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'Rare TACS/Neurostimulation' - Dr Manjit Matharu (Clinical Lead of the Headache Group, a senior lecturer at The Institute of Neurology and Honorary Consultant Neurologist at The National Hospital for Neurology and Neurosurgery) from the Cumbria Neuroscience Conference
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Manjit S Matharu
Headache Group, Institute of Neurology &The National Hospital for Neurology and Neurosurgery
London UK
29 March 2014Cumbria
Unilateral head pain, predominantly V1
Excruciating
Cranial autonomic symptomsParasympathetic hyperactivity
Sympathetic deficit
Attack frequency and duration differs
Treatment responses differ
Highly disabling disorders
Cluster headache
Paroxysmal hemicrania
Short-lasting unilateral neuralgiform headache attacks
SUNCT
SUNA
Hemicrania continua
IHS CLASSIFICATION CRITERIA
• Severe
• Unilateral
• Orbital, supraorbital or temporal pain
• 15-180 minutes duration
• Attack frequency ranging from 1 every other day to 8 daily
• Associated symptoms:
-Conjunctival injection
-Lacrimation
-Ptosis
-Miosis
-Eyelid oedema
-Nasal congestion
-Rhinorrhea
-Forehead and facial sweating/redness
-Aural fullness
• Sense of restlessness or agitation during headache
• Severe
• Unilateral
• Orbital, supraorbital or temporal pain
• 2-30 minutes duration
• >5 attacks daily at least 50% of the time
• Associated symptoms:
-Conjunctival injection
-Lacrimation
-Ptosis
-Miosis
-Eyelid oedema
-Nasal congestion
-Rhinorrhea
-Forehead and facial sweating
• Stopped completely by indometacin
IHS CLASSIFICATION CRITERIA
• Unilateral trigeminal distribution pain
• 1-600 seconds duration
• Isolated stabbing, repetitive stabs or saw-tooth pattern
• Attack frequency >1daily at least 50% of the time
• Pain is accompanied by cranial autonomic features
• Cutaneous triggers (similar to trigeminal neuralgia)
• Absence of refractory period
IHS CLASSIFICATION CRITERIA
IHS CLASSIFICATION CRITERIA
A. Unilateral headache
B. Present for >3 months, with exacerbations of moderate/severe intensity
C. At least one of the following
1. At least one ipsilateral cranial autonomic symptom2. Restless or agitated
D. Complete response to therapeutic doses of indomethacin
Cluster Headache
Paroxysmal Hemicrania
SUNCT/SUNA
Attack frequency (daily) 1-8 1-40 1-200
Duration of attack 15-180mins 2-30mins 1-600secs
Pain qualitySharp,
throbbingSharp,
throbbingNeuralgiform
Pain intensity Very severe Very severe Very severe
Circadian periodicity 70% 45% Absent
Cluster Headache
Paroxysmal Hemicrania
SUNCT/SUNA
Autonomic features +++ +++ +++
Migrainous features ++ ++ +
Restless or agitated 90% 80% 65%
Aura 14% Rare Rare
Triggers• Alcohol• Cutaneous
+++-
+-
-+++
Episodic : Chronic 90:10 35:65 10:90
Cluster Headache
Paroxysmal Hemicrania
SUNCT/SUNA
Lifetime prevalence 1/1000 1/50,000 1/15,000
F:M ratio 1:2.5-7.2 1:1 1:1.5
Age• Mean• Range
306-67
375-68
4819-75
HYPOTHALAMIC DYSFUNCTION?
