Susie Lagrata

Cutaneous atrophy and alopecia after greater occipital nerve injection using triamcinolone.

Greater occipital nerve (GON) infiltration is widely used for the treatment of primary and secondary headache disorders mainly on the basis of open‐label evidence, although recent double‐blinded placebo‐controlled trials have demonstrated its efficacy in cluster headache. The procedure is generally well tolerated although corticosteroid‐related side effects, including Cushings syndrome and local cutaneous changes, can occur. We report the occurrence of cutaneous atrophy and alopecia in 4 patients who underwent GON blockade with triamcinolone and lidocaine. Triamcinolone injection is associated with cutaneous atrophy, especially in superficial injection sites; therefore, alternative steroid preparations like methylprednisolone and betamethasone might be more appropriate for GON blockade.

Ventral tegmental area deep brain stimulation for refractory chronic cluster headache

Objective: To present outcomes in a cohort of medically intractable chronic cluster headache (CCH) patients treated with ventral tegmental area (VTA) deep brain stimulation (DBS). Methods: In an uncontrolled open-label prospective study, 21 patients (17 male; mean age 52 years) with medically refractory CCH were selected for ipsilateral VTA-DBS by a specialist multidisciplinary team including a headache neurologist and functional neurosurgeon. Patients had also failed or were denied access to occipital nerve stimulation within the UK National Health Service. The primary endpoint was improvement in the headache frequency. Secondary outcomes included other headache scores (severity, duration, headache load), medication use, disability and affective scores, quality of life (QoL) measures, and adverse events. Results: Median follow-up was 18 months (range 4–60 months). At the final follow-up point, there was 60% improvement in headache frequency (p = 0.007) and 30% improvement in headache severity (p = 0.001). The headache load (a composite score encompassing frequency, severity, and duration of attacks) improved by 68% (p = 0.002). Total monthly triptan intake of the group dropped by 57% posttreatment. Significant improvement was observed in a number of QoL, disability, and mood scales. Side effects included diplopia, which resolved in 2 patients following stimulation adjustment, and persisted in 1 patient with a history of ipsilateral trochlear nerve palsy. There were no other serious adverse events. Conclusions: This study supports that VTA-DBS may be a safe and effective therapy for refractory CCH patients who failed conventional treatments. Classification of evidence: This study provides Class IV evidence that VTA-DBS decreases headache frequency, severity, and headache load in patients with medically intractable chronic cluster headaches.

Occipital Nerve Stimulation for Medically Refractory Chronic Paroxysmal Hemicrania

To describe the outcome of a patient with refractory chronic paroxysmal hemicrania (CPH) to occipital nerve stimulation (ONS).

Microvascular decompression or neuromodulation in patients with SUNCT and trigeminal neurovascular conflict

Objectives To assess the effectiveness of neuromodulation and trigeminal microvascular decompression (MVD) in patients with medically-intractable short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT). Methods Two patients with medically refractory SUNCT underwent MVD following beneficial but incomplete response to neuromodulation (occipital nerve stimulation and deep brain stimulation). MRI confirmed neurovascular conflict with the ipsilateral trigeminal nerve in both patients. Results Although neuromodulation provided significant benefit, it did not deliver complete relief from pain and management required numerous postoperative visits with adjustment of medication and stimulation parameters. Conversely, MVD was successful in eliminating symptoms of SUNCT in both patients with no need for further medical treatment or neuromodulation. Conclusion Neuromodulation requires expensive hardware and lifelong follow-up and maintenance. These case reports highlight that microvascular decompression may be preferable to neuromodulation in the subset of SUNCT patients with ipsilateral neurovascular conflict.

EHMTI-0278. Onabotulinum toxin a for hemicrania continua: a case series of 8 patients

Hemicrania Continua (HC) is a strictly unilateral continuous headache that is exquisitely responsive to Indometacin but some patients cannot tolerate this drug. Evidence for other therapies is limited, often limited to single case reports.

EHMTI-0279. Deep brain stimulation for refractory chronic cluster headache

Chronic cluster headache (CCH) is an excruciating, unilateral headache with recurrent episodes of severe pain associated with ipsilateral autonomic features. 10-20% of patients are refractory to medical management. We present a prospective cohort of 19 patients with intractable CCH treated with posterior hypothalamic deep brain stimulation (DBS).