Brain, Vol. 125, No. 5, 976-984,
May 2002
© 2002 Guarantors of Brain
Persistence of attacks of cluster headache after trigeminal nerve root section
Headache Group, Institute of Neurology, University College London, UK
Correspondence to: Professor Peter J. Goadsby, Institute of Neurology, Queen Square, London WC1N 3BG, UK E-mail: peterg{at}ion.ucl.ac.uk
Received November 14, 2001. Revised January 5, 2002. Accepted January 5, 2002.
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Summary |
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Cluster headache is a strictly unilateral headache that occurs in association with cranial autonomic features. We report a patient with a trigeminal nerve section who continued to have attacks. A 59-year-old man described a 14-year history of left-sided episodes of excruciating pain centred on the retro-orbital and orbital regions. These episodes lasted 1–4 h, recurring 2–3 times daily. The attacks were associated with ipsilateral ptosis, conjunctival injection, lacrimation, rhinorrhoea and facial flushing. From 1986 to 1988, he had trials of medications without any benefit. In February 1988, he had complete surgical section of the left trigeminal sensory root that shortened the attacks in length for 1 month without change in their frequency or character. In April 1988, he had further surgical exploration and the root was found to be completely excised; post-operatively, there was no change in the symptoms. From 1988 to 1999, he had a number of medications, including verapamil and indomethacin, all of which were ineffective. Prednisolone 30 mg orally daily rendered the patient completely pain free. Sumatriptan 100 mg orally and 6 mg subcutaneously aborted the attack after
45 and 15 min, respectively. He was completely anaesthetic over the entire left trigeminal distribution. Left corneal reflex was absent. Motor function of the left trigeminal nerve was preserved. Neurological and physical examination was otherwise normal. MRI scan showed a marked reduction in the calibre of the left trigeminal nerve from the nerve root exit zone in the pons to Meckel’s cave. An ECG-gated three-dimensional multislab MRI inflow angiogram was performed. No dilatation was observed in the left internal carotid artery during the cluster attack. Blink reflexes were elicited with a standard electrode and stimulus. Stimulation of the left supraorbital nerve produced neither ipsilateral nor contralateral blink reflex response. Stimulation of the right supraorbital nerve produced an ipsilateral response with a mean R2 onset latency of 36 ms and a contralateral response with a mean R2 onset latency of 32 ms. Lack of ipsilateral vessel dilatation makes the role of vascular factors in the initiation of cluster attacks questionable. With complete section of the left trigeminal sensory root the brain would perceive neither vasodilatation nor a peripheral neural inflammatory process; however, the patient continued to have an excellent response to sumatriptan. The case illustrates that cluster headache may be generated primarily from within the brain, and that triptans may have anti-headache effects through an entirely central mechanism. Keywords: trigeminal autonomic cephalgia; sumatriptan; trigeminocervical; cluster headache; migraine
Abbreviations: MRA= MRI inflow angiogram; ROI = regions of interest
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Introduction |
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It is a basic tenet of the current understanding of headache that the pain is in some way generated by cranial nociceptors with the role of the brain to interpret, modulate and respond to afferent nociceptive traffic (Olesen et al., 2000
). Although centrally produced pain, such as that seen with thalamic lesions, is a well-accepted entity, this is a smaller part of the whole in terms of the clinical load of pain. Similarly, headache is not generally considered to be generated in the CNS without a peripheral input. In contrast, clinicians accept many aspects of the acute attack of primary neurovascular headaches, migraine and cluster headache to occur without any abnormality in the periphery (Goadsby et al., 2002). Consider photophobia, seen in both migraine (Headache Classification Committee of The International Headache Society, 1988) and cluster headache (Bahra et al., 2002); there is no suggestion that the sun burns brighter. Moreover, there are well-characterized cases of headache arising in the brain, such as in epileptic events (Young and Blume, 1983; Siegel et al., 1999), or as migraine-like headaches being generated from stimulation of brainstem regions (Raskin et al., 1987; Veloso et al., 1998) or local brainstem lesions (Haas et al., 1993; Goadsby, 2002). Could the generation of headache from the CNS be more important than has hitherto been considered?
