Radiosurgical Treatment of Cluster Headaches

Neurosurgery. 2007 Mar;60(3):E580-1; discussioin E581.

Cyberknife targeting the pterygopalatine ganglion for the treatment of chronic cluster headaches.

CLINICAL PRESENTATION: A 56-year-old man presented with a 20-year history of medically refractory CH. His symptoms were described as left-sided, severe, stabbing, burning, and often being associated with tearing and rhinorrhea. These headaches occurred virtually every morning and interfered with sleep, lifestyle, and work performance. 

INTERVENTION: The patient underwent two pterygopalatine nerve block trials, both of which resulted in the complete relief of headaches for a 24-hour period. Contrast-enhanced computed axial tomography and magnetic resonance imaging scans were fused for target identification and treatment planning. The target volume measured 0.296 cm3 and a single fraction of 45.50 Gy was delivered to the 78% isodose line with a maximum dose of 65 Gy. The patient kept a detailed diary of his headaches and was followed for 12 months after treatment. 

CONCLUSION: Results of CyberKnife targeting of the pterygopalatine ganglion in a patient with medically intractable CHs have revealed a significant decrease in the severity and frequency of headaches after a 12-month follow-up period. In addition, the patient has been able to reduce his medication intake, allowing for a significant decrease in medication-related side effects. Longer follow-up periods and additional studies are required to determine the long-term efficacy and late side effects of this treatment strategy.

Publication Types:

• Case Reports

----------

Headache. 2007 Feb;47(2):298-300.

Repeat trigeminal nerve radiosurgery for refractory cluster headache fails to provide long-term pain relief.

Objective/Background.-Medically refractory cluster headache (MRCH) is a debilitating condition that has proven resistant to many modalities. Previous reports have indicated that radiosurgery for MRCH provides little long-term pain relief, with moderate/significant morbidity. However, there have been no reports of repeated radiosurgery in this patient population. We present our findings from the first reports of repeat radiosurgery for MRCH. 

Methods.-Two patients with MRCH underwent repeat gamma knife radiosurgery at our institution. Each fulfilled clinical criteria for treatment, including complete resistance to pharmacotherapy, pain primarily localized to the ophthalmic division of the trigeminal nerve, and psychological stability. Both patients previously received gamma knife radiosurgery (75 Gy) for MRCH with no morbidity, but no long-term improvement of pain relief (Patient 1 = 5 months, Patient 2 = 10 months) after treatment. For repeat radiosurgery, each patient received 75 Gy to the 100% isodose line delivered to the root entry zone of the trigeminal nerve, and was evaluated postretreatment. Pain relief was defined as: excellent (free of MRCH with minimal/no medications), good (50% reduction of MRCH severity/frequency with medications), fair (25% reduction), or poor (less than 25% reduction). 

Results.-Following repeat radiosurgery, long-term pain relief was poor in both patients. Neither patient sustained any immediate morbidity following radiosurgery. Patient 2 experienced right facial numbness 4 months postretreatment, while Patient 1 experienced no morbidity. 

Conclusion.-Repeat radiosurgery of the trigeminal nerve fails to provide long-term pain relief for MRCH. Given the reported failures of initial and repeat radiosurgery for MRCH, trigeminal nerve radiosurgery should not be offered for MRCH.

PMID: 17300376

----------

Neurosurgery. 2006 Dec;59(6):1252-7; discussion 1257.  
 
Trigeminal nerve radiosurgical treatment in intractable chronic cluster headache: unexpected high toxicity.
 
Donnet A, Tamura M, Valade D, Regis J.
 
Department of Neurosurgery, Hopital la Timone, Marseille, France. adonnet@AP-HM.fr
 
OBJECTIVE: We have previously reported short-term results of a prospective open trial designed to evaluate trigeminal nerve radiosurgical treatment in intractable chronic cluster headache (CCH). Medium- and long-term results have not yet been reported. 

METHODS: Ten patients presenting with a severe and drug-resistant CCH were enrolled (nine men, one woman). The radiosurgical treatment was performed according to the technique usually used for trigeminal neuralgia in our department. A single 4-mm shot was positioned at the level of the cisternal portion of the trigeminal nerve. The median distance between the center of the shot and the emergence of the nerve was 9.35 mm (range, 7.5-13.3 mm). The median of this maximum dose to the brainstem was 8.0 Gy (range, 4.0-11.1 Gy). Mean age was 49.8 years (range, 32-77 yr). Mean duration of the CCH was 9 years (range, 2-33 yr). The mean follow-up period was 36.3 months (range, 24-48 mo). 

