Surgical treatment of cluster headache

Cluster headache is ordinarily managed medically, but may become refractory to such medical management. In this setting, surgical treatment has occasionally been performed, based on evidence that pertinent pain pathways and parasympathetic pathways may be interrupted at the main sensory root of the trigeminal nerve and at the nervus intermedius. Between 1976 and 1987, 13 patients underwent surgery for treatment of cluster headache that was refractory to medical therapy (15 procedures). Partial sectioning of the main sensory root and sectioning of the nervus intermedius were performed in nine patients; only partial sectioning of the main sensory root in one; only sectioning of the nervus intermedius in one; and nervus intermedius sectioning plus microvascular decompression of the trigeminal nerve in two. The average postoperative period for the 13 patients was 37 months (range 2 to 135 months). All patients had return of their headaches postoperatively except for one patient who obtained relief after a repeat procedure. Headache began to return between 2 days and 2 years postoperatively. Three patients are currently free of headache, including both patients who had nervus intermedius sectioning plus microvascular decompression of the trigeminal nerve. Together with recurrence of headache, cluster-associated autonomic disturbances recurred after 14 of the 15 operations but are currently absent in the three headache-free patients. Partial sectioning of the main sensory root and sectioning of the nervus intermedius, as performed in these patients, seem to have limited value in the treatment of cluster headache.