Broadly, headache may be classified as primary, where the headache syndrome is the core disorder; and secondary, where the pain is generated from some described locus, such as a brain tumour or infection (Headache Classification Committee of The International Headache Society, 1988). This is an uncomfortable distinction if the peripheral vessels generate the pain. The patient to be described challenges the view that the pain signal generator need necessarily be peripheral in primary neurovascular headache. Our patient has chronic cluster headache, an unremitting severe pain syndrome marked by discrete attacks accompanied by symptoms such as lacrimation, conjunctival injection or nasal congestion, and underwent a complete trigeminal sensory nerve root section. Cluster headache has been considered to be due to peripheral vascular change (Ekbom and Greitz, 1970; Waldenlind et al., 1993), or indeed a vascular or inflammatory process within the cavernous sinus (Moskowitz, 1988; Hardebo, 1994). Recent imaging data suggest an important involvement of the posterior hypothalamic grey matter in the active period as a central locus of dysfunction (May et al., 1998a, 1999a, 2000) and thus a CNS locus for the disorder. A further key question in primary headache arises from the development and clinical use of triptans, serotonin 5-HT1B/1D agonists, in migraine (Ferrari, 1998) and cluster headache (The Sumatriptan Cluster Headache Study Group, 1991). These compounds were developed as cranial vasoconstrictors (Humphrey et al., 1990), but it has become clear in experimental models that these compounds inhibit peripheral neuronal (Moskowitz and Cutrer, 1993) and trigeminal nucleus activation (Goadsby, 2000). The current patient presents a unique opportunity to reconsider some fundamental aspects of cluster headache pathophysiology and the site of action of treatments.
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Clinical case |
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A 59-year-old left-handed man presented with a 14-year history of intermittent, daily headaches. There was no prior history of headache or any obvious precipitant at onset.
Current clinical picture
The patient described strictly left-sided episodes of excruciating, sharp pain centred on the retro-orbital and orbital regions, forehead and temple. These episodes lasted between 1 and 4 h, recurring 2–3 times daily. The attacks were associated with ipsilateral ptosis, conjunctival injection, lacrimation, rhinorrhoea and facial flushing. He denied nausea, vomiting, photophobia, phonophobia or osmophobia. Movement had no effect on the pain. There were no aura symptoms. Alcohol triggered an attack within half an hour. Once or twice a day he had attacks of purely cranial autonomic symptoms without any accompanying pain. Left-sided conjunctival injection, lacrimation and rhinorrhoea occurred concurrently for 15–120 min, although these symptoms are milder in intensity than during an episode of pain. Also independently of the pain episodes, he had sharp stabbing pains in the left eye or upper lip 3–4 times a day, with each episode lasting a few seconds, consistent with idiopathic stabbing headache.
Previous history
His headaches began in 1986. Over a 2-year period he had trials of propranolol, amitriptyline, lithium, methysergide, isometheptene and ergotamine tablets and suppositories, all without any benefit as preventatives, or for the acute attacks. In February 1988, he had a complete surgical section of the left trigeminal sensory root. This led to the attacks being reduced in length for 1 month without any change in the severity or character of the symptoms. In April 1988, a further surgical exploration of the left trigeminal sensory root was performed as the symptoms had continued. The sensory root was found to be completely excised. Post-operatively, there was no change in the symptoms. Thereafter, he had trials of sodium valproate 1.8 g daily, verapamil 120 mg tds, pizotifen 1.5 mg tds, cyproheptadine 4 mg qds, indomethacin 75 mg tds, naproxen, diclofenac, mefenamic acid 500 mg as required, nortriptyline, dothiepin 175 mg daily, clonazepam 0.5 mg bd, carbamazepine 100 mg tds, vigabatrin 2 mg bd, gabapentin 900 mg daily, azathioprine 50 tds, nifedipine 10 mg bd, acetazolamide 500 mg bd, high-flow rate oxygen, intranasal lignocaine drops and zolmitriptan 2.5 mg, all of which had no effect. In addition, he had further trials of lithium 800 mg daily and methysergide 2 mg tds that were limited by side effects, but there was improvement in the symptoms.
In the past medical history, he twice had renal colic. On both occasions he had spontaneously passed a renal stone. There was no family history of headaches. He was a non-smoker. He ceased drinking alcohol with the onset of the headaches.