RESULTS: Two patients had complete relief of CCH. One patient had a good result with evolution in an episodic form. Seven patients had no improvement. Nine patients developed a new trigeminal nerve disturbance: three developed paresthesia with no hypoesthesia and six developed hypoesthesia, including two patients with deafferentation pain. Only one patient had neither paresthesia nor hypoesthesia. 

CONCLUSION: We confirmed, with medium- and long-term evaluation, the high rate of toxicity and failure of the technique. The high toxicity, despite a methodology identical to the one used in trigeminal neuralgia, leads us to suspect an underlying specificity of the nerve in CCH. We do not recommend radiosurgery for treatment of intractable CCH.
 
PMID: 17277687

----------

Neurosurgery. 2006 Dec;59(6):1258-62; discussion 1262-3.  
 
Long-term results of radiosurgery for refractory cluster headache.
 
McClelland S 3rd, Tendulkar RD, Barnett GH, Neyman G, Suh JH.
 
Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA.
 
OBJECTIVE: Medically refractory cluster headache (CH) is a debilitating condition for which few surgical modalities have proven effective. Previous reports involving short-term follow-up of CH patients have reported modest degrees of pain relief after radiosurgery of the trigeminal nerve ipsilateral to symptom onset. With the recent success of deep brain stimulation as a surgical modality for these patients, it becomes imperative for the long-term risks and benefits of radiosurgery to be more extensively delineated. To address this issue, we present our findings from the largest retrospective series of patients undergoing radiosurgery for CH with extended follow-up periods. 

METHODS: Between 1997 and 2001, 10 patients with CH underwent gamma knife radiosurgery at our institution. All patients fulfilled clinical criteria for treatment, including complete resistance to pharmacotherapy (usually methysergide, verapamil, and lithium), pain primarily localized to the ophthalmic division of the trigeminal nerve, and psychological stability. The mean age at radiosurgery was 40.3 years (range, 26-62 yr), and the average CH duration was 11.3 years (range, 2-21 yr). Patients received 75 Gy to the 100% isodose line delivered to the most proximal part of the trigeminal nerve where the 50% isodose line was outside the brainstem (4-mm collimator), with a mean follow-up period of 39.7 months (range, 5-88 mo). Pain relief was defined as excellent (free of CH with minimal or no medications), good (50% reduction of CH severity and frequency with medications), fair (25% reduction of CH severity and frequency with medications), or poor (less than 25% reduction of CH severity and frequency with medications). 

RESULTS: After radiosurgery, pain relief was poor in nine patients and fair in one patient. Six patients with poor to fair relief initially experienced excellent to good relief (range, 2 wk-2 yr after treatment) before regressing. Five patients (50%) experienced trigeminal nerve dysfunction, manifesting predominantly as facial numbness after treatment. 

CONCLUSION: Although some patients may experience short-term pain relief, none had relief sustainable for longer than 2 years. The results from this series indicate that radiosurgery of the trigeminal nerve does not provide long-term pain relief for medically refractory CH.
 
PMID: 17277688  

----------

J Neurol Neurosurg Psychiatry. 2005 Feb;76(2):218-21.

Gamma knife treatment for refractory cluster headache: prospective open trial.

Service de Neurochirurgie, Hopital la Timone, 264 bd Saint Pierre, 13385 Marseille Cedex 05, France. adonnet@AP-HM.fr

BACKGROUND: Since the initial report of Ford et al in 1998 no further study has evaluated radiosurgery of the trigeminal nerve in chronic cluster headache (CCH). 

METHODS: We carried out a prospective open trial of neurosurgery and enrolled 10 patients (nine men, one woman; mean age 49.8 years, range 32-77) presenting with severe and drug resistant CCH (mean duration 9 years, range 2-33). The cisternal segment of the nerve was targeted with a single 4 mm collimator (80-85 Gy max). 

RESULTS: The mean follow up was 13.2 months. No improvement was observed in two patients and three patients had no further attacks. Three patients showed dramatic improvement with a few attacks per month or very few attacks over the last six months. Two patients were pain free for only one and two weeks and their headaches recurred with the same severity as before. Three patients developed paraesthesia with no hypoaesthesia, one developed hypoaesthesia, and one developed deafferentation pain. 

