pain severity score (range 0-4) was 2.5 [0.7] for episodic CH and 2.7 [0.7] for chronic CH. Higher attack frequency was a possible predictor of response to galcanezumab; potential negative predictors of response were greater attack severity and duration. Conclusion This large dataset of patients with CH provides reliable systematically and prospectively collected information on disease characteristics. The analysis in episodic CH underscores potential predictors of response worth considering for future CH trial design. Clinical Trial Registration ClinicalTrials.gov, identifiers: NCT02397473 and NCT02438826.
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Affiliation(s)
- Rigmor Hoejland Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, University of Copenhagen, Copenhagen, Denmark
| | - Cristina Tassorelli
- Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
- Headache Science and Neurorehabilitation Centre, IRCCS Mondino Foundation, Pavia, Italy
| | - Tina M. Myers Oakes
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, United States
| | - Jennifer N. Bardos
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, United States
| | - Chunmei Zhou
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, United States
| | - Yan Dong
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, United States
| | - Sheena K. Aurora
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, United States
| | - James M. Martinez
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, United States
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Cheema S, Ferreira F, Parras O, Lagrata S, Kamourieh S, Pakzad A, Zrinzo L, Matharu M, Akram H. Association of Clinical and Neuroanatomic Factors With Response to Ventral Tegmental Area DBS in Chronic Cluster Headache. Neurology 2023; 101:e2423-e2433. [PMID: 37848331 PMCID: PMC10752645 DOI: 10.1212/wnl.0000000000207750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 09/13/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Deep brain stimulation (DBS) of the ventral tegmental area (VTA) is a surgical treatment option for selected patients with refractory chronic cluster headache (CCH). We aimed to identify clinical and structural neuroimaging factors associated with response to VTA DBS in CCH. METHODS This prospective observational cohort study examines consecutive patients with refractory CCH treated with VTA DBS by a multidisciplinary team in a single tertiary neuroscience center as part of usual care. Headache diaries and validated questionnaires were completed at baseline and regular follow-up intervals. All patients underwent T1-weighted structural MRI before surgery. We compared clinical features using multivariable logistic regression and neuroanatomic differences using voxel-based morphometry (VBM) between responders and nonresponders. RESULTS Over a 10-year period, 43 patients (mean age 53 years, SD 11.9), including 29 male patients, with a mean duration of CCH 12 years (SD 7.4), were treated and followed up for at least 1 year (mean follow-up duration 5.6 years). Overall, there was a statistically significant improvement in median attack frequency from 140 to 56 per month (Z = -4.95, p < 0.001), attack severity from 10/10 to 8/10 (Z = -4.83, p < 0.001), and duration from 110 to 60 minutes (Z = -3.48, p < 0.001). Twenty-nine (67.4%) patients experienced ≥50% improvement in attack frequency and were therefore classed as responders. There were no serious adverse events. The most common side effects were discomfort or pain around the battery site (7 patients) and transient diplopia and/or oscillopsia (6 patients). There were no differences in demographics, headache characteristics, or comorbidities between responders and nonresponders. VBM identified increased neural density in nonresponders in several brain regions, including the orbitofrontal cortex, anterior cingulate cortex, anterior insula, and amygdala, which were statistically significant (p < 0.001). DISCUSSION VTA DBS showed no serious adverse events, and, although there was no placebo control, was effective in approximately two-thirds of patients at long-term follow-up. This study did not reveal any reliable clinical predictors of response. However, nonresponders had increased neural density in brain regions linked to processing of pain and autonomic function, both of which are prominent in the pathophysiology of CCH.
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Affiliation(s)
- Sanjay Cheema
- From the Headache and Facial Pain Group (S.C., S.K., M.M.), UCL Queen Square Institute of Neurology; The National Hospital for Neurology and Neurosurgery (S.C., F.F., O.P., S.L., S.K., L.Z., M.M., H.A.); Functional Neurosurgery Unit (F.F., O.P., L.Z., H.A.), UCL Queen Square Institute of Neurology; Wellcome Centre for Human Neuroimaging (F.F.), 12 Queen Square; UCL EPSRC Centre for Doctoral Training in Intelligent Integrated Imaging in Healthcare (i4health) (F.F.); Centre for Medical Image Computing (A.P.), University College London; and Department of Medical Physics and Biomedical Engineering (A.P.), University College London, London, UK.
| | - Francisca Ferreira
- From the Headache and Facial Pain Group (S.C., S.K., M.M.), UCL Queen Square Institute of Neurology; The National Hospital for Neurology and Neurosurgery (S.C., F.F., O.P., S.L., S.K., L.Z., M.M., H.A.); Functional Neurosurgery Unit (F.F., O.P., L.Z., H.A.), UCL Queen Square Institute of Neurology; Wellcome Centre for Human Neuroimaging (F.F.), 12 Queen Square; UCL EPSRC Centre for Doctoral Training in Intelligent Integrated Imaging in Healthcare (i4health) (F.F.); Centre for Medical Image Computing (A.P.), University College London; and Department of Medical Physics and Biomedical Engineering (A.P.), University College London, London, UK
| | - Olga Parras
- From the Headache and Facial Pain Group (S.C., S.K., M.M.), UCL Queen Square Institute of Neurology; The National Hospital for Neurology and Neurosurgery (S.C., F.F., O.P., S.L., S.K., L.Z., M.M., H.A.); Functional Neurosurgery Unit (F.F., O.P., L.Z., H.A.), UCL Queen Square Institute of Neurology; Wellcome Centre for Human Neuroimaging (F.F.), 12 Queen Square; UCL EPSRC Centre for Doctoral Training in Intelligent Integrated Imaging in Healthcare (i4health) (F.F.); Centre for Medical Image Computing (A.P.), University College London; and Department of Medical Physics and Biomedical Engineering (A.P.), University College London, London, UK
| | - Susie Lagrata
- From the Headache and Facial Pain Group (S.C., S.K., M.M.), UCL Queen Square Institute of Neurology; The National Hospital for Neurology and Neurosurgery (S.C., F.F., O.P., S.L., S.K., L.Z., M.M., H.A.); Functional Neurosurgery Unit (F.F., O.P., L.Z., H.A.), UCL Queen Square Institute of Neurology; Wellcome Centre for Human Neuroimaging (F.F.), 12 Queen Square; UCL EPSRC Centre for Doctoral Training in Intelligent Integrated Imaging in Healthcare (i4health) (F.F.); Centre for Medical Image Computing (A.P.), University College London; and Department of Medical Physics and Biomedical Engineering (A.P.), University College London, London, UK
| | - Salwa Kamourieh
- From the Headache and Facial Pain Group (S.C., S.K., M.M.), UCL Queen Square Institute of Neurology; The National Hospital for Neurology and Neurosurgery (S.C., F.F., O.P., S.L., S.K., L.Z., M.M., H.A.); Functional Neurosurgery Unit (F.F., O.P., L.Z., H.A.), UCL Queen Square Institute of Neurology; Wellcome Centre for Human Neuroimaging (F.F.), 12 Queen Square; UCL EPSRC Centre for Doctoral Training in Intelligent Integrated Imaging in Healthcare (i4health) (F.F.); Centre for Medical Image Computing (A.P.), University College London; and Department of Medical Physics and Biomedical Engineering (A.P.), University College London, London, UK
| | - Ashkan Pakzad
- From the Headache and Facial Pain Group (S.C., S.K., M.M.), UCL Queen Square Institute of Neurology; The National Hospital for Neurology and Neurosurgery (S.C., F.F., O.P., S.L., S.K., L.Z., M.M., H.A.); Functional Neurosurgery Unit (F.F., O.P., L.Z., H.A.), UCL Queen Square Institute of Neurology; Wellcome Centre for Human Neuroimaging (F.F.), 12 Queen Square; UCL EPSRC Centre for Doctoral Training in Intelligent Integrated Imaging in Healthcare (i4health) (F.F.); Centre for Medical Image Computing (A.P.), University College London; and Department of Medical Physics and Biomedical Engineering (A.P.), University College London, London, UK
| | - Ludvic Zrinzo
- From the Headache and Facial Pain Group (S.C., S.K., M.M.), UCL Queen Square Institute of Neurology; The National Hospital for Neurology and Neurosurgery (S.C., F.F., O.P., S.L., S.K., L.Z., M.M., H.A.); Functional Neurosurgery Unit (F.F., O.P., L.Z., H.A.), UCL Queen Square Institute of Neurology; Wellcome Centre for Human Neuroimaging (F.F.), 12 Queen Square; UCL EPSRC Centre for Doctoral Training in Intelligent Integrated Imaging in Healthcare (i4health) (F.F.); Centre for Medical Image Computing (A.P.), University College London; and Department of Medical Physics and Biomedical Engineering (A.P.), University College London, London, UK
| | - Manjit Matharu
- From the Headache and Facial Pain Group (S.C., S.K., M.M.), UCL Queen Square Institute of Neurology; The National Hospital for Neurology and Neurosurgery (S.C., F.F., O.P., S.L., S.K., L.Z., M.M., H.A.); Functional Neurosurgery Unit (F.F., O.P., L.Z., H.A.), UCL Queen Square Institute of Neurology; Wellcome Centre for Human Neuroimaging (F.F.), 12 Queen Square; UCL EPSRC Centre for Doctoral Training in Intelligent Integrated Imaging in Healthcare (i4health) (F.F.); Centre for Medical Image Computing (A.P.), University College London; and Department of Medical Physics and Biomedical Engineering (A.P.), University College London, London, UK
| | - Harith Akram
- From the Headache and Facial Pain Group (S.C., S.K., M.M.), UCL Queen Square Institute of Neurology; The National Hospital for Neurology and Neurosurgery (S.C., F.F., O.P., S.L., S.K., L.Z., M.M., H.A.); Functional Neurosurgery Unit (F.F., O.P., L.Z., H.A.), UCL Queen Square Institute of Neurology; Wellcome Centre for Human Neuroimaging (F.F.), 12 Queen Square; UCL EPSRC Centre for Doctoral Training in Intelligent Integrated Imaging in Healthcare (i4health) (F.F.); Centre for Medical Image Computing (A.P.), University College London; and Department of Medical Physics and Biomedical Engineering (A.P.), University College London, London, UK
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Lim T, Anderson S, Stocum R, Ren K, Singleton W, Vallabh J, Noon K, Weaver T. Neuromodulation for the Sphenopalatine Ganglion-a Narrative Review. Curr Pain Headache Rep 2023; 27:645-651. [PMID: 37610504 DOI: 10.1007/s11916-023-01132-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 08/24/2023]
Abstract
PURPOSE OF REVIEW To provide an integrated overview of the current state of knowledge of neuromodulation for the sphenopalatine ganglion (SPG) by reviewing relevant and significant literature. RECENT FINDINGS There are several case reports and clinical trials evaluating neuromodulation for the SPG. We identified two blinded, randomized clinical trials for patients with chronic cluster headache. The randomized trials and additional studies demonstrated the long-term safety, efficacy, and cost-effectiveness of neuromodulation for the SPG. Recent studies in Europe and the USA suggest that SPG neuromodulation is a novel modality with clinical importance for treating acute cluster headaches and reducing the frequency of attacks.
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Affiliation(s)
- Taehong Lim
- Department of Neurology, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Stephen Anderson
- Department of Physical Medicine and Rehabilitation, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Robert Stocum
- Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Karen Ren
- Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Winston Singleton
- Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Jayesh Vallabh
- Department of Physical Medicine and Rehabilitation, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Kristen Noon
- Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Tristan Weaver
- Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, OH, USA.