Physical examination
On examination, he was completely anaesthetic over the entire left trigeminal distribution. The left corneal reflex was absent. Motor function of the left trigeminal nerve was preserved. Neurological and physical examination was otherwise normal. Routine haematological and biochemical screening was normal.
An MRI scan showed a marked reduction in the calibre of the left trigeminal nerve from the nerve root exit zone in the pons to Meckel’s cave, and evidence of previous posterior fossa craniectomy (Fig. 1). No other abnormality was identified.
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Successful treatments
Prednisolone 30 mg daily rendered the patient completely pain free; he had been taking short courses of prednisolone 2–3 times annually since 1990. Sumatriptan 100 mg orally and 6 mg subcutaneously aborted the attack after
45 and 15 min, respectively; this had been the mainstay of his treatment since 1995.
Physiological observations
Magnetic resonance angiography
An ECG-gated three-dimensional multislab MRI inflow angiogram (MRA) with a repetition time (TR) of 39 ms, 32 mm slab thickness, an effective slice thickness of 1 mm and a flip angle of 25° was performed, using a Siemens MAGNETOM Vision scanner operating at 2 T. The MRA was performed using a transverse section through the extracranial portion of the internal artery just distal to the carotid bifurcation. The patient had a scan at rest and after a nitroglycerine-induced attack of acute cluster headache. The entire three-dimensional data set was processed with maximum intensity projections. Using the integrated software (Siemens calculation tool), regions of interest (ROI) were drawn around the vessels identified as the internal carotid arteries on either side. The absolute values for vessel diameter (cm2), blood flow (cm3/s), and mean and peak velocity (cm/s) were calculated. The haemodynamic changes in the vessels between conditions are expressed as a percentage change from the rest to pain condition.
Blink reflexes
Blink reflexes were elicited with a standard electrode. This is a parallel assembly with two stimulation surfaces 25 mm apart, positioned over the left supraorbital nerve. The following stimulus parameters were used: monopolar square wave, duration 0.5 ms, interstimulus interval 12–18 s (pseudorandomized); current intensity 10 mA, six sweeps. EMG recordings were obtained from bilateral surface electrodes placed infraorbitally (different) and at the root of the nose (indifferent), acquisition bandwidth 1 Hz–1 kHz; digitization: sampling rate 2.5 kHz, sweep length 150 ms. PC-based offline analysis was performed with custom-written software. Recordings were obtained bilaterally stimulating first from the left side then from the right side.
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Results |
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Magnetic resonance angiography
The resting vessel area of the internal carotid was symmetrical comparing the ipsilateral and contralateral sides. No change in vessel area ipsilateral to pain was observed during acute cluster headache.
Blink reflexes
Stimulation of the left supraorbital nerve produced neither an ipsilateral nor contralateral blink reflex response (Fig. 2A and B). Stimulation of the right supraorbital nerve produced an ipsilateral response with a mean R2 onset latency of 36 ms (Fig. 2C) and a contralateral response with a mean R2 onset latency of 32 ms (Fig. 2D).
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Discussion |
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This patient with cluster headache was treated by trigeminal sensory root section, with denervation of the structures proposed to generate the pain; he continued to have attacks. If the denervation was complete, then, by definition, the structures innervated by this nerve, the cranial vessels and other intracranial pain-producing structures, such as the dura mater, must be unnecessary to the perception of the pain. This clinical therapeutic experiment suggests that only the brain pathways are required for cluster headache, at least once the condition is established. Furthermore, the therapeutic outcome with sumatriptan establishes that this triptan can act within the CNS to block cluster headache without any necessary peripheral input. It is of additional interest that his shorter lasting attacks, which are probably idiopathic stabbing headache, also continued, again suggesting their generation in the CNS.
The patient’s headache syndrome before the operation, from his account, and certainly by his current history, fulfils standard criteria for chronic cluster headache (Headache Classification Committee of The International Headache Society, 1988). He has been resistant to most treatments; chronic cluster headache is often a therapeutic challenge (Olesen and Goadsby, 1999). He has a typical response to oral corticosteroids and his current attacks are indistinguishable clinically from typical cluster headache. There is no neuropathic component to the pain, suggesting that it is not simply a response to nerve injury. Trigeminal neuropathic pain, as seen after injury, is more usually persistent and is difficult to confuse with typical cluster headache. Moreover, there is not a single case report in which there is triptan responsiveness to trigeminal neuropathic pains. Indeed, for atypical facial pain, sumatriptan has been reported to be ineffective in a controlled trial (Harrison et al., 1997). It is notable that his problems are the same now as they were after the surgery, which argues against plastic changes in the nervous system being the sole explanation for his problems.
