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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.