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Zheng Y, Liu CW, Hui Chan DX, Kai Ong DW, Xin Ker JR, Ng WH, Wan KR. Neurostimulation for Chronic Pain: A Systematic Review of High-Quality Randomized Controlled Trials With Long-Term Follow-Up. Neuromodulation 2023; 26:1276-1294. [PMID: 37436342 DOI: 10.1016/j.neurom.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/03/2023] [Accepted: 05/24/2023] [Indexed: 07/13/2023]
Abstract
OBJECTIVE This study aimed to review the best evidence on the long-term efficacy of neurostimulation for chronic pain. MATERIALS AND METHODS We systematically reviewed PubMed, CENTRAL, and WikiStim for studies published between the inception of the data bases and July 21, 2022. Randomized controlled trials (RCTs) with a minimum of one-year follow-up that were of high methodologic quality as ascertained using the Delphi list criteria were included in the evidence synthesis. The primary outcome was long-term reduction in pain intensity, and the secondary outcomes were all other reported outcomes. Level of recommendation was graded from I to III, with level I being the highest level of recommendation. RESULTS Of the 7119 records screened, 24 RCTs were included in the evidence synthesis. Therapies with recommendations for their usage include pulsed radiofrequency (PRF) for postherpetic neuralgia, transcutaneous electrical nerve stimulation for trigeminal neuralgia, motor cortex stimulation for neuropathic pain and poststroke pain, deep brain stimulation for cluster headache, sphenopalatine ganglion stimulation for cluster headache, occipital nerve stimulation for migraine, peripheral nerve field stimulation for back pain, and spinal cord stimulation (SCS) for back and leg pain, nonsurgical back pain, persistent spinal pain syndrome, and painful diabetic neuropathy. Closed-loop SCS is recommended over open-loop SCS for back and leg pain. SCS is recommended over PRF for postherpetic neuralgia. Dorsal root ganglion stimulation is recommended over SCS for complex regional pain syndrome. CONCLUSIONS Neurostimulation is generally effective in the long term as an adjunctive treatment for chronic pain. Future studies should evaluate whether the multidisciplinary management of the physical perception of pain, affect, and social stressors is superior to their management alone.
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Affiliation(s)
- Yilong Zheng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Diana Xin Hui Chan
- Anaesthesiology and Pain Management, Singapore General Hospital, Singapore
| | - Damian Wen Kai Ong
- Anaesthesia & Chronic and Interventional Pain Management, Tan Tock Seng Hospital, Singapore
| | | | - Wai Hoe Ng
- Department of Neurosurgery, National Neuroscience Institute, Singapore
| | - Kai Rui Wan
- Department of Neurosurgery, National Neuroscience Institute, Singapore.
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9
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Pant A, Farrokhi F, Krause K, Marsans M, Roberts J. Ten-Year Durability of Hypothalamic Deep Brain Stimulation in Treatment of Chronic Cluster Headaches: A Case Report and Literature Review. Cureus 2023; 15:e47338. [PMID: 38021829 PMCID: PMC10657219 DOI: 10.7759/cureus.47338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2023] [Indexed: 12/01/2023] Open
Abstract
Chronic cluster headache (CCH) is a debilitating primary headache that causes excruciating pain without remission. Various medical and surgical treatments have been implemented over the years, yet many provide only short-term relief. Deep brain stimulation (DBS) is an emerging treatment alternative that has been shown to dramatically reduce the intensity and frequency of headache attacks. However, reports of greater than 10-year outcomes after DBS for CCH are scant. Here, we report the durability of DBS in the posterior inferior hypothalamus after 10 years on a patient with CCH. Our patient experienced an 82% decrease in the frequency of headaches after DBS, which was maintained for over 10 years. The side effects observed included depression, irritability, anxiety, and dizziness, which were alleviated by changing programming settings. In the context of current literature, DBS shows promise for long-term relief of cluster headaches when other treatments fail.
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Affiliation(s)
- Aaradhya Pant
- Neurosurgery, Virginia Mason Medical Center, Seattle, USA
| | - Farrokh Farrokhi
- Neurological Surgery, Virginia Mason Medical Center, Seattle, USA
| | - Katie Krause
- Neurological Surgery, Virginia Mason Medical Center, Seattle, USA
| | - Maria Marsans
- Neurological Surgery, Virginia Mason Medical Center, Seattle, USA
| | - John Roberts
- Neurology, Virginia Mason Medical Center, Seattle, USA
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10
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May A, Evers S, Goadsby PJ, Leone M, Manzoni GC, Pascual J, Carvalho V, Romoli M, Aleksovska K, Pozo-Rosich P, Jensen RH. European Academy of Neurology guidelines on the treatment of cluster headache. Eur J Neurol 2023; 30:2955-2979. [PMID: 37515405 DOI: 10.1111/ene.15956] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND AND PURPOSE Cluster headache is a relatively rare, disabling primary headache disorder with a major impact on patients' quality of life. This work presents evidence-based recommendations for the treatment of cluster headache derived from a systematic review of the literature and consensus among a panel of experts. METHODS The databases PubMed (Medline), Science Citation Index, and Cochrane Library were screened for studies on the efficacy of interventions (last access July 2022). The findings in these studies were evaluated according to the recommendations of the European Academy of Neurology, and the level of evidence was established using GRADE (Grading of Recommendations Assessment, Development, and Evaluation). RECOMMENDATIONS For the acute treatment of cluster headache attacks, there is a strong recommendation for oxygen (100%) with a flow of at least 12 L/min over 15 min and 6 mg subcutaneous sumatriptan. Prophylaxis of cluster headache attacks with verapamil at a daily dose of at least 240 mg (maximum dose depends on efficacy and tolerability) is recommended. Corticosteroids are efficacious in cluster headache. To reach an effect, the use of at least 100 mg prednisone (or equivalent corticosteroid) given orally or at up to 500 mg iv per day over 5 days is recommended. Lithium, topiramate, and galcanezumab (only for episodic cluster headache) are recommended as alternative treatments. Noninvasive vagus nerve stimulation is efficacious in episodic but not chronic cluster headache. Greater occipital nerve block is recommended, but electrical stimulation of the greater occipital nerve is not recommended due to the side effect profile.
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Affiliation(s)
- Arne May
- Department of Systems Neuroscience, University Medical Center Hamburg- Eppendorf, Hamburg, Germany
| | - Stefan Evers
- Department of Neurology, Lindenbrunn Hospital, Coppenbrügge, Germany
- Faculty of Medicine, University of Münster, Münster, Germany
| | - Peter J Goadsby
- NIHR King's CRF, SLaM Biomedical Research Centre, King's College London, London, UK
| | - Massimo Leone
- Neuroalgology Department, Foundation of the Carlo Besta Neurological Institute, IRCCS, Milan, Italy
| | | | - Julio Pascual
- Service of Neurology, University Hospital Marqués de Valdecilla, Universidad de Cantabria and IDIVAL, Santander, Spain
| | - Vanessa Carvalho
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
- Centro de Estudos Egas Moniz, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Michele Romoli
- Neurology and Stroke Unit, Bufalini Hospital, Cesena, Italy
| | | | - Patricia Pozo-Rosich
- Headache Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Headache Research Group, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rigmor H Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, University of Copenhagen, Copenhagen, Denmark
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11
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Lund NLT, Petersen AS, Fronczek R, Tfelt-Hansen J, Belin AC, Meisingset T, Tronvik E, Steinberg A, Gaul C, Jensen RH. Current treatment options for cluster headache: limitations and the unmet need for better and specific treatments-a consensus article. J Headache Pain 2023; 24:121. [PMID: 37667192 PMCID: PMC10476341 DOI: 10.1186/s10194-023-01660-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/22/2023] [Indexed: 09/06/2023] Open
Abstract
AIM Treatment for cluster headache is currently based on a trial-and-error approach. The available preventive treatment is unspecific and based on few and small studies not adhering to modern standards. Therefore, the authors collaborated to discuss acute and preventive treatment in cluster headache, addressing the unmet need of safe and tolerable preventive medication from the perspectives of people with cluster headache and society, headache specialist and cardiologist. FINDINGS The impact of cluster headache on personal life is substantial. Mean annual direct and indirect costs of cluster headache are more than 11,000 Euros per patient. For acute treatment, the main problems are treatment response, availability, costs and, for triptans, contraindications and the maximum use allowed. Intermediate treatment with steroids and greater occipital nerve blocks are effective but cannot be used continuously. Preventive treatment is sparsely studied and overall limited by relatively low efficacy and side effects. Neurostimulation is a relevant option for treatment-refractory chronic patients. From a cardiologist's perspective use of verapamil and triptans may be worrisome and regular follow-up is essential when using verapamil and lithium. CONCLUSION We find that there is a great and unmet need to pursue novel and targeted preventive modalities to suppress the horrific pain attacks for people with cluster headache.
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Affiliation(s)
- Nunu Laura Timotheussen Lund
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Valdemar Hansens Vej 5, 2600, Glostrup, Denmark.
- Department of Neurology, Sjællands Universitetshospital Roskilde, Roskilde, Denmark.
| | - Anja Sofie Petersen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Valdemar Hansens Vej 5, 2600, Glostrup, Denmark
| | - Rolf Fronczek
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
- Stichting Epilepsie Instellingen Nederlands (SEIN), Sleep-Wake Centre, Heemstede, The Netherlands
| | - Jacob Tfelt-Hansen
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Forensic Medicine, Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Andrea Carmine Belin
- Centre for Cluster Headache, Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Tore Meisingset
- Norwegian Advisory Unit On Headaches, St. Olav University Hospital, Trondheim, Norway
- NorHEAD, Norwegian Headache Research Centre, NTNU, Trondheim, Norway
| | - Erling Tronvik
- Norwegian Advisory Unit On Headaches, St. Olav University Hospital, Trondheim, Norway
- NorHEAD, Norwegian Headache Research Centre, NTNU, Trondheim, Norway
| | - Anna Steinberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Charly Gaul
- Charly Gaul, Headache Center, Frankfurt, Germany
| | - Rigmor Højland Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Valdemar Hansens Vej 5, 2600, Glostrup, Denmark
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12
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Peng KP, Burish MJ. Management of cluster headache: Treatments and their mechanisms. Cephalalgia 2023; 43:3331024231196808. [PMID: 37652457 DOI: 10.1177/03331024231196808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
BACKGROUND The management of cluster headache is similar to that of other primary headache disorders and can be broadly divided into acute and preventive treatments. Acute treatments for cluster headache are primarily delivered via rapid, non-oral routes (such as inhalation, nasal, or subcutaneous) while preventives include a variety of unrelated treatments such as corticosteroids, verapamil, and galcanezumab. Neuromodulation is becoming an increasingly popular option, both non-invasively such as vagus nerve stimulation when medical treatment is contraindicated or side effects are intolerable, and invasively such as occipital nerve stimulation when medical treatment is ineffective. Clinically, this collection of treatment types provides a range of options for the informed clinician. Scientifically, this collection provides important insights into disease mechanisms. METHODS Two authors performed independent narrative reviews of the literature on guideline recommendations, clinical trials, real-world data, and mechanistic studies. RESULTS Cluster headache is treated with acute treatments, bridge treatments, and preventive treatments. Common first-line treatments include subcutaneous sumatriptan and high-flow oxygen as acute treatments, corticosteroids (oral or suboccipital injections) as bridge treatments, and verapamil as a preventive treatment. Some newer acute (non-invasive vagus nerve stimulation) and preventive (galcanezumab) treatments have excellent clinical trial data for episodic cluster headache, while other newer treatments (occipital nerve stimulation) have been specifically tested in treatment-refractory chronic cluster headache. Most treatments are suspected to act on the trigeminovascular system, the autonomic system, or the hypothalamus. CONCLUSIONS The first-line treatments have not changed in recent years, but new treatments have provided additional options for patients.
