Láinez Miguel Ja, Guillamón Edelmira
Department of Neurology, Hospital Clínico Universitario de Valencia, Valencia, Spain.
Department of Neurology, Universidad Católica de Valencia, Spain.
Headache. 2017 Feb;57(2):327-335. doi: 10.1111/head.12874. Epub 2016 Aug 4.
The trigeminal autonomic cephalalgias (TACs) are highly disabling primary headache disorders. There are several issues that remain unresolved in the understanding of the pathophysiology of the TACs, although activation of the trigeminal-autonomic reflex and ipsilateral hypothalamic activation both play a central role. The discovery of the central role of the hypothalamus led to its use as a therapeutic target. After the good results obtained with hypothalamic stimulation, other peripheral neuromodulation targets were tried in the management of refractory cluster headache (CH) and other TACs.
This review is a summary both of CH pathophysiology and of efficacy of the different neuromodulation techniques.
In chronic cluster headache (CCH) patients, hypothalamic deep brain stimulation (DBS) produced a decrease in attack frequency of more than 50% in 60% of patients. Occipital nerve stimulation (ONS) also elicited favorable outcomes with a reduction of more than 50% of attacks in around 70% of patients with medically intractable CCH. Stimulation of the sphenopalatine ganglion (SPG) with a miniaturized implanted stimulator produced a clinically significant improvement in 68% of patients (acute, preventive, or both). Vagus nerve stimulation (VNS) with a portable device used in conjunction with standard of care in CH patients resulted in a reduction in the number of attacks. DBS and ONS have been used successfully in some cases of other TACs, including hemicrania continua (HC) and short-lasting unilateral headache attacks (SUNHA).
DBS has good results, but it is a more invasive technique and can generate serious adverse events. ONS has good results, but frequent and not serious adverse events. SPG stimulation (SPGS) is also efficacious in the acute and prophylactic treatment of refractory cluster headache. At this moment, ONS and SPG stimulation techniques are recommended as first line therapy in refractory cluster patients. New recent non-invasive approaches such as the non-invasive vagal nerve stimulator (nVNS) have shown efficacy in a few trials and could be an interesting alternative in the management of CH, but require more testing and positive randomized controlled trials.
三叉神经自主性头痛（TACs）是严重致残的原发性头痛疾病。尽管三叉神经自主性反射激活和同侧下丘脑激活均起核心作用，但在TACs病理生理学的理解方面仍有几个问题尚未解决。下丘脑核心作用的发现促使其成为治疗靶点。在经下丘脑刺激取得良好效果后，其他外周神经调节靶点也被尝试用于难治性丛集性头痛（CH）和其他TACs的治疗。
本综述是CH病理生理学及不同神经调节技术疗效的总结。
在慢性丛集性头痛（CCH）患者中，下丘脑深部脑刺激（DBS）使60%的患者发作频率降低超过50%。枕神经刺激（ONS）也取得了良好效果，在约70%药物难治性CCH患者中发作减少超过50%。使用小型植入式刺激器刺激蝶腭神经节（SPG）使68%的患者（急性、预防性或两者兼具）有临床显著改善。在CH患者中，使用便携式设备结合标准治疗进行迷走神经刺激（VNS）可减少发作次数。DBS和ONS已在包括持续性偏侧头痛（HC）和短暂性单侧头痛发作（SUNHA）在内的一些其他TACs病例中成功应用。
DBS效果良好，但它是一种侵入性更强的技术，可能产生严重不良事件。ONS效果良好，但不良事件频繁且不严重。SPG刺激（SPGS）在难治性丛集性头痛的急性和预防性治疗中也有效。目前，ONS和SPG刺激技术被推荐为难治性丛集性头痛患者的一线治疗方法。近期新的非侵入性方法，如非侵入性迷走神经刺激器（nVNS），在一些试验中已显示出疗效，可能是CH治疗中一个有趣的替代方法，但需要更多测试和阳性随机对照试验。