• Clinical features
• Neuroendocrine studies
• Genetics
• Functional imaging studies
• Structural imaging studies
• Magnetic resonance spectroscopy
• Animal experimental work
• Deep brain stimulation
HYPOTHALAMIC DYSFUNCTION
Cluster HeadachePET Study
SUNCTfMRI Study
May et al, Lancet 1998
Paroxysmal HemicraniaPET Study
Matharu et al, Ann Neurol 2006
Hemicrania ContinuaPET Study
Matharu et al, Headache 2004May et al, Ann Neurol 1999
Cranial autonomic symptoms mediated via trigemino-autonomic loop Hypothalamus is involved in mediating anti-nociceptive and autonomic responses. There are direct hypothalamic-trigeminal connections. TACs occur due to a central disinhibition of the trigeminal-autonomic reflex by the hypothalamus
Trigeminal neuralgia: 47-90%
Cohen et al, Brain 2006: 7%, dedicated trigeminal scans NOT performed
Williams et al, J Clin Neurosc 2008: 88%
Lambru et al, Abstract presented at AAN, Hawaii 2011
SUNA(N=35)
SUNCT(N=52)
Total(N=87)
Ipsilateral 15 (43%) 20 (39%) 35 (40%)
Bilateral 4 (11%) 8 (15%) 12 (14%)
Contralateral 2 (6%) 1 (2%) 3 (3%)
No loop 14 (40%) 23 (44%) 37 (43%)
IPSILATERAL LOOP : 54%
CONTRALATERAL LOOP : 17%
Williams et al, JNNP 2010Trigeminal microvascular decompression in 9 patients; 6 pain free at 2 years follow up
Medical Treatment
Abortive Therapy Preventative Therapy
Transitional Therapy
2026 26
21
78 74
57
40
0102030405060708090
Oxygen Sumatriptaninjection
Sumatriptannasal spray
Zomitriptannasal spray
% p
atie
nts
wit
h h
ead
ach
e re
spo
nse
Placebo
Treatment
Time= 15min 15 min 30 min 30 min
N= 150 134 77 69
Cohen et al, JAMA 2009; van Vliet J et al, Neurology 2003; Cittadini E et al. Arch Neurol 2006; Ekbom K et al. Acta Neurol Scand. 1993
• Randomised, controlled, double blind studies in cluster headache
**
*
*
*P<0.05
Leone M et al. Neurology. 2000.
0
0.5
1
1.5
2
2.5
3
Run in 5 days 1st week 2nd week
Verapamil 120 mg tid
Placebo* p < 0.001 vs
placebo
N=30
6/15 0/15
12/15 0/15
*
*15 15
PREVENTIVE TREATMENTS
Doses Comments
Verapamil 240-960mg/d ECG monitoring required
Lithium 400-2000mg/d(0.8-1.0mM)
Regular serum lithium levels, thyroid function and renal function checks
Methysergide 3-12mg/d European Medicines Agency restrictions:• Started and supervised by specialist
headache clinics• Severe intractable cluster headache• 6 monthly monitoring for visceral fibrosis
Topiramate 50-800mg/d
Gabapentin 900-3600mg/d
Melatonin 9-15mg/d
Valproate 600-2000mg/d
Oral corticosteroidsSuboccipital steroid injection
• 43 patients (15 CCH, 28 ECH), with >2 attacks per day• 3 suboccipital injections of cortivazol 3.75mg or placebo, 48-72 hours
apart• Primary outcome: reduction of daily attacks to mean of <2 in the 72 hours
period after the third injection
Leroux et al, Lancet Neurology 2011
• Open label study suggests efficacy of GONB (using methylprednisolone and lidocaine) in CCH
CH
Number 83
Complete response 42%
Partial response (>50%) 15%
Median duration (days) 21
Abu Bakar et al, Eur J Neurol. 2014 Feb;21(2):338-43
• Cutaneous atrophy and alopecia are well recognised complications of GONB
• Risk increases with low solubility agents (triamcinilone) and superficial injections
Lambru et al, Headache 2012
Doses Number Efficacy
Indometacin 75-300mg/d 47 100%
COX-2 Inhibitors 16 44%
Topiramate 50-400mg/d 15 46%
Greater Occipital Nerve Blocks
22 45%
Cittadini, Matharu, Goadsby AAN 2008
Doses Number Efficacy
Indometacin 75-225mg/d 39 100%
COX-2 Inhibitors:
Rofecoxib
Celecoxib
9
5
33%
60%
Topiramate 12 41%
Greater Occipital Nerve Blocks
23 35%
Cittadini et al, Brain 2010; Peres & Silberstein, Headache 2002
Doses Number Efficacy
Lamotrigine 100-600mg/d 94 70%
Oxcarbazepine 600-2400mg/d 35 63%
Topiramate 50-800mg/d 59 49%
Duloxetine 60-120mg/d 17 53%
Gabapentin 600-3600mg/d 62 31%
IV lidocaine 1.3-3.3 mg/kg/hr 32 91%
Greater occipital nerve injection
61 34%
Lambru et al. International Headache Society Congress, 2011
Destructive surgeryNo role in primary headache syndromes
Dissectional SurgeryMVD in SUNCT/SUNA
Neuromodulation Targets for stimulation• Occipital nerves
• Migraine• TAC• Hemicrania continua
• Sphenopalatine ganglion• Cluster headache
• Hypothalamus• TAC
Occipital Nerve Stimulation
• Subcutaneous leads inserted to cross greater and lesser occipital nerves
• Inserted via midline incision or lateral incision under local or general anaesthesia
• Cylindrical or paddle style electrodes
• Battery and pulse generator sited over chest or in abdomen
• Stimulation parameters adjusted so that patients experience comfortable paraesthesia
Occipital Nerve Stimulation for the Treatment of Intractable Chronic Migraine Headache
Saper JR, et al Cephalalgia. 2011;31(3):271-285.