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Affiliation(s)
- Kuan-Po Peng
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mark J Burish
- Department of Neurosurgery, UTHealth Houston, Houston, Texas, USA
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13
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Fisher LE, Lempka SF. Neurotechnology for Pain. Annu Rev Biomed Eng 2023; 25:387-412. [PMID: 37068766 DOI: 10.1146/annurev-bioeng-111022-121637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
Neurotechnologies for treating pain rely on electrical stimulation of the central or peripheral nervous system to disrupt or block pain signaling and have been commercialized to treat a variety of pain conditions. While their adoption is accelerating, neurotechnologies are still frequently viewed as a last resort, after many other treatment options have been explored. We review the pain conditions commonly treated with electrical stimulation, as well as the specific neurotechnologies used for treating those conditions. We identify barriers to adoption, including a limited understanding of mechanisms of action, inconsistent efficacy across patients, and challenges related to selectivity of stimulation and off-target side effects. We describe design improvements that have recently been implemented, as well as some cutting-edge technologies that may address the limitations of existing neurotechnologies. Addressing these challenges will accelerate adoption and change neurotechnologies from last-line to first-line treatments for people living with chronic pain.
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Affiliation(s)
- Lee E Fisher
- Rehab Neural Engineering Labs, Department of Physical Medicine and Rehabilitation, and Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA;
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Scott F Lempka
- Department of Biomedical Engineering, Biointerfaces Institute, and Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA;
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Szymoniuk M, Chin JH, Domagalski Ł, Biszewski M, Jóźwik K, Kamieniak P. Brain stimulation for chronic pain management: a narrative review of analgesic mechanisms and clinical evidence. Neurosurg Rev 2023; 46:127. [PMID: 37247036 PMCID: PMC10227133 DOI: 10.1007/s10143-023-02032-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/01/2023] [Accepted: 05/10/2023] [Indexed: 05/30/2023]
Abstract
Chronic pain constitutes one of the most common chronic complaints that people experience. According to the International Association for the Study of Pain, chronic pain is defined as pain that persists or recurs longer than 3 months. Chronic pain has a significant impact on individuals' well-being and psychosocial health and the economy of healthcare systems as well. Despite the availability of numerous therapeutic modalities, treatment of chronic pain can be challenging. Only about 30% of individuals with non-cancer chronic pain achieve improvement from standard pharmacological treatment. Therefore, numerous therapeutic approaches were proposed as a potential treatment for chronic pain including non-opioid pharmacological agents, nerve blocks, acupuncture, cannabidiol, stem cells, exosomes, and neurostimulation techniques. Although some neurostimulation methods such as spinal cord stimulation were successfully introduced into clinical practice as a therapy for chronic pain, the current evidence for brain stimulation efficacy in the treatment of chronic pain remains unclear. Hence, this narrative literature review aimed to give an up-to-date overview of brain stimulation methods, including deep brain stimulation, motor cortex stimulation, transcranial direct current stimulation, repetitive transcranial magnetic stimulation, cranial electrotherapy stimulation, and reduced impedance non-invasive cortical electrostimulation as a potential treatment for chronic pain.
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Affiliation(s)
- Michał Szymoniuk
- Student Scientific Association at the Department of Neurosurgery, Medical University of Lublin, Lublin, Poland
| | - Jia-Hsuan Chin
- Student Scientific Association at the Department of Neurosurgery, Medical University of Lublin, Lublin, Poland
| | - Łukasz Domagalski
- Student Scientific Association at the Department of Neurosurgery, Medical University of Lublin, Lublin, Poland.
| | - Mateusz Biszewski
- Student Scientific Association at the Department of Neurosurgery, Medical University of Lublin, Lublin, Poland
| | - Katarzyna Jóźwik
- Student Scientific Association at the Department of Neurosurgery, Medical University of Lublin, Lublin, Poland
| | - Piotr Kamieniak
- Department of Neurosurgery, Medical University of Lublin, Lublin, Poland
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15
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Murray M, Pahapill PA, Awad AJ. Deep Brain Stimulation for Chronic Cluster Headaches: A Systematic Review and Meta-Analysis. Stereotact Funct Neurosurg 2023; 101:232-243. [PMID: 37245509 DOI: 10.1159/000530508] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 03/29/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Chronic cluster headache (CCH) is a severe and debilitating sub-type of trigeminal autonomic cephalalgia that can be resistant to medical management and associated with significant impairment in quality of life. Studies of deep brain stimulation (DBS) for CCH have provided promising results but have not been assessed in a comprehensive systematic review/meta-analysis. OBJECTIVE The objective was to perform a systematic literature review and meta-analysis of patients with CCH treated with DBS to provide insight on safety and efficacy. METHODS A systematic review and meta-analysis were performed according to PRISMA 2020 guidelines. 16 studies were included in final analysis. A random-effects model was used to meta-analyze data. RESULTS Sixteen studies reported 108 cases for data extraction and analysis. DBS was feasible in >99% of cases and was performed either awake or asleep. Meta-analysis revealed that the mean difference in headache attack frequency and headache intensity after DBS were statistically significant (p < 0.0001). Utilization of microelectrode recording was associated with statistically significant improvement in headache intensity postoperatively (p = 0.006). The average overall follow-up period was 45.4 months and ranged from 1 to 144 months. Death occurred in <1%. The rate of major complications was 16.67%. CONCLUSIONS DBS for CCHs is a feasible surgical technique with a reasonable safety profile that can be successfully performed either awake or asleep. In carefully selected patients, approximately 70% of patients achieve excellent control of their headaches.
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Affiliation(s)
- Molly Murray
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Peter A Pahapill
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Ahmed J Awad
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
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16
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Spindler P, Braun F, Truckenmüller P, Wasilewski D, Faust K, Schneider GH, Trampuz A, Conen A, Kühn AA, Vajkoczy P, Prinz V. Surgical Site Infections Associated With Implanted Pulse Generators for Deep Brain Stimulation: Meta-Analysis and Systematic Review. Neuromodulation 2023; 26:280-291. [PMID: 35970765 DOI: 10.1016/j.neurom.2022.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/18/2022] [Accepted: 03/14/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The aim of this study was to identify and systematically analyze relevant literature on surgical site infections (SSIs) associated with implantable pulse generator (IPG) procedures for deep brain stimulation (DBS). MATERIALS AND METHODS In compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic review and meta-analyses of 58 studies that reported SSI rates of 11,289 patients and 15,956 IPG procedures. A meta-analysis of proportions was performed to estimate the pooled proportion of SSIs across DBS procedures in general and to estimate the proportion of SSIs that occur at the IPG pocket. Moreover, a meta-analysis of odds ratio (OR) was conducted on those studies that reported their results of applying topical vancomycin powder during closure of the IPG wound. Results are presented as rates and OR with 95% CIs. RESULTS The pooled proportion of SSIs was 4.9% (95% CI, 4.1%-6.1%) among all DBS procedures. The dominant SSI localization was the IPG pocket in 61.2% (95% CI, 53.4%-68.5%). A trend toward a beneficial effect of vancomycin powder over standard wound closure was found with an OR of 0.46 (95% CI, 0.21-1.02). Most studies (79.1%) that reported their treatment strategy in case of SSI had a strict protocol of removal of the IPG, followed by antimicrobial treatment and reimplantation of the IPG once the SSI had been eradicated. CONCLUSIONS The IPG pocket was identified as the main site of SSI after DBS procedures. Most studies recommend complete IPG removal, antimicrobial treatment, and reimplantation of an IPG once the SSI has been eradicated. Future studies are needed to clarify the role of alternative approaches (eg, topical vancomycin powder) in the prevention of SSI associated with IPG.
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Affiliation(s)
- Philipp Spindler
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Franziska Braun
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Peter Truckenmüller
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - David Wasilewski
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Katharina Faust
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Gerd-Helge Schneider
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Anna Conen
- Clinic for Infectious Diseases and Infection Prevention, Department of Infectious Diseases and Hospital Hygiene, Kantonsspital Aarau, Aarau, Switzerland
| | - Andrea A Kühn
- Department of Neurology, Movement Disorder Section, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Vincent Prinz
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Department of Neurosurgery, University Hospital, Goethe University, Frankfurt am Main, Germany.
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17
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Membrilla JA, Roa J, Díaz-de-Terán J. Preventive treatment of refractory chronic cluster headache: systematic review and meta-analysis. J Neurol 2023; 270:689-710. [PMID: 36310189 DOI: 10.1007/s00415-022-11436-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Preventive treatment for refractory chronic cluster headache (rCCH) is challenging and many therapies have been tried. OBJECTIVE To study what could be considered the therapy of choice in rCCH through a systematic review and meta-analysis. METHODS This review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The protocol was registered in PROSPERO (ID CRD42021290983). A systematic search was performed in MEDLINE, Embase, Cochrane, clinicaltrials.gov, and the WHO's-International-Clinical-Trials-Registry-Platform. Studies on the preventive treatment for rCCH as defined by the European Headache Federation consensus statement were included. A meta-analysis of the pooled response rate was conducted for the different therapies. RESULTS Of 336 results, 45 were eligible for inclusion. Most articles studied the effect of neuromodulation as a preventive treatment for rCCH. The most studied neuromodulation technique was occipital nerve stimulation (ONS), with a pooled response rate in the meta-analysis of 57.3% (95% CI 0.481-0.665). Deep brain stimulation (DBS) was the second most studied treatment with a pooled response rate of 77.0% (95% CI 0.594-0.957). DBS results were more heterogeneous than ONS, which could be related to the different stimulation targets in DBS studies, and reported more serious adverse events than in ONS studies. The remaining therapies (anti-CGRP pathway drugs, warfarin, ketamine-magnesium infusions, serial occipital nerve blocks, clomiphene, onabotulinum toxin A, ketogenic diet, sphenopalatine ganglion radiofrequency or stimulation, vagus nerve stimulation, percutaneous bioelectric current stimulation, upper cervical cord stimulation, and vidian neurectomy) present weaker results or have less quality of evidence. CONCLUSIONS The results of this systematic review and meta-analysis suggest that ONS could be the first therapeutic strategy for patients with rCCH based on the current evidence.
