Print
CloseTreatment Options for Cluster Headaches
The Role of Surgery for Cluster Headaches
Surgical techniques for cluster headache are considered only for those patients who respond poorly to all attempted medical therapies. Only persons with unilateral symptoms can be considered for surgical intervention. Surgical procedures have proven very effective for many individuals, and research is attempting to improve existing technologies as well as develop new techniques. Most surgical procedures, however, do not result in permanent relief from cluster headache.
Surgical procedures are targeted at treating the trigeminal nerve or the autonomic nervous system. Patients should discuss the procedures in depth with their physicians regarding benefits and risks, since one of the most common side effects of surgery for some people is trigeminal neuralgia and/or anesthesia dolorosa (numbness in part of the face while the sense of pain remains).
There are three different types of surgical procedures for treatment of refractory cluster headache:
- Procedures targeting the trigeminal nerve
- Procedures targeting the autonomic pathways
- New and experimental surgical treatments
Procedures Targeting the Trigeminal Nerve
The goal of these procedures is to destroy afferent nerve fibers (fibers which carry impulses to the central nervous system) in an attempt to interrupt the transmission of pain signals from the peripheral trigeminal nerve to the brain. This can be achieved via chemical, thermal, or surgical techniques such as:
- Alcohol or lidocaine injection into the supraorbital and infraorbital nerves
- Avulsion of infraorbital/supraorbital/suprachochlear nerves
- Alcohol injection into the Gasserian ganglion
- Radiofrequency (RF) trigeminal gangliorhyzolysis
- Glycerol trigeminal rhizotomy
- Trigeminal nerve root section
- Gamma knife radiosurgery
- Microvascular decompression
Alcohol or Lidocaine Injection into the Supraorbital and Infraorbital Nerves
Alcohol injection or lidocaine injection can be a painful procedure if not done under sedation and the pain relief is temporary (hours or days with lidocaine and up to 18 months with alcohol).
Advantages of this treatment include:
- Less invasive than other techniques
- Procedure is done quickly
- No risk of damage to the cornea
Complications are rare but may include:
- Eye hemorrhage
- Skin necrosis
Avulsion of Infraorbital/Supraorbital/Suprachochlear Nerves
Avulsion (tearing away a peripheral nerve from its site of origin), also called neurectomy, is a more permanent procedure. Pain relief has been noted to last up to 30 months following this treatment.
Alcohol Injection into the Gasserian Ganglion
The Gasserian ganglion is the point at which all of the sensory divisions of the trigeminal nerve, (i.e., the mandibular, maxillary and ophthalmic branch) join together. This is the central point from which the sensory message is sent to the brain stem.
Studies involving small numbers of cluster headache patients have reported variable results ranging from transient relief to long-term relief for up to 6 years.
Radiofrequency Trigeminal Gangliorhizolysis (Neurolysis)
Radiofrequency trigeminal gangliorhyzolysis, also known as radiofrequency thermocoagulation or radiofrequency rhizotomy of the trigeminal ganglion, is the most effective surgical therapy for cluster headache and also offers the best option for pain relief. This treatment abolishes the function of certain divisions of the trigeminal nerve and thereby reduces pain. The surgery requires a highly skilled surgeon and is, therefore, performed only at select institutions. Based on a limited number of studies, results seem encouraging with some patients reporting pain relief ranging from 32 months (average) to 20 years. The overall data from investigations regarding this technique indicates that approximately 50% of patients experience a high degree of pain relief, approximately 20% report fair to good results, and about 30% achieve no relief.
Advantages of radiofrequency trigeminal gangliorhizolysis include:
- It is safe for elderly people
- Associated with low headache recurrence rate and low mortality rate
- Provides relief for many patients suffering from refractory cluster headache
The adverse effects of radiofrequency trigeminal gangliorhizolysis may include:
- Moderate or severe reduced abnormal sensation in the face
- Corneal sensory loss
- Anesthesia dolorosa - damage to the trigeminal nerve results in reduction or elimination of facial sensation but the sense of pain remains.
Approximately 50% of the patients who fail radiofrequency thermocoagulation benefit from subsequent trigeminal nerve root section.
Glycerol Trigeminal Rhizotomy
This procedure is similar to radiofrequency rhizotomy except that instead of using radiofrequency waves, glycerol is injected into the trigeminal ganglion where it acts as a denerving (destroys the nerve) agent. Glycerol trigeminal rhizotomy has good results in terms of pain free periods but it has a higher rate of recurrence of cluster headaches (approximately 40% of cases) than does radiofrequency rhizotomy.
The advantages of glycerol trigeminal rhizotomy include:
- Safe for elderly
- No general anesthesia is needed
- Less complicated technically than radiofrequency
- Fewer incidences of complications than radiofrequency rhizotomy (e.g., corneal anesthesia and keratitis)
Disadvantages of this procedure include:
- High rate of initial failure which requires a second treatment
- Highly skilled surgeon is required since correct needle placement is crucial
- Higher recurrence rate of cluster headache than with radiofrequency rhizotomy
- Multiple treatments may potentially damage the area of needle placement and reduce the efficacy of further injections
Trigeminal Nerve Root Section
With this procedure, a lesion is created in the trigeminal nerve at the root entry zone. Complete or near-complete pain relief was reported in 12 out of 14 patients who participated in one study for the period of observation (5.5 years). One patient developed cluster headache on the opposite side. Complete resection of the trigeminal nerve is more likely to offer complete relief as compared to partial trigeminal nerve root section.
