Therapeutic stimulation of the hypothalamus: pathophysiological insights and prerequisites for management.

We thank Dr Gupta for his interest in our work. Verapamil was in fact tried in this patient up to 960 mg day with no benefit (Attanasio et al., 2000), as were all known cluster headache (CH) prophylactics. In our patient, the pain attacks were always accompanied by drug-resistant blood pressure crises (diastolic pressure up to 160 mmHg), during which repeated retinal and vitreous humour haemorrhages occurred, resulting in right eye blindness and severely compromised left visus—clear evidence of target organ damage. These hypertensive crises would inevitably have caused irreversible damage to other organs, had they not been controlled; they have not recurred since DBS. Furthermore, the pressure crises only occurred with CH attacks, beginning at the same time but peaking long before the pain peak, indicating they were pain-independent. The patient also had sleep disturbances, hyperphagia, aggression and hypersexuality (Attanasio et al., 2000), all of which ceased completely under hypothalamic stimulation, thereby implicating the hypothalamus (Fig. 1).