Abstract In recent years, neuroimaging data have greatly improved the knowledge on trigeminal autonomic cepha- lalgias’ (TACs) central mechanisms. Positron emission tomography studies have shown that the posterior inferior hypothalamic grey matter is activated during cluster headache attacks as well as in short-lasting unilateral neu- ralgiform headache attacks with conjunctival injection and tearing (SUNCT). Voxel-based morphometric MRI has also documented alteration in the same area in cluster headache patients. These data suggest that the cluster headache generator is located in this region and leads us to hypothesise that stimulation of this brain area could relieve intractable cluster headache just as deep brain stimulation improves intractable movements disorders. This view received support by the observation that high frequency stimulation of the ipsilateral hypothalamus prevented attacks in an otherwise intractable chronic cluster headache patient previously treated unsuccessfully by sur- gical procedures to the trigeminal nerve. So far, 16 patients with intractable cronic cluster headache (CCH) and one intractable SUNCT patient have been successfully treated by hypothalamic stimulation. The procedures were well tolerated with no significant adverse events. Hypothalamic DBS is an efficacious and safe procedure to relieve other- wise intractable CCH and SUNCT. Key words Cluster headache • Paroxysmal hemicrania • SUNCT • Therapy • Deep brain stimulation Introduction Trigeminal autonomic cephalalgias (TACs) are a group of primary headache syndromes characterised by two main clinical characteristics: pain and oculofacial autonomic phenomena [1]. Three headache forms are grouped as TACs: cluster headache (CH), paroxysmal hemicrania (PH) and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) [1]. These are distinguished mainly on the basis of attack dura- tion. It lasts from 15 to 180 min in CH, from 2 to 30 min in PH and from 5 to 240 s in SUNCT. The most effective preventative drug in PH is indomethacin, although in a few cases other non-steroidal anti-inflammatory drugs have been reported to be effective [2]. SUNCT is commonly described as drug resistant. Recent studies report that lam- otrigine may be the drug of choice for SUNCT [3, 4]. In otherwise drug-resistant patients, surgical procedures have to be taken in consideration. Candidates for destruc- tive surgery are chronically intractable cluster patients whose headaches are unilateral with no history of side shift. In patients whose attacks alternate sides, the risk of a con- tralateral recurrence after surgery is rather high. Various procedures that interrupt either the trigeminal sensory or autonomic (cranial parasympathetic) pathways can be per- formed although few are associated with long-lasting bene- fit; in addition side effects can be severely debilitating. Lack of knowledge on TACs’ pathophysiology has hampered development of new therapeutic strategies. In Neurol Sci (2005) 26:S138–S139 DOI 10.1007/s10072-005-0427-4 M. Leone • A. Franzini • G. Felisati • E. Mea • M. Curone • V. Tullo • G. Broggi • G. Bussone Deep brain stimulation and cluster headache M. Leone () • A. Franzini • E. Mea • M. Curone V. Tullo • G. Broggi • G. Bussone Headache Centre C. Besta National Neurological Institute Via Celoria 11, I-20133 Milan, Italy e-mail: leone@istituto-besta.it G. Felisati Divisione di Otorinolaringoiatria, Ospedale San Paolo Università degli Studi di Milano Milan, Italy HEADACHES: FOCUS ON NEW TREATMENTS