Intractable cluster headache and therapeutic stimulation of the hypothalamus: pathophysiological and management insights from a rare experiment

Sir, Leone et al . (2004) present the first patient whose cluster headache (CH) attacks were controlled by bilateral hypothalamic stimulation. In-depth study of this rare occurrence offers an unusual opportunity to discuss certain key aspects surrounding CH management and pathophysiology. Clinical experience indicates that despite a negative chronotropic action, verapamil is probably the most effective agent in the treatment of CH; surgical procedures for CH should be considered only following total resistance to medical therapy (Mathew, 1990). Surprisingly, Leone et al . (2004) did not attempt CH prophylaxis with verapamil in this patient at any time. This therapeutic strategy would be particularly indicated in patients with bilateral CH attacks associated with hypertensive crises. To label a CH patient as being ‘intractable’ without attempting prophylaxis with verapamil is questionable. The only contraindication to verapamil prophylaxis in this case might be the relative bradycardia; however, bradycardia around 40 beats per minute is not unusual in CH (Attanasio et al ., 1990; Mathew, 1990). In this athletic subject with physiological vagotonia, bilateral hypothalamic stimulation itself caused bradycardia sufficient to induce vertigo (Leone et al ., 2004), possibly due to diminished cardiac output and brain perfusion. Secondly, there …