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Affiliation(s)
- Javier A Membrilla
- Neurology Department, "La Paz" University Hospital, P.º de la Castellana 261, 28046, Madrid, Spain.
| | - Javier Roa
- Neurology Department, "La Paz" University Hospital, P.º de la Castellana 261, 28046, Madrid, Spain
| | - Javier Díaz-de-Terán
- Neurology Department, "La Paz" University Hospital, P.º de la Castellana 261, 28046, Madrid, Spain
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Ali I, Houck KM, Sully K. Neuromodulation in Children with Drug-Resistant Epilepsy. JOURNAL OF PEDIATRIC EPILEPSY 2023. [DOI: 10.1055/s-0042-1760293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
AbstractThe introduction of neuromodulation was a revolutionary advancement in the antiseizure armamentarium for refractory epilepsy. The basic principle of neuromodulation is to deliver an electrical stimulation to the desired neuronal site to modify the neuronal functions not only at the site of delivery but also at distant sites by complex neuronal processes like disrupting the neuronal circuitry and amplifying the functions of marginally functional neurons. The modality is considered open-loop when electrical stimulation is provided at a set time interval or closed-loop when delivered in response to an incipient seizure. Neuromodulation in individuals older than 18 years with epilepsy has proven efficacious and safe. The use of neuromodulation is extended off-label to pediatric patients with epilepsy and the results are promising. Vagus nerve stimulation (VNS), responsive neurostimulation (RNS), and deep brain stimulation (DBS) are Food and Drug Administration-approved therapeutic techniques. The VNS provides retrograde signaling to the central nervous system, whereas DBS and RNS are more target specific in the central nervous system. While DBS is open-loop and approved for stimulation of the anterior nucleus of the thalamus, the RNS is closed-loop and can stimulate any cortical or subcortical structure. We will review different modalities and their clinical efficacy in individuals with epilepsy, with a focus on pediatric patients.
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Affiliation(s)
- Irfan Ali
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States
| | - Kimberly M. Houck
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States
| | - Krystal Sully
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States
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Deep Brain Stimulation for Chronic Pain. Neurosurg Clin N Am 2022; 33:311-321. [DOI: 10.1016/j.nec.2022.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Dodick DW, Goadsby PJ, Ashina M, Tassorelli C, Hundemer HP, Bardos JN, Wenzel Md R, Kemmer P, Conley R, Martinez JM, Oakes T. Challenges and complexities in designing cluster headache prevention clinical trials: A narrative review. Headache 2022; 62:453-472. [PMID: 35363381 PMCID: PMC9325511 DOI: 10.1111/head.14292] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/24/2022] [Accepted: 02/22/2022] [Indexed: 12/28/2022]
Abstract
Objective To provide a review of challenges in clinical trials for the preventive treatment of cluster headache (CH) and highlight considerations for future studies. Background Current guidelines for preventive treatment of CH are largely based on off‐label therapies supported by a limited number of small randomized controlled trials. Guidelines for clinical trial design for CH treatments from the International Headache Society were last issued in 1995. Methods/Results Randomized controlled clinical trials were identified in the European and/or United States clinical trial registries with a search term of “cluster headache,” and manually reviewed. Cumulatively, there were 27 unique placebo‐controlled prevention trials for episodic and/or chronic CH, of which 12 were either ongoing, not yet recruiting, or the status was unknown. Of the remaining 15 trials, 5 were terminated early and 7 of the 10 completed trials enrolled fewer patients than planned or did not report the planned sample size. A systematic search of PubMed was also utilized to identify published manuscripts reporting results from placebo‐controlled preventive trials of CH. This search yielded 16 publications, of which 7 were registered. Through critical review of trial data and published manuscripts, challenges and complexities encountered in clinical trials for the preventive treatment of CH were identified. For example, the excruciating pain associated with CH demands a suitably limited baseline duration, rapid treatment efficacy onset, and poses a specific issue regarding duration of investigational treatment period and length of exposure to placebo. In episodic CH, spontaneous remission as part of natural history, and the unpredictability and irregularity of cluster periods across patients present additional key challenges. Conclusions Optimal CH trial design should balance sound methodology to demonstrate efficacy of a potential treatment with patient needs and the natural history of the disease, including unique outcome measures and endpoint timings for chronic versus episodic CH.
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Affiliation(s)
- David W Dodick
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Peter J Goadsby
- National Institute for Health Research (NIHR) Wellcome Trust King's Clinical Research Facility, King's College London, London, UK.,Department of Neurology, University of California, Los Angeles, California, USA
| | - Messoud Ashina
- Department of Neurology, Danish Headache Center, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Cristina Tassorelli
- Headache Science Centre, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
| | | | | | | | - Phebe Kemmer
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Robert Conley
- Eli Lilly and Company, Indianapolis, Indiana, USA.,University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Tina Oakes
- Eli Lilly and Company, Indianapolis, Indiana, USA
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21
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Medrea I, Christie S, Tepper SJ, Thavorn K, Hutton B. Effects of acute and preventive therapies for episodic and chronic cluster headache: A scoping review of the literature. Headache 2022; 62:329-362. [PMID: 35315067 DOI: 10.1111/head.14284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 01/19/2022] [Accepted: 02/01/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cluster headache is the most common primary headache disorder of the trigeminal autonomic cephalalgias, and it is highly disabling. OBJECTIVE We undertake a scoping review to characterize therapies to prevent and acutely treat cluster headache, characterize trial methodology utilized in studies, and recommend future trial "good practices." We also assess homogeneity of studies and feasibility for future network meta-analyses (NMAs) to compare acute and preventive treatments for cluster headache. METHODS A priori protocol for this scoping review was registered and available on Open Science Forum. We sought studies that enrolled adult patients with cluster headache as identified by accepted diagnostic criteria. Both randomized controlled trials (RCTs) and observational studies (with a control group) were included. The interventions of interest were medications, procedures, devices, surgeries, and behavioral/psychological interventions, whereas comparators of interest were placebo, sham, or other active treatments. Outcomes were predefined; however, we did not exclude studies lacking these outcomes. A systemic search was conducted in Ovid Medline, Embase, and Cochrane. We performed a targeted search for conference abstracts from journals prominent in the field. RESULTS We identified 56 studies: 45 RCTs, four studies only available in clinical trial registries, and seven observational studies. Of the 45 RCTs, 20 focused on acute therapies and 25 on preventive therapies. Overall, we determined that it is feasible to pursue a NMA for acute therapy focusing on 15 or 30-min headache reduction for acute trials, as we identified 11 trials in the combined population of patients with either episodic or chronic cluster headache (2 trials in populations with chronic cluster headache were also found). For preventive therapy of cluster headache, we identified trials with common outcomes that may be considered for NMA, however, as these trials had differences in treatment effect modifiers that could not be corrected, NMAs appear infeasible for this indication. We identified new studies looking at noninvasive vagal nerve stimulation, sphenopalatine ganglion stimulation, prednisone, and oxygen published since the most recent systematic review in the field, although these acute treatments were previously identified as effective. However, for calcitonin gene-related peptide (CGRP) monoclonal antibodies, galcanezumab demonstrated effectiveness in episodic cluster headache, but a lack of effectiveness in chronic cluster headache, and fremanezumab was not effective for episodic nor chronic cluster headache. This finding highlights that CGRP monoclonal antibodies may not show a class effect in cluster headache prevention and need to be considered individually. CONCLUSIONS We describe the treatment landscape of cluster headache for both acute and preventive treatments. Last, we present the NMAs we will undertake in acute therapies of cluster headache.
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Affiliation(s)
- Ioana Medrea
- University of Ottawa Ottawa Ontario Canada
- SUNY Upstate Medical University Syracuse New York USA
| | - Suzanne Christie
- University of Ottawa Ottawa Ontario Canada
- Ottawa Headache Centre Ottawa Ontario Canada
| | | | - Kednapa Thavorn
- University of Ottawa Ottawa Ontario Canada
- Ottawa Hospital Research Institute Ottawa Ontario Canada
| | - Brian Hutton
- University of Ottawa Ottawa Ontario Canada
- Ottawa Hospital Research Institute Ottawa Ontario Canada
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22
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Coppola G, Magis D, Casillo F, Sebastianelli G, Abagnale C, Cioffi E, Di Lenola D, Di Lorenzo C, Serrao M. Neuromodulation for Chronic Daily Headache. Curr Pain Headache Rep 2022; 26:267-278. [PMID: 35129825 PMCID: PMC8927000 DOI: 10.1007/s11916-022-01025-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2022] [Indexed: 11/29/2022]
Abstract
Purpose of Review We reviewed the literature that explored the use of central and peripheral neuromodulation techniques for chronic daily headache (CDH) treatment. Recent Findings Although the more invasive deep brain stimulation (DBS) is effective in chronic cluster headache (CCH), it should be reserved for extremely difficult-to-treat patients. Percutaneous occipital nerve stimulation has shown similar efficacy to DBS and is less risky in both CCH and chronic migraine (CM). Non-invasive transcutaneous vagus nerve stimulation is a promising add-on treatment for CCH but not for CM. Transcutaneous external trigeminal nerve stimulation may be effective in treating CM; however, it has not yet been tested for cluster headache. Transcranial magnetic and electric stimulations have promising preventive effects against CM and CCH. Summary Although the precise mode of action of non-invasive neuromodulation techniques remains largely unknown and there is a paucity of controlled trials, they should be preferred to more invasive techniques for treating CDH.
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Affiliation(s)
- Gianluca Coppola
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, Latina, Italy.
| | - Delphine Magis
- Headache and Pain Multimodal Treatment Centre (CMTCD), Department of Neurology, Neuromodulation Centre, CHR East Belgium, Verviers, Belgium
| | - Francesco Casillo
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, Latina, Italy
| | - Gabriele Sebastianelli
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, Latina, Italy
| | - Chiara Abagnale
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, Latina, Italy
| | - Ettore Cioffi
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, Latina, Italy
| | - Davide Di Lenola
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, Latina, Italy
| | - Cherubino Di Lorenzo
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, Latina, Italy
| | - Mariano Serrao
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, Latina, Italy
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Dzhafarov V, Moysak G, Rzaev J, Isagulyan E, Aslakhanova K, Murtazin V, Genov P, Vostretsova I. Sphenopalatine ganglion stimulation in the treatment of chronic refractory cluster headache. A preliminary multicenter study in Russia. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:68-73. [DOI: 10.17116/jnevro202212202168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
PURPOSE OF REVIEW In this narrative review, the current literature on neurostimulation methods in the treatment of chronic cluster headache is evaluated. These neurostimulation methods include deep brain stimulation, vagus nerve stimulation, greater occipital nerve stimulation, sphenopalatine ganglion stimulation, transcranial magnetic stimulation, transcranial direct current stimulation, supraorbital nerve stimulation, and cervical spinal cord stimulation. RECENT FINDINGS Altogether, only nVNS and SPG stimulation are supported by at least one positive sham-controlled clinical trial for preventive and acute attack (only SPG stimulation) treatment. Other clinical trials either did not control at all or controlled by differences in the stimulation technique itself but not by a sham-control. Case series report higher responder rates. The evidence for these neurostimulation methods in the treatment of chronic cluster headache is poor and in part contradictive. However, except deep brain stimulation, tolerability and safety of these methods are good so that in refractory situations application might be justified in individual cases.
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Keuken MC, Alkemade A, Stevenson N, Innes RJ, Forstmann BU. Structure-function similarities in deep brain stimulation targets cross-species. Neurosci Biobehav Rev 2021; 131:1127-1135. [PMID: 34715147 DOI: 10.1016/j.neubiorev.2021.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 10/22/2021] [Accepted: 10/24/2021] [Indexed: 11/24/2022]
Abstract
Deep Brain Stimulation (DBS) is an effective neurosurgical treatment to alleviate motor symptoms of advanced Parkinson's disease. Due to its potential, DBS usage is rapidly expanding to target a large number of brain regions to treat a wide range of diseases and neuropsychiatric disorders. The identification and validation of new target regions heavily rely on the insights gained from rodent and primate models. Here we present a large-scale automatic meta-analysis in which the structure-function associations within and between species are compared for 21 DBS targets in humans. The results indicate that the structure-function association for the majority of the 21 included subcortical areas were conserved cross-species. A subset of structures showed overlapping functional association. This can potentially be attributed to shared brain networks and might explain why multiple brain areas are targeted for the same disease or neuropsychiatric disorder.
