Brain Advance Access originally published online on November 7, 2003
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Brain, Vol. 127, No. 1, 220-230, 2004
© 2004 Guarantors of Brain
doi: 10.1093/brain/awh022
Central neuromodulation in chronic migraine patients with suboccipital stimulators: a PET study
1 Headache Group and 2 Wellcome Department of Imaging Neuroscience, Institute of Neurology and The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK and 3 Department of Neurosurgery, Presbyterian Hospital of Dallas, Dallas, Texas, USA
Correspondence to: Professor Peter J. Goadsby, Institute of Neurology, Queen Square, London WC1N 3BG, UK E-mail: peterg{at}ion.ucl.ac.uk
Electrical stimulation of primary sensory afferents is known to have an antinociceptive effect. Animal and functional imaging studies suggest a role for supraspinal structures in this response. Eight patients with chronic migraine (
15 days per month of attacks of migraine without aura), who had shown a marked beneficial response to implanted bilateral suboccipital stimulators, were studied. Stimulation evoked local paraesthesia, the presence of which was a criterion of pain relief. On stimulation, the headache began to improve instantaneously and was completely suppressed within 30 min. On switching off the stimulation, the headache recurred instantly and peaked within 20 min. PET scans were performed using regional cerebral blood flow (rCBF) as a marker of neuronal activity. Each patient was scanned in the following three states: (1) stimulator at optimum settings: patient pain-free but with paraesthesia; (2) stimulator off: patient in pain and no paraesthesia; (3) stimulator partially activated: patient with intermediate levels of pain and paraesthesia. All scans were processed and analysed using Statistical Parametric Mapping (SPM) 99. There were significant changes in rCBF in the dorsal rostral pons, anterior cingulate cortex (ACC) and cuneus, correlated to pain scores, and in the ACC and left pulvinar, correlated to stimulation-induced paraesthesia scores. The activation pattern in the dorsal rostral pons is highly suggestive of a role for this structure in the pathophysiology of chronic migraine. The localization and persistence of activity during stimulation is exactly consistent with a region activated in episodic migraine, and with the persistence of activation of that area after successful treatment. The dorsal rostral pons may be a locus of neuromodulation by suboccipital stimulation. In addition, suboccipital stimulation modulated activity in the left pulvinar.
Key Words: headache; migraine; periaqueductal grey; pons; pulvinar
Abbreviations: ACC = anterior cingulate cortex; CDH = chronic daily headache; GON = greater occipital nerve; IHS = International Headache Society; PAG = periaqueductal grey; PET = positron emission tomography; rCBF = regional cerebral blood flow; VRS = verbal rating scale
Received April 15, 2003. Revised August 24, 2003. Accepted August 25, 2003.
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