• Multicentre, prospective, single blind, controlled feasibility study
• 66 medically intractable chronic migraine • Failed at least 2 classes of preventives • Bilateral ONS• Randomised 2:1:1 to
– Adjustable stimulation (AS)– Preset stimulation (PS)– Medical Management (MM)
• Responder defined as:– 50% reduction in headaches days/month– 3-point drop (VRS 0-10) in pain intensity
Patients enrolled
who responded to an occipital nerve block Preset Stimulation (PS)
Medical Management (MM)
2:1:1 ratio
Adjustable Stimulation (AS)
12 Weeks
(Active, N=29 completed)
(Control, N=16 completed)
(Comparator, N=17 completed)
This prospective, randomized, double-blind, controlled study examined the efficacy and safety of occipital nerve stimulation in adult chronic migraine patients.
Responder rates
39%
6%0%
0%
10%
20%
30%
40%
50%
AdjustableStimulation (AS)
PresetStimulation (PS)
MedicalManagement
(MM)
6.7
1.5
1
0
1
2
3
4
5
6
7
8
AdjustableStimulation (AS)
PresetStimulation (PS)
MedicalManagement
(MM)
Mean (SD) reductions in actual headache days per month
(10.0)
(4.6)
(4.2)
22.4+6.3 23.4+5.1 23.7+4.3
Advances and challenges in neurostimulation for headachesDelphine Magis and Jean Schoenen, Lancet Neurology 2012
9 medically intractable patients: 6 SUNCT, 3 SUNA
At least 5 preventives tried: lamotrigine, topiramate, gabapentin, pregabalin, carbamazepine, oxcarbazepine, mexiletine
Bilateral ONS
Follow up 38 months (24-55 months)
Prospective follow up
Lambru G et al, Pain Physician 2014;17(1):29-41.
Results
8/9 (89%) reported meaningful benefit
Benefit built up over 2 weeks – 3 months
Worsened rapidly with flat battery
1 patient developed hemicrania continua - successfully treated with indomethacin
Response to GON not predictive of response to ONS
Degree of Improvement % Number
Pain free 100% 4
Substantial 81-98 4
No benefit 0% 1
Miniaturised BION Device
Burns et al, Lancet Neurol 2008
6 medically intractable hemicrania continua patients ( one patient did not have hemicrania continua)
At least 4 groups of preventives tried:
BION
Cross-over design:
Follow up 14 months (6-21 months)
AED, Antidepressants, Calcium channel blockers, Beta-blockers, Serotonergic modulators
3 months on, 1 month off, subsequently on
Burns et al, Lancet Neurol 2008Results
5/6 (83%) reported meaningful benefit
Benefit built up over 2 days -3 months
Worsened rapidly when stimulator off
Degree of Improvement % Number
Substantial 80-95% 4
Moderate 30% 1
Worse* -20% 1
* Patient has migraine not hemicrania continua
Safety data are good but surgical revision are frequent
Low post-operative infection risk
Electrode migration – frequent, often in the first year
Electrode site pain
Myofascial incision site pain,
Muscle recruitment
Neck stiffness
Battery site pain and contact dermatitis
Despite adverse events and revisions, most undergo procedure again and recommend it to others
Definitive diagnosis of primary headache syndrome
Highly disabled
Medically intractable – failed trials (lack of efficacy or developed adverse effects) of appropriate preventives
PRIMARY HEADACHE DRUGS
Chronic migraine Beta-blocker, Tricyclics, Serotonergic antagonists , Antiepileptics (Topiramate, Sodium Valproate, Gabapentin), Calcium channel antagonists, Botox, GONB, IV DHE
Chronic cluster headache
Verapamil, Lithium, Methysergide, Topiramate, Gabapentin, Sodium Valproate, Melatonin, GONB, IV DHE