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Affiliation(s)
- Max C Keuken
- Integrative Model-based Cognitive Neuroscience Research Unit, University of Amsterdam, Nieuwe Achtergracht 129B, Postbus 15926, 1001 NK, Amsterdam, The Netherlands.
| | - Anneke Alkemade
- Integrative Model-based Cognitive Neuroscience Research Unit, University of Amsterdam, Nieuwe Achtergracht 129B, Postbus 15926, 1001 NK, Amsterdam, The Netherlands
| | - Niek Stevenson
- Integrative Model-based Cognitive Neuroscience Research Unit, University of Amsterdam, Nieuwe Achtergracht 129B, Postbus 15926, 1001 NK, Amsterdam, The Netherlands
| | - Reilly J Innes
- Integrative Model-based Cognitive Neuroscience Research Unit, University of Amsterdam, Nieuwe Achtergracht 129B, Postbus 15926, 1001 NK, Amsterdam, The Netherlands; Newcastle Cognition Lab, University of Newcastle, Callaghan, NSW, Australia
| | - Birte U Forstmann
- Integrative Model-based Cognitive Neuroscience Research Unit, University of Amsterdam, Nieuwe Achtergracht 129B, Postbus 15926, 1001 NK, Amsterdam, The Netherlands
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Yamamoto K, Elias GJB, Beyn ME, Zemmar A, Loh A, Sarica C, Germann J, Parmar R, Wong EHY, Boutet A, Kalia S, Hodaie M, Lozano AM. Neuromodulation for Pain: A Comprehensive Survey and Systematic Review of Clinical Trials and Connectomic Analysis of Brain Targets. Stereotact Funct Neurosurg 2021; 100:14-25. [PMID: 34380132 DOI: 10.1159/000517873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 05/28/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic pain is a debilitating condition that imposes a tremendous burden on health-care systems around the world. While frontline treatments for chronic pain involve pharmacological and psychological approaches, neuromodulation can be considered for treatment-resistant cases. Neuromodulatory approaches for pain are diverse in both modality and target and their mechanism of action is incompletely understood. OBJECTIVES The objectives of this study were to (i) understand the current landscape of pain neuromodulation research through a comprehensive survey of past and current registered clinical trials (ii) investigate the network underpinnings of these neuromodulatory treatments by performing a connectomic mapping analysis of cortical and subcortical brain targets that have been stimulated for pain relief. METHODS A search for clinical trials involving pain neuromodulation was conducted using 2 major trial databases (ClinicalTrials.gov and the International Clinical Trials Registry Platform). Trials were categorized by variables and analyzed to gain an overview of the contemporary research landscape. Additionally, a connectomic mapping analysis was performed to investigate the network connectivity patterns of analgesic brain stimulation targets using a normative connectome based on a functional magnetic resonance imaging dataset. RESULTS In total, 487 relevant clinical trials were identified. Noninvasive cortical stimulation and spinal cord stimulation trials represented 49.3 and 43.7% of this count, respectively, while deep brain stimulation trials accounted for <3%. The mapping analysis revealed that superficial target connectomics overlapped with deep target connectomics, suggesting a common pain network across the targets. CONCLUSIONS Research for pain neuromodulation is a rapidly growing field. Our connectomic network analysis reinforced existing knowledge of the pain matrix, identifying both well-described hubs and more obscure structures. Further studies are needed to decode the circuits underlying pain relief and determine the most effective targets for neuromodulatory treatment.
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Affiliation(s)
- Kazuaki Yamamoto
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada,
| | - Gavin J B Elias
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Michelle E Beyn
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Ajmal Zemmar
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
- Department of Neurosurgery, People's Hospital of Zhengzhou University, Henan Provincial People's Hospital, Henan University People's Hospital, Henan University School of Medicine, Zhengzhou, China
| | - Aaron Loh
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Can Sarica
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Jürgen Germann
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Roohie Parmar
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Emily H Y Wong
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Alexandre Boutet
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Suneil Kalia
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Mojgan Hodaie
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
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Wilbrink LA, de Coo IF, Doesborg PGG, Mulleners WM, Teernstra OPM, Bartels EC, Burger K, Wille F, van Dongen RTM, Kurt E, Spincemaille GH, Haan J, van Zwet EW, Huygen FJPM, Ferrari MD. Safety and efficacy of occipital nerve stimulation for attack prevention in medically intractable chronic cluster headache (ICON): a randomised, double-blind, multicentre, phase 3, electrical dose-controlled trial. Lancet Neurol 2021; 20:515-525. [PMID: 34146510 DOI: 10.1016/s1474-4422(21)00101-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 02/14/2021] [Accepted: 03/17/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Occipital nerve stimulation (ONS) has shown promising results in small uncontrolled trials in patients with medically intractable chronic cluster headache (MICCH). We aimed to establish whether ONS could serve as an effective treatment for patients with MICCH. METHODS The ONS in MICCH (ICON) study is an investigator-initiated, international, multicentre, randomised, double-blind, phase 3, electrical dose-controlled clinical trial. The study took place at four hospitals in the Netherlands, one hospital in Belgium, one in Germany, and one in Hungary. After 12 weeks' baseline observation, patients with MICCH, at least four attacks per week, and history of being non-responsive to at least three standard preventive drugs, were randomly allocated (at a 1:1 ratio using a computer-generated permuted block) to 24 weeks of occipital nerve stimulation at either 100% or 30% of the individually determined range between paraesthesia threshold and near-discomfort (double-blind study phase). Because ONS causes paraesthesia, preventing masked comparison versus placebo, we compared high-intensity versus low-intensity ONS, which are hypothesised to cause similar paraesthesia, but with different efficacy. In weeks 25-48, participants received individually optimised open-label ONS. The primary outcome was the weekly mean attack frequency in weeks 21-24 compared with baseline across all patients and, if a decrease was shown, to show a group-wise difference. The trial is closed to recruitment (ClinicalTrials.gov NCT01151631). FINDINGS Patients were enrolled between Oct 12, 2010, and Dec 3, 2017. We enrolled 150 patients and randomly assigned 131 (87%) to treatment; 65 (50%) patients to 100% ONS and 66 (50%) to 30% ONS. One of the 66 patients assigned to 30% ONS was not implanted and was therefore excluded from the intention-to-treat analysis. Because the weekly mean attack frequencies at baseline were skewed (median 15·75; IQR 9·44 to 24·75) we used log transformation to analyse the data and medians to present the results. Median weekly mean attack frequencies in the total population decreased from baseline to 7·38 (2·50 to 18·50; p<0·0001) in weeks 21-24, a median change of -5·21 (-11·18 to -0·19; p<0·0001) attacks per week. In the 100% ONS stimulation group, mean attack frequency decreased from 17·58 (9·83 to 29·33) at baseline to 9·50 (3·00 to 21·25) at 21-24 weeks (median change from baseline -4·08, -11·92 to -0·25), and for the 30% ONS stimulation group, mean attack frequency decreased from 15·00 (9·25 to 22·33) to 6·75 (1·50 to 16·50; -6·50, -10·83 to -0·08). The difference in median weekly mean attack frequency between groups at the end of the masked phase in weeks 21-24 was -2·42 (95% CI -5·17 to 3·33). In the masked study phase, 129 adverse events occurred with 100% ONS and 95 occurred with 30% ONS. None of the adverse events was unexpected but 17 with 100% ONS and eight with 30% ONS were labelled as serious, given they required brief hospital admission for minor hardware-related issues. The most common adverse events were local pain, impaired wound healing, neck stiffness, and hardware damage. INTERPRETATION In patients with MICCH, both 100% ONS intensity and 30% ONS intensity substantially reduced attack frequency and were safe and well tolerated. Future research should focus on optimising stimulation protocols and disentangling the underlying mechanism of action. FUNDING The Netherlands Organisation for Scientific Research, the Dutch Ministry of Health, the NutsOhra Foundation from the Dutch Health Insurance Companies, and Medtronic.
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Affiliation(s)
- Leopoldine A Wilbrink
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands; Department of Neurology, Zuyderland Medical Centre, Heerlen, Netherlands
| | - Ilse F de Coo
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands; Basalt Rehabilitation Centre, the Hague, Netherlands
| | - Patty G G Doesborg
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands
| | - Wim M Mulleners
- Department of Neurology, Canisius-Wilhelmina Hospital, Nijmegen, Netherlands
| | - Onno P M Teernstra
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Eveline C Bartels
- Department of Anaesthesiology, Leiden University Medical Centre, Leiden, Netherlands
| | - Katja Burger
- Department of Anaesthesiology, Alrijne Hospital, Leiderdorp, Netherlands
| | - Frank Wille
- Department of Anaesthesiology, Diakonessenhuis Hospital, Zeist, Netherlands
| | - Robert T M van Dongen
- Department of Anaesthesiology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Erkan Kurt
- Department of Neurosurgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Geert H Spincemaille
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Joost Haan
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands; Department of Neurology, Alrijne Hospital, Leiderdorp, Netherlands
| | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, Netherlands
| | | | - Michel D Ferrari
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands.
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Abdallat M, Saryyeva A, Blahak C, Wolf ME, Weigel R, Loher TJ, Runge J, Heissler HE, Kinfe TM, Krauss JK. Centromedian-Parafascicular and Somatosensory Thalamic Deep Brain Stimulation for Treatment of Chronic Neuropathic Pain: A Contemporary Series of 40 Patients. Biomedicines 2021; 9:731. [PMID: 34202202 PMCID: PMC8301341 DOI: 10.3390/biomedicines9070731] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/17/2021] [Accepted: 06/20/2021] [Indexed: 02/05/2023] Open
Abstract
Introduction: The treatment of neuropathic and central pain still remains a major challenge. Thalamic deep brain stimulation (DBS) involving various target structures is a therapeutic option which has received increased re-interest. Beneficial results have been reported in several more recent smaller studies, however, there is a lack of prospective studies on larger series providing long term outcomes. Methods: Forty patients with refractory neuropathic and central pain syndromes underwent stereotactic bifocal implantation of DBS electrodes in the centromedian-parafascicular (CM-Pf) and the ventroposterolateral (VPL) or ventroposteromedial (VPM) nucleus contralateral to the side of pain. Electrodes were externalized for test stimulation for several days. Outcome was assessed with five specific VAS pain scores (maximum, minimum, average pain, pain at presentation, allodynia). Results: The mean age at surgery was 53.5 years, and the mean duration of pain was 8.2 years. During test stimulation significant reductions of all five pain scores was achieved with either CM-Pf or VPL/VPM stimulation. Pacemakers were implanted in 33/40 patients for chronic stimulation for whom a mean follow-up of 62.8 months (range 3-180 months) was available. Of these, 18 patients had a follow-up beyond four years. Hardware related complications requiring secondary surgeries occurred in 11/33 patients. The VAS maximum pain score was improved by ≥50% in 8/18, and by ≥30% in 11/18 on long term follow-up beyond four years, and the VAS average pain score by ≥50% in 10/18, and by ≥30% in 16/18. On a group level, changes in pain scores remained statistically significant over time, however, there was no difference when comparing the efficacy of CM-Pf versus VPL/VPM stimulation. The best results were achieved in patients with facial pain, poststroke/central pain (except thalamic pain), or brachial plexus injury, while patients with thalamic lesions had the least benefit. Conclusion: Thalamic DBS is a useful treatment option in selected patients with severe and medically refractory pain.
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Affiliation(s)
- Mahmoud Abdallat
- Department of Neurosurgery, Hannover Medical School, 30625 Hannover, Germany; (M.A.); (R.W.); (J.R.); (H.E.H.); (J.K.K.)
- Department of Neurosurgery, University of Jordan, Amman 11183, Jordan
| | - Assel Saryyeva
- Department of Neurosurgery, Hannover Medical School, 30625 Hannover, Germany; (M.A.); (R.W.); (J.R.); (H.E.H.); (J.K.K.)
| | - Christian Blahak
- Department of Neurology, University Hospital Mannheim, 68167 Mannheim, Germany; (C.B.); (M.E.W.)
- Department of Neurology, Ortenau-Klinikum Lahr-Ettenheim, 77933 Lahr Ettenheim, Germany
| | - Marc E. Wolf
- Department of Neurology, University Hospital Mannheim, 68167 Mannheim, Germany; (C.B.); (M.E.W.)
- Department of Neurology, Katharinenhospital, 70174 Stuttgart, Germany
| | - Ralf Weigel
- Department of Neurosurgery, Hannover Medical School, 30625 Hannover, Germany; (M.A.); (R.W.); (J.R.); (H.E.H.); (J.K.K.)
- Department of Neurosurgery, St. Katharinen Krankenhaus, 60389 Frankfurt, Germany
| | | | - Joachim Runge
- Department of Neurosurgery, Hannover Medical School, 30625 Hannover, Germany; (M.A.); (R.W.); (J.R.); (H.E.H.); (J.K.K.)
| | - Hans E. Heissler
- Department of Neurosurgery, Hannover Medical School, 30625 Hannover, Germany; (M.A.); (R.W.); (J.R.); (H.E.H.); (J.K.K.)
| | - Thomas M. Kinfe
- Department of Neurosurgery, Division of Functional Neurosurgery and Stereotaxy, Friedrich-Alexander University, 91054 Erlangen-Nürnberg, Germany;
| | - Joachim K. Krauss
- Department of Neurosurgery, Hannover Medical School, 30625 Hannover, Germany; (M.A.); (R.W.); (J.R.); (H.E.H.); (J.K.K.)
- Center for Systems Neuroscience, 30559 Hannover, Germany
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Abstract
Background Cluster headache is a highly disabling primary headache disorder which is widely described as the most painful condition a human can experience. Aim To provide an overview of the clinical characteristics, epidemiology, risk factors, differential diagnosis, pathophysiology and treatment options of cluster headache, with a focus on recent developments in the field. Methods Structured review of the literature on cluster headache. Results Cluster headache affects approximately one in 1000 of the population. It is characterised by attacks of severe unilateral head pain associated with ipsilateral cranial autonomic symptoms, and the tendency for attacks to occur with circadian and circannual periodicity. The pathophysiology of cluster headache and other primary headache disorders has recently become better understood and is thought to involve the hypothalamus and trigeminovascular system. There is good quality evidence for acute treatment of attacks with parenteral triptans and high flow oxygen; preventive treatment with verapamil; and transitional treatment with oral corticosteroids or greater occipital nerve injection. New pharmacological and neuromodulation therapies have recently been developed. Conclusion Cluster headache causes distinctive symptoms, which once they are recognised can usually be managed with a variety of established treatments. Recent pathophysiological understanding has led to the development of newer pharmacological and neuromodulation therapies, which may soon become established in clinical practice.
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Affiliation(s)
- Sanjay Cheema
- Headache and Facial Pain Group, University College London (UCL) Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
| | - Manjit Matharu
- Headache and Facial Pain Group, University College London (UCL) Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
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Knotkova H, Hamani C, Sivanesan E, Le Beuffe MFE, Moon JY, Cohen SP, Huntoon MA. Neuromodulation for chronic pain. Lancet 2021; 397:2111-2124. [PMID: 34062145 DOI: 10.1016/s0140-6736(21)00794-7] [Citation(s) in RCA: 186] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 03/24/2021] [Accepted: 03/31/2021] [Indexed: 12/23/2022]
Abstract
Neuromodulation is an expanding area of pain medicine that incorporates an array of non-invasive, minimally invasive, and surgical electrical therapies. In this Series paper, we focus on spinal cord stimulation (SCS) therapies discussed within the framework of other invasive, minimally invasive, and non-invasive neuromodulation therapies. These therapies include deep brain and motor cortex stimulation, peripheral nerve stimulation, and the non-invasive treatments of repetitive transcranial magnetic stimulation, transcranial direct current stimulation, and transcutaneous electrical nerve stimulation. SCS methods with electrical variables that differ from traditional SCS have been approved. Although methods devoid of paraesthesias (eg, high frequency) should theoretically allow for placebo-controlled trials, few have been done. There is low-to-moderate quality evidence that SCS is superior to reoperation or conventional medical management for failed back surgery syndrome, and conflicting evidence as to the superiority of traditional SCS over sham stimulation or between different SCS modalities. Peripheral nerve stimulation technologies have also undergone rapid development and become less invasive, including many that are placed percutaneously. There is low-to-moderate quality evidence that peripheral nerve stimulation is effective for neuropathic pain in an extremity, low quality evidence that it is effective for back pain with or without leg pain, and conflicting evidence that it can prevent migraines. In the USA and many areas in Europe, deep brain and motor cortex stimulation are not approved for chronic pain, but are used off-label for refractory cases. Overall, there is mixed evidence supporting brain stimulation, with most sham-controlled trials yielding negative findings. Regarding non-invasive modalities, there is moderate quality evidence that repetitive transcranial magnetic stimulation does not provide meaningful benefit for chronic pain in general, but conflicting evidence regarding pain relief for neuropathic pain and headaches. For transcranial direct current stimulation, there is low-quality evidence supporting its benefit for chronic pain, but conflicting evidence regarding a small treatment effect for neuropathic pain and headaches. For transcutaneous electrical nerve stimulation, there is low-quality evidence that it is superior to sham or no treatment for neuropathic pain, but conflicting evidence for non-neuropathic pain. Future research should focus on better evaluating the short-term and long-term effectiveness of all neuromodulation modalities and whether they decrease health-care use, and on refining selection criteria and treatment variables.
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Affiliation(s)
- Helena Knotkova
- MJHS Institute for Innovation in Palliative Care, New York, NY, USA; Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Clement Hamani
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Harquail Centre for Neuromodulation, University of Toronto, Toronto, ON, Canada
| | - Eellan Sivanesan
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Jee Youn Moon
- Department of Anesthesiology, Seoul National University, Seoul, South Korea
| | - Steven P Cohen
- Department of Neurology, Department of Physical Medicine & Rehabilitation, and Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA; Department of Anesthesiology and Department of Physical Medicine & Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
| | - Marc A Huntoon
- Department of Anesthesiology, Virginia Commonwealth University, Richmond, VA, USA
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Deer TR, Falowski S, Arle JE, Vesper J, Pilitsis J, Slavin KV, Hancu M, Grider JS, Mogilner AY. A Systematic Literature Review of Brain Neurostimulation Therapies for the Treatment of Pain. PAIN MEDICINE 2021; 21:1415-1420. [PMID: 32034418 DOI: 10.1093/pm/pnz371] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To conduct a systematic literature review of brain neurostimulation for pain. DESIGN Grade the evidence for deep brain neurostimulation (DBS). METHODS An international, interdisciplinary work group conducted a literature search for brain stimulation. Abstracts were reviewed to select studies for grading. Randomized controlled trials (RCTs) meeting inclusion/exclusion criteria were graded by two independent reviewers. General inclusion criteria were prospective trials (RCTs and observational) that were not part of a larger or previously reported group. Excluded studies were retrospective or existed only as abstracts. Studies were graded using the modified Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment, the Cochrane Collaborations Risk of Bias assessment, and the United States Preventative Services Task Force level-of-evidence criteria. RESULTS Two high-quality RCTs and three observational trials supported DBS, resulting in Level II (moderate) evidence. CONCLUSION Moderate evidence supports DBS to treat chronic pain. Additional Level I RCTs are needed to further the strength of the evidence in this important area of medicine, but the current evidence suggests that DBS should be considered as an option in treating complex pain cases.
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Affiliation(s)
- Timothy R Deer
- Spine and Nerve Center of the Virginias, Charleston, West Virginia
| | - Steven Falowski
- Department of Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, Pennsylvania
| | - Jeff E Arle
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jan Vesper
- Department of Functional Neurosurgery and Stereotaxy, Heinrich Heine University, Dusseldorf, Germany
| | - Julie Pilitsis
- Department of Neurosurgery, Albany Medical College, Albany, New York
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Maria Hancu
- Department of Neurosurgery, Albany Medical College, Albany, New York
| | - Jay S Grider
- UK HealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Alon Y Mogilner
- Department Neurosurgery, NYU Langone Medical Center, New York, New York, USA
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Mavridis T, Breza M, Deligianni C, Mitsikostas DD. Current advances in the management of cluster headaches. Expert Opin Pharmacother 2021; 22:1931-1943. [PMID: 33989098 DOI: 10.1080/14656566.2021.1924148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Cluster headache (CH) is probably the most severe idiopathic pain condition, yet its current medical management remains poor.Areas covered: Only repurpose medicines are currently in use for the prevention of CH, partially because the pathophysiology of the condition is still elusive. In this article we performed a systematic review to evaluate the evidence for efficacy of the currently available or emerging treatments for CH.Expert opinion: We found several ongoing randomized clinical trials testing prophylactic treatments for CH and only few for the standard ones. Recent data from randomized trials with monoclonal antibodies targeting the calcitonin gene related peptide pathway (anti-CGRP mAbs) are controversial, although its role in the pathogenesis of the condition is well documented. This inconsistency may depict inadequacies in clinical trial designing. Anti-CGRP mAbs and antagonists of pituitary adenylate cyclase-activating polypeptide (PACAP) along with neuromodulation techniques, are curing the necessary valuable evidence that could illuminate the therapeutical future for cluster headache. Orexin pathway is another attractive target for CH treatment. To improve the evidence for efficacy, we further propose that the design of the clinical trials for CH needs to be radically reviewed to allow more patients to participate.
