Beyond biochemical control: headache resolution with pasireotide in a patient with acromegaly and residual tumor

Acromegaly management is particularly challenging when pituitary adenomas invade the cavernous sinus, limiting the likelihood of complete surgical resection. We describe a case of a 40-year-old woman with acromegaly caused by a growth hormone and prolactin co-secreting pituitary macroadenoma with bilateral cavernous sinus invasion and severe, frequent headache. Despite transsphenoidal surgery, radiotherapy, and sequential medical therapy with octreotide, cabergoline, and pegvisomant over 3 years, insulin-like growth factor 1 (IGF-1) levels remained elevated and headache burden persisted. Initiation of pasireotide long-acting release was followed by rapid normalization of IGF-1 levels and complete resolution of headache, with improvement in other acromegaly related symptoms. This case supports the potential role of pasireotide in selected patients with biochemically and clinically treatment-resistant acromegaly and contributes to the growing real-world evidence regarding its use in patients with residual disease in surgically challenging locations.