Is it possible that the nerve was not cut? Certainly it must be possible without post-mortem confirmation that the nerve is intact. However, it is remarkable that the patient was re-explored with confirmation of the section and has the predicted clinical findings of a dense anaesthesia ipsilateral to the section, as well as clear findings on brain imaging of the nerve, and an absent blink reflex. The absence of both an ipsilateral and contralateral blink reflex response when stimulating the left (lesioned) side clearly demonstrates absence of the afferent arc (first division of the trigeminal nerve) of the blink reflex. The normal ipsilateral and contralateral responses when stimulating on the right demonstrate both a normal right-sided afferent arc and a normal right and left efferent (facial nerve) pathways. There is some suggestion in the literature that trigeminal root section is curative for cluster headache (Kirkpatrick et al., 1993). However, given the fact that cluster headache by its nature can have long remissions, it could not be concluded that an initial amelioration after root section reflected the long-term outcome. Indeed, it is clear from this published series that some patients remain with their attacks (O’Brien et al., 1999). Some patients with cluster headache even after trigeminal nerve block with local anaesthetic can experience nitrate triggering of their attacks (O’Brien et al., 1999), as our patient does. This may be due to a central triggering effect of nitrates rather than the traditional peripheral effect.
Could other pathways have been involved? Hardebo (1994) has suggested a role for the VIIth cranial nerve for nociceptive transmission in cluster headache. Anatomical evidence suggests a limited role for the facial (VIIth) nerve providing afferent information from the head (Boudreau et al., 1977). In humans, this is limited to the ear and some skin around it (White and Sweet, 1955). Direct evidence of dural or substantial cranial vessel innervation from those nerves is lacking. Indeed, Cushing (1904) noted that after total extirpation of the trigeminal ganglion, there was ipsilateral dural insensitivity. Moreover, patients with a dull headache associated with placement of a CSF drain, probably a low CSF pressure headache (Mokri et al., 1997), would only complain of pain contralateral to the extirpation. Another possibility would be some involvement of branches of C2, which projects into the caudal trigeminal nucleus. After trigeminal root section in primates, Denny-Brown and Yanagisawa (1973) showed that substantial areas of cutaneous facial input could be re-activated after intravenous strychnine injection. In this patient, the functional re-innervation would have to be for non-cutaneous pain structures only. This is possible, but unlikely. Finally, there is evidence for crossed trigeminal innervation from cranial vessels in experimental animals (Edvinsson et al., 1993); indeed, for non-human primates; there is functional anatomical evidence using Fos immunohistochemistry (Hoskin et al., 1999). The crossover occurs in the brainstem so, as an example, the right carotid artery may project to the right and left trigeminal nucleus caudalis and on to the thalamus. However, there is no evidence that the contralateral vessel has peripherally crossed innervation, which would be needed to explain the findings in this case on a peripheral basis.
In addition to the clinical observations, MRAs were conducted at rest and during cluster headache. It has been known for some years that the internal carotid artery dilates during acute cluster headache (Ekbom and Greitz, 1970; Waldenlind et al., 1993). Indeed, there is pooling of PET tracer in the region of the cavernous sinus (May et al., 1998a, 2000) that corresponds to internal carotid dilatation (May et al., 1999b). Similarly, pooling of PET tracer (May et al., 1998b) and internal carotid dilatation of 17% (May et al., 2000) is reported after injection of the pain-producing substance capsaicin into the forehead. There is no dilatation in this patient. It has been suggested that the vasodilatation in cluster headache is due to activation of the trigeminal-autonomic (parasympathetic) reflex (May and Goadsby, 1999). It is remarkable that this is dilatation is not seen here, lending physiological support to the notion that the sensory root has indeed been sectioned. The fact that the patient still has cranial autonomic symptoms, such as lacrimation, suggests that this pathway can be activated from the brain without the reflex trigeminal connection. A similar phenomenon, cranial autonomic symptoms without pain, has been demonstrated after percutaneous radiofrequency ganglio-rhizolysis (Maxwell, 1982). Certainly there is evidence in experimental animals for a direct pathway from hypothalamus to superior salivatory nucleus (Spencer et al., 1990), the latter containing the pre-ganglionic cell bodies of the cranial autonomic outflow. We have seen isolated autonomic activation in the cohort of cluster headache patients we have managed in recent years, and this phenomenon is reported in another trigeminal-autonomic cephalgia, paroxysmal hemicrania (Bogucki et al., 1984; Pareja, 1995).
