The Surgical Treatment of Headache

Jennifer Hong MD; David W. Roberts MD


Headache. 2014;54(3):409-429. 

In This Article

Abstract and Introduction


Medically refractory headache is an uncommon but difficult-to-treat clinical problem. Patients who fail maximal medical management may be candidates for invasive treatment. In this review, we critically examine the literature on the range of surgical treatments currently available for migraine, trigeminal autonomic cephalalgias, idiopathic intracranial hypertension and Chiari malformation type 1, with particular attention to patient selection, treatment efficacy, and complications.


Headache is the most common presenting complaint of patients who are referred to neurologists. Recent epidemiological data estimate that between 16.1–22.7% of adults in the United States are affected by severe headache.[1] The majority of patients with headache respond readily to medical management. Patients who have severe debilitating headache that is refractory to medication, or who do not tolerate medical therapy are a difficult-to-treat minority. A carefully selected subgroup of these patients may benefit from invasive treatment. Invasive treatment for headache is an evolving, expanding field with therapies that range from implantation of deep brain stimulators to craniectomy, to bariatric surgery. Because the population of patients who are candidates for invasive treatment is small, and because many of these treatments are new, there is at best level 3 evidence for the utility of these procedures.[2] Data for invasive treatments are primarily derived from small case series or meta-analyses, often with heterogeneous patient populations. Further complicating analysis of these studies are the variable definitions of headache type between studies and subjective and nonuniform outcome measures.

In this review, we will comprehensively evaluate the current range of procedures used to treat headache, organized by indication, with emphasis on the efficacy and major complications of each method. In the interest of length, detailed review of peripheral nerve stimulation for headache will be addressed in a separate paper.