DBS for chronic cluster headache: meta-analysis of individual patient data

Objective: Deep brain stimulation (DBS) is a treatment alternative for refractory chronic Cluster headache (CCH). Despite several recent prospective case series reporting on good outcome, the effectiveness and the optimal stimulation target of DBS for CCH remain unclear. We aimed to obtain precise estimates and predictors of long-term pain relief in an individual patient data meta-analysis. Further, we aimed to construct a probabilistic stimulation map of effective DBS.

Methods: We invited investigators of published cohorts of patients undergoing DBS for CCH, identified by a systematic review of MEDLINE from inception to Febuary 15, 2019, to provide individual patient data on baseline covariates, pre- and postoperative headache scores at median (12-month) and long-term follow-up as well as individual imaging data to obtain individual electrode positions. We calculated a stimulation map using voxel-wise statistical analysis. We used multiple regression analysis to estimate predictors of pain-relief.

Results: Among 40 patients from four different cohorts representing about 50% of all previously published cases, we found a significant 77% mean reduction in headache attack frequency over a mean follow-up of 44 months with an overall 75% response rate. Positive outcome was not associated with baseline covariates. We identified two hotspots of stimulation covering the midbrain ventral and retrorubral tegmentum.

Interpretation: This study supports that DBS provides long-term pain relief for the majority of CCH patients. Our stimulation map of the region of influence of therapeutic DBS identified an optimal anatomical target site that can help surgeons guide their surgical planning in the future. This article is protected by copyright. All rights reserved.