Headaches: Cluster

Description

Surgery

Surgical intervention may be considered for patients with chronic cluster headaches that do not respond to treatments at all or when they have not gone into remission for at least a year. To date, surgery has limited success and can have distressing side effects. Deep brain electrical stimulation is showing promise, however.

Deep Brain Electrical Stimulation

Relief of chronic cluster headaches has been achieved in a small number of patients using deep brain stimulation (also called neurostimulation). A similar technique is now being used in Parkinson's disease. The surgeon implants a tiny wire in a specific part of the hypothalamus, which receives electrical pulses from a small generator implanted under the collarbone.

Although only a handful of patients have been treated, results to date are promising. Some patients have remained completely free of pain for an average of more than seven months when the electrode is switched on. When the device is turned off, headaches reappear within days to weeks. The procedure is reversible and appears to be generally safe, although one patient developed a fatal cerebral hemorrhage within four hours of the procedure.

Procedures to Block or Remove Facial Nerves That Cause Pain

Percutaneous Radiofrequency Retrogasserian Rhizotomy.Percutaneous radiofrequency retrogasserian rhizotomy (PRFR) generates heat to destroy pain-carrying nerve fibers in the face. Small studies have reported good to excellence results in 83% to 92% patients. Unfortunately complications are common and include numbness, weakness during chewing, changes in tearing and salivation, and facial pain. In severe, but rare, cases, complications include damage to the cornea and cause vision loss.

Percutaneous Retrogasserian Glycerol Rhizolysis. Percutaneous retrogasserian glycerol rhizolysis (PRGR) is a less invasive technique than PRFR and has fewer complications. It involves injections of glycerol to block the facial nerves that cause the pain. In one study, 83% of patients reported immediate relief after one or two injections. Cluster headaches recurred, however, in about 40% of the patients.

Trigeminal Resection. Resection involves cutting part of the trigeminal nerve, which is the major nerve responsible for facial sensation. Studies on trigeminal resection report near-complete to complete relief in 75% of patients.

Microvascular Decompression of the Trigeminal Nerve. Microvascular decompression frees the trigeminal nerve from any blood vessels that are pressing against it. In one study, over 73% of patients reported at least 50% relief. Half of these patients reported 90% relief but the level of benefit fell to less than 50% over time. Repeat procedures are rarely successful. The procedure is risky, and possible complications include nerve and blood vessel injury and spinal fluid leakage. It does not have the common nerve damage effects in the face that PRFR does, however.