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Affiliation(s)
- Theodoros Mavridis
- 1st Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Marianthi Breza
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Dimos D Mitsikostas
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Neuromodulation in headache and craniofacial neuralgia: Guidelines from the Spanish Society of Neurology and the Spanish Society of Neurosurgery. NEUROLOGÍA (ENGLISH EDITION) 2021. [DOI: 10.1016/j.nrleng.2020.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Courault P, Demarquay G, Zimmer L, Lancelot S. Cluster headache: state of the art of pharmacological treatments and therapeutic perspectives. Fundam Clin Pharmacol 2020; 35:595-619. [DOI: 10.1111/fcp.12636] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/13/2020] [Accepted: 12/03/2020] [Indexed: 12/26/2022]
Affiliation(s)
- Pierre Courault
- Lyon Neuroscience Research Center (CRNL) Université de LyonCNRSINSERM Lyon France
- Hospices Civils de Lyon (HCL) Lyon France
| | | | - Luc Zimmer
- Lyon Neuroscience Research Center (CRNL) Université de LyonCNRSINSERM Lyon France
- Hospices Civils de Lyon (HCL) Lyon France
- CERMEP‐Imaging Platform Groupement Hospitalier Est Bron France
- National Institute for Nuclear Science and Technology (INSTN) CEA Saclay France
| | - Sophie Lancelot
- Lyon Neuroscience Research Center (CRNL) Université de LyonCNRSINSERM Lyon France
- Hospices Civils de Lyon (HCL) Lyon France
- CERMEP‐Imaging Platform Groupement Hospitalier Est Bron France
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35
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Donnet A. Algia vascolare del volto. Neurologia 2020. [DOI: 10.1016/s1634-7072(20)44228-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Nowacki A, Schober M, Nader L, Saryyeva A, Nguyen TK, Green AL, Pollo C, Krauss JK, Fontaine D, Aziz TZ. Deep Brain Stimulation for Chronic Cluster Headache: Meta‐Analysis of Individual Patient Data. Ann Neurol 2020; 88:956-969. [DOI: 10.1002/ana.25887] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 08/20/2020] [Accepted: 08/20/2020] [Indexed: 01/01/2023]
Affiliation(s)
- Andreas Nowacki
- Department of Neurosurgery, Inselspital Bern University Hospital, University Bern Bern Switzerland
| | - Martin Schober
- Department of Neurosurgery, Inselspital Bern University Hospital, University Bern Bern Switzerland
| | - Lydia Nader
- Thuy Hospital Universitario Central de Asturias Oviedo Spain
| | - Assel Saryyeva
- Department of Neurosurgery Medical School Hannover Hannover Germany
| | - Thuy‐Anh Khoa Nguyen
- Department of Neurosurgery, Inselspital Bern University Hospital, University Bern Bern Switzerland
- ARTORG Center for Biomedical Engineering Research University of Bern Bern Switzerland
| | - Alexander L. Green
- Nuffield Department of Clinical Neuroscience University of Oxford Oxford UK
| | - Claudio Pollo
- Department of Neurosurgery, Inselspital Bern University Hospital, University Bern Bern Switzerland
| | | | - Denys Fontaine
- Department of Neurosurgery, Centre Hospitalier Universitaire de Nice, FHU INOVPAIN University Cote d'Azur Nice France
| | - Tipu Z. Aziz
- Nuffield Department of Clinical Neuroscience University of Oxford Oxford UK
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Belvís R, Irimia P, Seijo-Fernández F, Paz J, García-March G, Santos-Lasaosa S, Latorre G, González-Oria C, Rodríguez R, Pozo-Rosich P, Láinez JM. Neuromodulation in headache and craniofacial neuralgia: guidelines from the Spanish Society of Neurology and the Spanish Society of Neurosurgery. Neurologia 2020; 36:61-79. [PMID: 32718873 DOI: 10.1016/j.nrl.2020.04.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/11/2020] [Accepted: 04/15/2020] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Numerous invasive and non-invasive neuromodulation devices have been developed and applied to patients with headache and neuralgia in recent years. However, no updated review addresses their safety and efficacy, and no healthcare institution has issued specific recommendations on their use for these 2 conditions. METHODS Neurologists from the Spanish Society of Neurology's (SEN) Headache Study Group and neurosurgeons specialising in functional neurosurgery, selected by the Spanish Society of Neurosurgery (SENEC), performed a comprehensive review of articles on the MEDLINE database addressing the use of the technique in patients with headache and neuralgia. RESULTS We present an updated review and establish the first set of consensus recommendations of the SEN and SENC on the use of neuromodulation to treat headache and neuralgia, analysing the current levels of evidence on its effectiveness for each specific condition. CONCLUSIONS Current evidence supports the indication of neuromodulation techniques for patients with refractory headache and neuralgia (especially migraine, cluster headache, and trigeminal neuralgia) selected by neurologists and headache specialists, after pharmacological treatment options are exhausted. Furthermore, we recommend that invasive neuromodulation be debated by multidisciplinary committees, and that the procedure be performed by teams of neurosurgeons specialising in functional neurosurgery, with acceptable rates of morbidity and mortality.
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Affiliation(s)
- R Belvís
- Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - P Irimia
- Clínica Universitaria de Navarra, Pamplona, España.
| | | | - J Paz
- Hospital Universitario La Paz, Madrid, España
| | | | | | - G Latorre
- Hospital Universitario de Fuenlabrada, Madrid, España
| | | | - R Rodríguez
- Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | | | - J M Láinez
- Hospital Clínico Universitario, Valencia, España
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Roointan S, Tovbis D, Elder C, Yoo PB. Enhanced transcutaneous electrical nerve stimulation achieved by a localized virtual bipole: a computational study of human tibial nerve stimulation. J Neural Eng 2020; 17:026041. [PMID: 32241001 DOI: 10.1088/1741-2552/ab85d3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Electrical neuromodulation is a clinically effective therapeutic instrument, currently expanding into newer indications and larger patient populations. Neuromodulation technologies are also moving towards less invasive approaches to nerve stimulation. In this study, we investigated an enhanced transcutaneous electrical nerve stimulation (eTENS) system that electrically couples a conductive nerve cuff with a conventional TENS electrode. The objectives were to better understand how eTENS achieves lower nerve activation thresholds, and to test the feasibility of applying eTENS in a human model of peripheral nerve stimulation. APPROACH A finite element model (FEM) of the human lower leg was constructed to simulate electrical stimulation of the tibial nerve, comparing TENS and eTENS. Key variables included surface electrode diameter, nerve cuff properties (conductivity, length, thickness), and cuff location. Enhanced neural excitability was predicted by relative excitability (RE > 1), derived using either the activating function (AF) or the nerve activation threshold (MRG model). MAIN RESULTS Simulations revealed that a localized 'virtual bipole' was created on the target nerve, where the isopotential surface of the cuff resulted in large potential differences with the surrounding tissue. The cathodic part (nerve depolarization) of the bipole enhanced neural excitability, predicted by RE values of up to 2.2 (MRG) and 5.5 (AF) when compared to TENS. The MRG model confirmed that action potentials were initiated at the cathodic edge of the nerve cuff. Factors contributing to eTENS were larger surface electrodes, longer cuffs, cuff conductivity (>1×103 S m-1), and cuff position relative to the cathodic surface electrode. SIGNIFICANCE This study provides a theoretical basis for designing and testing eTENS applied to various neural targets and data suggesting function of eTENS in large models of nerve stimulation. Although eTENS carries key advantages over existing technologies, further work is needed to translate this approach into effective clinical applications.
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Affiliation(s)
- Sohrab Roointan
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, 164 College Street, Room 407, Toronto, Ontario M5S 3G9, Canada
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D'Amico D, Raggi A, Grazzi L, Lambru G. Disability, Quality of Life, and Socioeconomic Burden of Cluster Headache: A Critical Review of Current Evidence and Future Perspectives. Headache 2020; 60:809-818. [DOI: 10.1111/head.13784] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 02/06/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Domenico D'Amico
- Neuroalgology Unit and Headache Center Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - Alberto Raggi
- Neurology, Public Health and Disability Unit Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - Licia Grazzi
- Neuroalgology Unit and Headache Center Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - Giorgio Lambru
- Guy's and St Thomas' NHS Foundation Trust King's College London London UK
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40
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Dantas SAF, Alho EJL, da Silva JJ, Mendes Neto NN, Fonoff ET, Hamani C. Deep brain stimulation modulates hypothalamic-brainstem fibers in cluster headache: case report. J Neurosurg 2020; 132:717-720. [PMID: 30835692 DOI: 10.3171/2018.11.jns181412] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 11/15/2018] [Indexed: 11/06/2022]
Abstract
Hypothalamic deep brain stimulation (DBS) has been used for more than a decade to treat cluster headache (CH) but its mechanisms remain poorly understood. The authors have successfully treated a patient with CH using hypothalamic DBS and found that the contact used for chronic stimulation was located in a white matter region posterior to the mammillary bodies. Fiber tracts crossing that region were the medial forebrain bundle and those interconnecting the hypothalamus and brainstem, including the dorsal longitudinal fasciculus. Because the stimulation of axons is an important mechanism of DBS, some of its clinical effects in CH may be related to the stimulation of fibers interconnecting the hypothalamus and brainstem.
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Affiliation(s)
- Sérgio A F Dantas
- 1Department of Neurosurgery, Federal University of Rio Grande do Norte, Natal
| | - Eduardo J L Alho
- 2Department of Neurology, University of São Paulo Medical School, São Paulo
| | - Juliano J da Silva
- 1Department of Neurosurgery, Federal University of Rio Grande do Norte, Natal
| | - Nilson N Mendes Neto
- 3Department of Internal Medicine, Onofre Lopes University Hospital, Natal, Brazil
- 4Extension Center, University of California, Davis, California; and
| | | | - Clement Hamani
- 2Department of Neurology, University of São Paulo Medical School, São Paulo
- 5Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
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41
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Akram H, Zrinzo L. Cluster Headache: Deep Brain Stimulation. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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42
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Nwazota N, Pyati S, Fisher K, Roy L. Device review: Pulsante™ sphenopalatine ganglion microstimulator. Pain Manag 2019; 9:535-541. [PMID: 31782695 DOI: 10.2217/pmt-2018-0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Cluster headache (CH) is a primary headache disorder. The use of neuromodulation in treatment of CH is well documented. The sphenopalatine ganglion (SPG) has long been a target for management of CH. Intervention at the level of the SPG can interrupt the trigemino-autonomic reflex, which mediates CH pain. The Pulsante system is the only device on the market created for SPG stimulation. The Pulsante device consists of the device body, a lead with six stimulating electrodes placed in the pterygopalatine fossa, and a fixation plate to allow anchoring of the device to the maxilla. Stimulation is administered via a patient-controlled handheld remote control held over the cheek. SPG stimulation is an important treatment option for CH patients.
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Affiliation(s)
- Nenna Nwazota
- Department of Anesthesiology, Duke University, Durham, NC 27710, USA
| | - Srinivas Pyati
- Department of Anesthesiology, Durham VA Medical Center, Durham, NC 27710, USA
| | - Kyle Fisher
- Department of Anesthesiology, Duke University, Durham, NC 27710, USA
| | - Lance Roy
- Department of Anesthesiology, Duke University, Durham, NC 27710, USA
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Efficacy and safety of surgical treatment of cluster headache. Med Clin (Barc) 2019; 154:75-79. [PMID: 31753322 DOI: 10.1016/j.medcli.2019.03.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 02/16/2019] [Accepted: 03/07/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Cluster headache (CR) is the most severe human headache and is chronic in 10%-20% of patients, and 10% can become refractory to all effective drugs. In this scenario, surgical procedures are indicated: radiofrequencies of the sphenopalatine ganglion ipsilateral to pain (RF-SPG), bilateral stimulation of the occipital nerves (NOM-S) and deep brain stimulation (DBS) of the ipsilateral posterior hypothalamus. The efficacy and safety of each of these procedures has been specifically analyzed, but the progress of a series of patients following this surgical route in order of aggressiveness has not been described. PATIENTS Patients with chronic and refractory CR according to the criteria of the European Headache Federation. The patients underwent RF-SPG, NOM-S sequentially if the previous procedure had been ineffective, and DBS if the previous procedure had been ineffective. RESULTS We prospectively included 44 patients between November 2003 and June 2018 with an average age of 38.3 years; 70% were men. The mean follow-up was 87.4 months. Nineteen patients responded to 74 procedures of RF-SPG (33.3%). Of the remaining 25 patients, a NOM-S device was implanted in 22, showing an efficacy of 50%. Finally, 9 patients underwent ECP of the ipsilateral lower-posterior hypothalamus with an efficacy of 88.8%. No serious complications were found following any of these 3 procedures. CONCLUSIONS The sequential application of these three surgical procedures succeeded in reversing the serious situation of chronic CR refractory to an episodic CR in 93% of patients with acceptable surgical morbidity.
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Moisset X, Lanteri-Minet M, Fontaine D. Neurostimulation methods in the treatment of chronic pain. J Neural Transm (Vienna) 2019; 127:673-686. [PMID: 31637517 DOI: 10.1007/s00702-019-02092-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 10/06/2019] [Indexed: 02/07/2023]
Abstract
The goal of this narrative review was to give an up-to-date overview of the peripheral and central neurostimulation methods that can be used to treat chronic pain. Special focus has been given to three pain conditions: neuropathic pain, nociplastic pain and primary headaches. Both non-invasive and invasive techniques are briefly presented together with their pain relief potentials. For non-invasive stimulation techniques, data concerning transcutaneous electrical nerve stimulation (TENS), transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS), remote electrical neuromodulation (REN) and vagus nerve stimulation (VNS) are provided. Concerning invasive stimulation techniques, occipital nerve stimulation (ONS), vagus nerve stimulation (VNS), epidural motor cortex stimulation (EMCS), spinal cord stimulation (SCS) and deep brain stimulation (DBS) are presented. The action mode of all these techniques is only partly understood but can be very different from one technique to the other. Patients' selection is still a challenge. Recent consensus-based guidelines for clinical practice are presented when available. The development of closed-loop devices could be of interest in the future, although the clinical benefit over open loop is not proven yet.
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Affiliation(s)
- X Moisset
- Service de Neurologie, Université Clermont-Auvergne, INSERM, Neuro-Dol, CHU Clermont-Ferrand, Clermont-Ferrand, France.
| | - M Lanteri-Minet
- Pain Department, CHU Nice, FHU InovPain Côte Azur University, Nice, France
- Université Clermont-Auvergne, INSERM, Neuro-Dol, Clermont-Ferrand, France
| | - D Fontaine
- Department of Neurosurgery, Université Côte Azur University, CHU de Nice, FHU InovPain, Nice, France
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45
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Farrell SM, Green A, Aziz T. The Use of Neuromodulation for Symptom Management. Brain Sci 2019; 9:brainsci9090232. [PMID: 31547392 PMCID: PMC6769574 DOI: 10.3390/brainsci9090232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/07/2019] [Accepted: 09/09/2019] [Indexed: 01/23/2023] Open
Abstract
Pain and other symptoms of autonomic dysregulation such as hypertension, dyspnoea and bladder instability can lead to intractable suffering. Incorporation of neuromodulation into symptom management, including palliative care treatment protocols, is becoming a viable option scientifically, ethically, and economically in order to relieve suffering. It provides further opportunity for symptom control that cannot otherwise be provided by pharmacology and other conventional methods.
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Affiliation(s)
- Sarah Marie Farrell
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK.
| | - Alexander Green
- Nuffield department of clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK.
| | - Tipu Aziz
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK.
- Nuffield department of clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK.
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46
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Halker Singh RB, Ailani J, Robbins MS. Neuromodulation for the Acute and Preventive Therapy of Migraine and Cluster Headache. Headache 2019; 59 Suppl 2:33-49. [DOI: 10.1111/head.13586] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2019] [Indexed: 12/15/2022]
Affiliation(s)
| | - Jessica Ailani
- Department of Neurology Georgetown University Washington DC USA
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47
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Goadsby PJ. Primary headache disorders: Five new things. Neurol Clin Pract 2019; 9:233-240. [PMID: 31341711 PMCID: PMC6615655 DOI: 10.1212/cpj.0000000000000654] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 04/17/2019] [Indexed: 12/12/2022]
Abstract
Purpose of review To review 5 new areas in primary headache disorders, especially migraine and cluster headache. Recent findings Calcitonin gene-related peptide (CGRP) receptor antagonists (gepants-rimegepant and ubrogepant) and serotonin 5-HT1F receptor agonists (ditans-lasmiditan) have completed phase 3 clinical trials and will soon offer novel, effective, well-tolerated nonvasoconstrictor options to treat acute migraine. CGRP preventive treatment is being revolutionized after the licensing of 3 monoclonal antibodies (MABs), erenumab, fremanezumab, and galcanezumab, with eptinezumab to follow, especially designed for migraine; they are effective and well tolerated. For patients seeking a nondrug therapy, neuromodulation approaches, single-pulse transcranial magnetic stimulation, noninvasive vagus nerve stimulation (nVNS), and external trigeminal nerve stimulation, represent licensed, well-tolerated approaches to migraine treatment. For the acute treatment of episodic cluster headache, nVNS is effective, well tolerated, and licensed; nVNS is effective and well tolerated in preventive treatment of cluster headache. The CGRP MAB galcanezumab was effective and well tolerated in a placebo-controlled trial in the preventive treatment of episodic cluster headache. Sphenopalatine ganglion stimulation has been shown to be effective and well tolerated in 2 randomized sham-controlled studies on chronic cluster headache. Understanding the premonitory (prodromal) phase of migraine during which patients experience symptoms such as yawning, tiredness, cognitive dysfunction, and food cravings may help explain apparent migraine triggers in some patients, thus offering better self-management. Summary Headache medicine has made remarkable strides, particularly in understanding migraine and cluster headache in the past 5 years. For the most common reason to visit a neurologist, therapeutic advances offer patients reduced disability and neurologists a rewarding, key role in improving the lives of those with migraine and cluster headache.
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Affiliation(s)
- Peter J Goadsby
- NIHR-Wellcome Trust King's Clinical Research Facility and SLaM Biomedical Research Centre, King's College London, UK; and Department of Neurology, University of California, San Francisco
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Abstract
OBJECTIVE The goal of this narrative review is to provide an overview of migraine pathophysiology, with an emphasis on the role of calcitonin gene-related peptide (CGRP) within the context of the trigeminovascular system. BACKGROUND Migraine is a prevalent and disabling neurological disease that is characterized in part by intense, throbbing, and unilateral headaches. Despite recent advances in understanding its pathophysiology, migraine still represents an unmet medical need, as it is often underrecognized and undertreated. Although CGRP has been known to play a pivotal role in migraine for the last 2 decades, this has now received more interest spurred by the early clinical successes of drugs that block CGRP signaling in the trigeminovascular system. DESIGN This narrative review presents an update on the role of CGRP within the trigeminovascular system. PubMed searches were used to find recent (ie, 2016 to November 2018) published articles presenting new study results. Review articles are also included not as primary references but to bring these to the attention of the reader. Original research is referenced in describing the core of the narrative, and review articles are used to support ancillary points. RESULTS The trigeminal ganglion neurons provide the connection between the periphery, stemming from the interface between the primary afferent fibers of the trigeminal ganglion and the meningeal vasculature and the central terminals in the trigeminal nucleus caudalis. The neuropeptide CGRP is abundant in trigeminal ganglion neurons, and is released from the peripheral nerve and central nerve terminals as well as being secreted within the trigeminal ganglion. Release of CGRP from the peripheral terminals initiates a cascade of events that include increased synthesis of nitric oxide and sensitization of the trigeminal nerves. Secreted CGRP in the trigeminal ganglion interacts with adjacent neurons and satellite glial cells to perpetuate peripheral sensitization, and can drive central sensitization of the second-order neurons. A shift in central sensitization from activity-dependent to activity-independent central sensitization may indicate a mechanism driving the progression of episodic migraine to chronic migraine. The pathophysiology of cluster headache is much more obscure than that of migraine, but emerging evidence suggests that it may also involve hypersensitivity of the trigeminovascular system. Ongoing clinical studies with therapies targeted at CGRP will provide additional, valuable insights into the pathophysiology of this disorder. CONCLUSIONS CGRP plays an essential role in the pathophysiology of migraine. Treatments that interfere with the functioning of CGRP in the peripheral trigeminal system are effective against migraine. Blocking sensitization of the trigeminal nerve by attenuating CGRP activity in the periphery may be sufficient to block a migraine attack. Additionally, the potential exists that this therapeutic strategy may also alleviate cluster headache as well.
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Affiliation(s)
- Smriti Iyengar
- Eli Lilly and CompanyIndianapolisINUSA
- Present address:
Indiana University School of MedicineIndianapolisINUSA
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Abstract
PURPOSE OF REVIEW Cluster headache stands among the worst debilitating pain conditions. Available treatments for cluster headache have often disabling side effects, are not tolerated, or are ineffective. The management of drug-refractory chronic forms is challenging. New treatments are warranted and reported here. RECENT FINDINGS In cluster headache acute treatment, delivery systems like Demand Valve Oxygen or nonrebreather-type masks could enhance the effectiveness of inhaled oxygen therapy. Noninvasive vagus nerve stimulation relieves cluster headache pain at short-term in episodic patients. Sphenopalatine ganglion stimulation combines acute and preventive properties in subsets of patients and is of interest in selected refractory chronic forms. In cluster headache prevention, 'hypothalamic' deep brain stimulation is being refined using slightly different stereotactic coordinates or lower risk methods like endoventricular stimulation. Anti-CGRP monoclonal antibodies provide interesting results in episodic cluster headache, have a good safety profile, but do not appear effective in chronic cluster headache. SUMMARY These novel approaches provide additional alternatives to conventional cluster headache management, but results obtained in chronic forms are often disappointing. Research on cluster headache is often hampered by the lack of awareness in the medical world and by the relatively low prevalence of cluster headache compared with migraine. However, common features shared by these two primary headaches could help developing disease-specific therapies.
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Nowacki A, Moir L, Owen SL, Fitzgerald JJ, Green AL, Aziz TZ. Deep brain stimulation of chronic cluster headaches: Posterior hypothalamus, ventral tegmentum and beyond. Cephalalgia 2019; 39:1111-1120. [PMID: 30897941 DOI: 10.1177/0333102419839992] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We present long-term follow-up results and analysis of stimulation sites of a prospective cohort study of six patients with chronic cluster headaches undergoing deep brain stimulation of the ipsilateral posterior hypothalamic region. METHODS The primary endpoint was the postoperative change in the composite headache severity score "headache load" after 12 months of chronic stimulation. Secondary endpoints were the changes in headache attack frequency, headache attack duration and headache intensity, quality of life measures at 12, 24, and 48 months following surgery. Stimulating contact positions were analysed and projected onto the steroetactic atlas of Schaltenbrand and Wahren. RESULTS There was a significant reduction of headache load of over 93% on average at 12 months postoperatively that persisted over the follow-up period of 48 months (p = 0.0041) and that was accompanied by a significant increase of reported quality of life measures (p = 0.03). Anatomical analysis revealed that individual stimulating electrodes were located in the red nucleus, posterior hypothalamic region, mesencephalic pretectal area and centromedian nucleus of the thalamus. CONCLUSIONS Our findings confirming long-term effectiveness of deep brain stimulation for chronic cluster headaches suggest that the neuroanatomical substrate of deep brain stimulation-induced headache relief is probably not restricted to the posterior hypothalamic area but encompasses a more widespread area.
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Affiliation(s)
- Andreas Nowacki
- 1 Department of Neurosurgery, Oxford University Hospital Foundation Trust, Oxford, UK
| | - Liz Moir
- 1 Department of Neurosurgery, Oxford University Hospital Foundation Trust, Oxford, UK
| | - Sarah Lf Owen
- 2 Department of Psychology, Health and Professional Development, Oxford Brookes University, Oxford, UK
| | - James J Fitzgerald
- 3 Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, UK
| | - Alexander L Green
- 3 Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, UK
| | - Tipu Z Aziz
- 3 Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, UK
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