Another vexed issue in primary headache is the site of action of anti-migraine compounds. This issue has exercised the headache community in the last decade (Humphrey and Goadsby, 1994) with the development of the triptans. Triptans are serotonin-5HT1B/1D agonists (Goadsby, 2000), which are specific treatments of migraine (Ferrari et al., 2001) and cluster headache (The Sumatriptan Cluster Headache Study Group, 1991) with no general anti-pain or even facial pain (Harrison et al., 1997) properties. Sumatriptan was developed as a selective constrictor of large extracerebral vessels that was designed to have no significant CNS actions (Humphrey et al., 1990). In experimental animals, it can be shown that blood–brain barrier disruption is required for the trigeminal inhibitory effect of sumatriptan (Kaube et al., 1993; Shepheard et al., 1995). Other more brain-penetrant triptans, such as naratriptan (Goadsby and Knight, 1997; Cumberbatch et al., 1998), rizatriptan (Cumberbatch et al., 1997), eletriptan (Goadsby and Hoskin, 1999) or zolmitriptan (Goadsby and Hoskin, 1996), act to inhibit trigeminal neurones in experimental animals, and trigeminal nucleus neurones may be inhibited by local microiontophoresis of triptans (Storer and Goadsby, 1997) or ergots (Lambert et al., 1992). Taken together, these data suggest that one mechanism of action of triptans might be direct inhibition of the trigeminal second order synapse (Goadsby, 2000).
The patient described has an excellent clinical response to sumatriptan in the absence of either cranial vessels or the peripheral nerve as a target for the intervention. This patient demonstrates, given that the clinical picture is as it seems, that triptans, certainly sumatriptan, can act solely through central inhibition of trigeminal neurones. This does not suggest that the peripheral actions are not adjunctive, but does suggest a possible pre-eminence for the brain site of action. The patient’s results predict that an appropriate neurally active compound will be efficacious in cluster headache. Whether such a compound would also have acute anti-migraine actions is a further crucial question.
In summary, we present a patient with typical chronic cluster headache who had an ipsilateral trigeminal nerve sensory root section. This procedure denervates the ipsilateral cranial vessels and dura mater but neither stopped his attacks, nor affected their treatment. In the absence of a post-mortem, one cannot be completely sure of the root section; however, after two operations, and with a dense trigeminal sensory loss, this patient presents a profound clinical and therapeutic conundrum. His picture challenges conventional wisdom and demands consideration of the brain mechanisms in primary headache as, perhaps, pre-eminent. Primary headache probably requires the head, peripheral structures but at least due consideration to central processing and mechanisms is likely to be fundamental to understanding primary neurovascular headaches.
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Acknowledgements |
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The authors wish to thank Drs Holger Kaube and Nicola Giffin for carrying out the blink reflex study, and Dr Catriona Good for reviewing the MRI. The work reported has been supported by the Migraine Trust and the Wellcome Trust. M.S.M is a Migraine Trust Research Fellow. P.J.G. is a Wellcome Trust Senior Research Fellow.
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M. Leone, A. Franzini, G. Broggi, A. May, and G. Bussone Long-term follow-up of bilateral hypothalamic stimulation for intractable cluster headache Brain, October 1, 2004; 127(10): 2259 - 2264. [Abstract] [Full Text] [PDF]
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Y. Avnon, M. Nitzan, E. Sprecher, Z. Rogowski, and D. Yarnitsky Different patterns of parasympathetic activation in uni- and bilateral migraineurs Brain, July 1, 2003; 126(7): 1660 - 1670. [Abstract] [Full Text] [PDF]
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