SUNCT Lamotrigine, Topiramate, Gabapentin, Pregabalin, Carbamazepine/oxcarbazepine, Duloxetine, Mexiletine, IV lidocaine, GONB
Hemicrania continua / Chronic Paroxysmal hemicrania
Indometacin, COX-II inhibitors, Topiramate, Verapamil, Gabapentin, Pregabalin, Melatonin, GONB
Anatomical and Functional Convergence of Trigeminal and Cervical input
MECHANISM OF ACTION
Bartsch et al, Brain 2002
1. Effect at Segmental level
Gate-Control Theory of Pain Activation of somatosensory afferent A-b nerve fibres blocks nociceptive transmission at a segmental level
2. Involvement of Supraspinal Structures
Gate control at supraspinal level
Activation of descending antinociceptive pathways
3. Neuroplasticity
MECHANISM OF ACTION
Paraesthesia-related rCBF changes
Significant activation in the dorsal rostral pons, anterior cingulate cortex and left pulvinar
Matharu et al, Brain 2004
MECHANISM OF ACTION
18FDG-PET study in 10 chronic cluster (CCH) patients
7 patients had ≥ 90% improvement with ONS
Magis et al, BMC Neurology 2011
Metabolic normalization in the pain neuromatrix suggests that ONS acts in CCH through slow neuromodulatory processes.
• Randomly treated attacks with full, sub-perception, or sham stimulation.
• Assessed pain relief at 15 minutes • 32 patients enrolled; 28 completed
study • Most patients (81%) experienced
transient, mild/moderate loss of sensation within distinct maxillary nerve regions; 65% of events resolved within three months.
• Repeated SPG neurostimulation may decrease the frequency of CH attacks – warrants further investigation
* P<0.0001
Schoenen J, et al. Cephalalgia. 2013.
Electrodes implanted PRECISELY into region of abnormal brain activity
Connected with wires to a battery implanted under the skin in the chest
High frequency electrical current inhibits abnormal brain activity around electrode tip
HYPOTHALAMIC DYSFUNCTION
Cluster HeadachePET Study
SUNCTfMRI Study
May et al, Lancet 1998
Paroxysmal HemicraniaPET Study
Matharu et al, Ann Neurol 2006
Hemicrania ContinuaPET Study
Matharu et al, Headache 2004May et al, Ann Neurol 1999
Advances and challenges in neurostimulation for headachesDelphine Magis and Jean Schoenen, Lancet Neurology 2012
• 64% of the patients report at least 50% improvement• Mean follow up 1.6 years• Adverse events: death (1), haemorrhage (1), TIA (1)
Patients (n) Pain free patients
At least 50% improvement in headache frequency and/or intensity
Total number improved
Total 64 27 (42%) 14 (22%) 41 (64%)
Bartsch, Cephalalgia 2008
• Median improvement in Headache load (HAL) was 79% (range 22-100%)
• Time lag to greatest response
• 5 patients showed 50% or more objective improvement in HAL at last follow up
0
10
20
30
40
50
60
70
80
90
100
BASELINE 3 MONTH 6 MONTH 9 MONTH 12 MONTH 24 MONTH 36 MONTH
P1
P2
P3
P4
P5
P6
Miller et al, International Headache Society Congress, 2013
Trigeminal Autonomic Cephalalgias• Cause of significant disability thereby underlining the
importance of rapid diagnosis and treatment• Progress in unravelling the pathophysiology of these disorders• New treatments are being developed on the basis of the
anatomy and physiology of these conditions
Neuromodulation• Promising treatment for primary headache syndromes• Large randomised controlled studies are needed• Predictors of response and long-term outcome are largely
unknown• Reserved for medically-intractable and highly disabled
patients• Performed in experienced headache centres