Gamma Knife Radiosurgery
Gamma knife radiosurgery, also known as stereotactic radiosurgery, is a type of radiation therapy in which the trigeminal nerve is injured with a beam of radiation. This procedure can be done on an outpatient basis and typically only takes several hours to complete. At present only a limited number of medical institutions have gamma knife capabilities. A study performed in 1998 evaluated the use of gamma knife in cluster headaches and results were promising. Four men and two women with cluster headache were treated. Five of the patients had chronic cluster headache (daily cluster headaches without periods of remission) and one had episodic cluster headache (daily attacks for weeks or months and then headache free time for weeks or months). Four patients experienced pain relief after gamma knife radiosurgery, which was judged excellent. Of the two remaining patients, one had pain relief judged as good and the other fair. Five of the six patients had relief within a few days to a week following gamma knife. None of the patients treated developed significant post-radiation side effects during a follow-up period of 8 or 14 months.
No one yet knows, however, the true delayed complications of gamma knife, especially in young patients. Gamma knife radiosurgery is being used for cluster headache treatment by some headache centers and the impression is that it works initially, but there are high relapse rates (return of cluster pain) questioning if this treatment strategy is indeed useful in cluster headache.
In 2005, a study of gamma knife radiosurgery was carried out on 10 patients with severe and drug resistant chronic cluster headache. The results of the study were mixed and the authors concluded that the pain relief noted in some of the subjects may be outweighed by the potential treatment complications. To read more about this study, please click on the following link:
Microvascular Decompression
Microvascular decompression involves exposing the vascular system in the region of the trigeminal nerve via craniectomy (creating a small opening in the skull). The objective is to ascertain if there are any vascular loops pressing on the nerve which may be causing the pain and to restore the layout of the blood vessels to their proper anatomical position.
When performed either alone or combined with section of the nervus intermedius and followed up for 5 years, approximately 73% of patients undergoing neurovascular decompression for the first time reported pain relief of 50% or greater. In approximately 15% of the patients, 90% or greater pain relief was achieved. Of patients undergoing the procedure for the first time, approximately 80% were found to have vascular compression of the trigeminal nerve.
Procedures Targeted at Autonomic Pathways
- Sectioning (cutting) of the greater superficial petrosal nerve
- Sectioning of the nervus intermedius
- Blockade of the sphenopalatine ganglion by radiofrequency
Sectioning of the Greater Superficial Petrosal Nerve
The greater superficial petrosal nerve connects into a ganglion which gives off nerve branches that supply the lacrimal (tear) gland and the mucous secreting glands of the nasal and oral cavities. Sectioning this nerve is intended to reduce the autonomic symptoms, (e.g., tearing, sweating) associated with cluster headache.
Sectioning of the Nervus Intermedius
In this procedure, a craniectomy (small opening of the skull) is performed and the 7th and 8th cranial nerves are exposed. The nervus intermedius is then sectioned. Some patients benefit from this procedure when combined with microvascular decompression of blood vessels in the region. In one study, five out of eight patients who underwent both procedures experienced recurrence of headaches within 4 months, however, the headaches were not as severe as before the surgery.
Adverse effects of surgery or complications may include:
- Hearing loss
- Facial palsy
- Loss of taste
- Vertigo
Blockade of the Sphenopalatine Ganglion by Radiosurgery
In a small study which investigated blockade of the sphenopalatine ganglion by radiosurgery and followed patients for up to 5 years, approximately 60% of the patients with episodic cluster headache and 40% of patients with chronic cluster headache experienced full pain relief for up to 2 years.
Adverse effects of this procedure include:
- Temporary postoperative epistaxis (bleeding)
- Cheek hematoma (bruising of the cheek)
- Hypesthesia of the palate (impairment or decrease of sensitivity)
Most of the procedures directed at autonomic pathways are not associated with long-lasting pain relief and can actually lead to significant long-term complications (e.g., double vision, hyperacusia/abnormal intolerance of loud sounds, corneal anesthesia). For this reason, all patients undergoing these procedures require ophthalmic follow-up. Also, the headaches may recur on the opposite side of the head and they are as intense if not worse than before surgery.
New Surgical Treatments for Cluster Headaches
Greater Occipital Nerve Blockade
In a very limited number of patients suffering from chronic cluster headache, blockade of the greater occipital nerve yielded promising results. Further investigation is underway. You can read more about greater occipital nerve injection by clicking on the following link:
Hypothalamic Deep Brain Stimulation
Hypothalamic deep brain stimulation is a very exciting but truly investigational surgical treatment for severe, intractable, chronic cluster headache that has been studied by an Italian group of researchers. Recent studies have shown that during a cluster headache attack, there is an actual difference in the density of brain tissue in a specific area of the hypothalamus. Based upon imaging studies showing that the hypothalamus is activated during cluster headache attacks and, indeed, may be a generator of cluster headache, stereotactic stimulation of this area may interfere with the onset of cluster headache. A stimulator was placed into the hypothalamus of 6 study patients with refractory chronic cluster headache to see if stimulating the hypothalamus could stop a patient from having cluster headaches. The researchers found that once the stimulator was turned on, the cluster headaches started to disappear. In some patients pain relief was immediate, while in others it took up to 4 months for patients to become pain free. When the stimulator was turned off, the attacks resumed, though not immediately. So far the patients have had no side-effects with the stimulator. Preliminary results indicate that at 42 months post surgery, some patients remain pain free.
This treatment is completely experimental at present and must be performed by a highly skilled and experienced neurosurgeon. Close follow-up after the procedure is required. Hypothalamic stimulation is still new and needs to be studied for further safety issues. Some patients report transient vertigo or bradycardia (slow heart rate) while stimulation is in process but most patients tolerate the procedure well. Subsequent studies have reported success in a total of 16 patients with intractable chronic cluster headache after being followed for four years. None of the patients developed any numbness or reduction of feeling in the trigeminal nerve.
To read more about hypothalamic stimulation, click on the following links: