Cluster Headache - Diagnosis and Treatment

Cluster Headache - Diagnosis and Treatment

Todd D Rozen
US Neurology Review 2005
Published: October 2008
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Surgical Techniques for Cluster Headache

Surgeryon the Cranial Parasympathetic System
The parasympathetic autonomic pathway can be interrupted by sectioning the greater superficial petrosal nerve, the nervus intermedius, or the sphenopalatine ganglion. Based on the trigeminal autonomic (TAC) reflex pathway hypothesis for cluster pathogenesis, this technique should obliterate the autonomic symptoms associated with a cluster headache but would not appear likely to affect the cluster associated pain because this is a trigeminal nerve-driven response, although the nervus intermedius may have nociceptive fibers. From reports in literature, techniques targeting the autonomic system in cluster have provided very inconsistent pain relief in patients and when deemed initially effective have had high recurrence rates.

Surgery on the Sensory Trigeminal Nerve

Procedures directed toward the sensory trigeminal nerve include:

  • alcohol injection into supra-orbital and infraorbital nerves;
  • alcohol injection into the Gasserian (trigeminal) ganglion;
  • avulsion of infraorbital/supraorbital/supratrochlear nerves;
  • retrogasserian glycerol injection;
  • radiofrequency trigeminal gangliorhyzolysis; and
  • trigeminal root section.


Based on the TAC reflex hypothesis this would mechanistically make the most sense for aborting both the pain and possibly the autonomic symptoms related to the cluster attack.Overall, these techniques have been the most successful at alleviating cluster pain, especially radiofrequency trigeminal gangliorhyzolysis.5 With some of the procedures there is the possibility of very severe adverse events including anesthesia dolorosa.

A New Direction

Hypothalamic Stimulation
A recent series of patients reported by Leone et al.23 may completely change the way that chronic intractable cluster headache is treated. Based upon the positron emission tomography (PET) studies by May et al.24 suggesting a hypothalamic generator for cluster, Leone et al. have treated several chronic cluster patients by electrode implantation into the posterior inferior hypothalamus.When the stimulator is activated in these patients the cluster pain vanishes. When the stimulator is turned off the headaches reappear. This technique is novel and more investigation is necessary before it can be considered a rational treatment of cluster. What is exciting about this is that knowledge of pathogenesis will help to discover new and better therapies for cluster headache.

Conclusion
Cluster headache is a primary headache syndrome that is under-diagnosed and in many instances undertreated. Cluster headache is very stereotyped in its presentation and fairly easy to diagnose with an in depth headache history. Treatment of cluster headache can be very successful if the correct medications are used and the correct dosages are prescribed. New understanding of cluster pathogenesis has led to better medicinal and surgical treatment strategies.

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