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• Introduction
• Cluster Headaches
• Causes
• Prognosis
• Risk Factors
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• Managing Cluster Headaches
• Treatment for Acute Attacks
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• Surgery
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Headaches - cluster

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of cluster headaches.

Surgery

Surgical intervention may be considered for patients with chronic cluster headaches that do not respond to treatments. Patients whose headaches have not gone into remission for at least a year may also be candidates for surgery. Most surgical approaches for cluster headache are still considered experimental. To date, surgery has shown limited success and can have distressing side effects. However, some surgical techniques, such as deep brain electrical stimulation, are showing promise.

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 approved for treating the tremors associated with 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 4 hours of the procedure.

Vagus Nerve Stimulation

The vagus nerve runs between the brain and the abdomen. Vagus nerve stimulation (VNS) is a surgical procedure in which a small generator is placed under the skin on the left side of the chest. A surgeon makes a second incision in the neck and connects a wire from the generator to the vagus nerve. A doctor programs the generator to send mild electrical pulses at regular intervals. These pulses stimulate the vagus nerve.

VNS is sometimes used to treat epilepsy and depression that does not respond to drugs. It is also being investigated as a possible treatment for chronic migraine and cluster headaches. In a 2005 study of six patients, VNS improved headache and helped a few patients return to work.

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 - 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 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.

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, however, have the common nerve damage effects in the face that PRFR does.

• Review Date: 10/19/2006
• Reviewed By: Harvey Simon, M.D., Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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