Cluster Headache—Acute and Prophylactic Therapy

Avi Ashkenazi, MD; Todd Schwedt, MD

Disclosures

Headache. 2011;51(2):272-286. 

In This Article

Ablative Surgical Procedures

With the emergence of a variety of pharmacologic and non-pharmacologic therapies for CH, the role of ablative surgery in this disease has declined.[1] Candidates for surgery should have strictly unilateral, side-locked, CH attacks. A number of procedures have been used with some success for this indication, including radiofrequency ablation of the trigeminal ganglion, trigeminal sensory rhizotomy, gamma knife surgery, and microvascular trigeminal nerve decompression.[1] Radiofrequency trigeminal gangliorhizolysis has been shown as effective in up to 75% of refractory CCH patients.[78,79] In a case series of 27 patients who underwent this procedure, 2 developed anesthesia dolorosa.[79] Other complications included corneal anesthesia, keratitis, and diplopia. Trigeminal root section has been reported to be effective in 88% of 17 patients with refractory CCH, with 76% experiencing long-term pain relief.[80] Complications included corneal abrasion, masticatory muscle weakness, anesthesia dolorosa and the development of CH on the other side. One patient, who underwent the procedure twice, died after the second surgery. The authors concluded that trigeminal nerve section is a viable therapeutic option for selected refractory CCH patients. Microvascular decompression of the trigeminal nerve, with or without section of the nervus intermedius, has shown some efficacy in refractory CCH; however, response rate decreased over time.[81] Gamma knife radiosurgery is a relatively recent therapeutic approach for CH.[82,83] Despite early encouraging results,[82] more recent data showed only modest long-term pain relief and high rate of AEs, including deafferentation pain.[83]

Another surgical approach for CH targets the parasympathetic component of the disease, typically by blocking or ablating the SPG.[67,84,85] In 1 study, radiofrequency blockade of the SPG was performed in 66 CH patients.[84] Complete pain relief was achieved in 61% and 30% of ECH and CCH patients, respectively. In a more recent study, 15 refractory CCH patients were treated with radiofrequency ablation of the SPG.[85] The treatment decreased significantly the mean attack frequency, mean pain intensity and pain-related disability, and these effects lasted for 12–18 months.

In summary, ablative surgical procedures should be reserved as the last resort for refractory CH patients. The procedures that appear to be more effective in the long-term management of the disease are radiofrequency trigeminal ganglion ablation and trigeminal rhizotomy. It should be noted, however, that CH attacks have been shown to persist after trigeminal root section in a case report of man with CH, supporting the hypothesis of a central pain generator in this disease.[86]

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