CONCLUSIONS: The rate and severity of trigeminal nerve injury appeared to be significantly higher than in trigeminal neuralgia, and this study does not support the positive results of the study of Ford et al. We consider the morbidity to be significant for the low rate of pain cessation, making this procedure less attractive even for the more severely affected subgroup of patients.

PMID: 15654036

----------

Headache. 1998 Jan;38(1):3-9

Gamma knife treatment of refractory cluster headache.

Ford Headache Clinic, Birmingham, AL 35213, USA.

Four men and two women were treated for refractory cluster headache by gamma knife radiosurgery of the trigeminal nerve root entry zone. The maximum dose of radiation was 70 Gy to the isocenter. Of five patients treated who had refractory chronic cluster headache and one with refractory episodic cluster headache, four had relief judged excellent. Of the two remaining patients with refractory chronic cluster headache, one had relief judged good and the other fair. Five of the six patients treated had relief within a few days to a week following gamma knife radiosurgery. Three with chronic cluster headache had remissions allowing cessation of all preventive and abortive medication. Although one patient experienced complete relief of chronic cluster headache, he continued to have migraine requiring medication. None of the patients treated developed significant postradiation side effects during a follow-up period of 8 to 14 months. The authors conclude that gamma knife radiosurgery of the trigeminal nerve affords great promise in the management of chronic and refractory cluster headache. The technique seemingly carries negligible short- and long- term risk.

PMID: 9504996

----------

Headache, 1995 Apr;35(4):193-6

Long-term Results of Radiofrequency Rhizotomy in the Treatment of Cluster Headache

Department of Neurosurgery, University of Cincinnati College of Medicine, OH 45267-0515, USA.

Although the primary treatment of chronic cluster headache is medical, surgical treatment is sometimes used. The authors reviewed the charts of seven patients (ages 36 to 68 years) with chronic cluster headache to identify who responded best to percutaneous stereotactic radiofrequency rhizotomy after medical treatment failed. All patients had immediate pain relief after surgery. At follow-up (median 5 years, range 2 to 20 years), two patients remained pain-free 7 and 20 years later (excellent results); three patients had mild pain recurrence that was well controlled on medications (good results) 6 to 12 months after surgery; and two patients had major pain recurrence 4 days and 2 months after surgery (poor results). Six patients had relief of vasomotor symptoms. One patient had transient diplopia and keratitis without permanent sequelae. Both patients with excellent results had preoperative major pain around the eye; both patients with poor results had major pain around the temple, ear, and cheek; and the three patients with good results had pain equally severe in the eye, temple, and cheek. There was no association between patient age or sex, pain duration, preoperative response to lidocaine blockade, or previous surgery with pain relief. No differences occurred in pain relief between patients with dense hypalgesia and patients with analgesia. The authors conclude that (1) some patients with chronic cluster headache treated by percutaneous stereotactic radiofrequency rhizotomy achieve long-term pain relief, and (2) surgery on the trigeminovascular system alone may not cure the condition in patients with major pain around the temple, ear, and cheek.

PMID: 7775174

http://www.blackwell-synergy.com/doi/abs/10.1111/j.1526-4610.1995.hed3504193.x?journalCode=hed

----------

Headache. 1988 Jun;28(5):328-31.

Percutaneous Radiofrequency Trigeminal Gangliorhizolysis in Intractable Cluster Headache

The Houston Headache Clinic, Houston, Texas and The Methodist Hospital, Houston, Texas.

SYNOPSIS

Recent interest in the possible role of substance P and other vaso-active polypeptides of the trigeminal vascular system, in the pathogenesis of vascular headache, has lad to a reconsideration of the value of ablative procedures on the trigeminal nerve in the control of chronic, medically intractable cluster headache. Twenty-seven patients with disabling intractable chronic cluster headache underwent radiofrequency trigeminal gangliorhizolysis. Indications included total resistance to prophylactic treatment, narcotic dependency, hypercorticism, and contra-indications to ergotamine and methysergide as a result of severe ischemic heart disease. The procedure had to be repeated in 6 patients, once in 4 and twice in 2. The average follow-up period was 28 months with a range of 6 to 63 months. Excellent results were obtained in 15 patients, very good in 2, good in 3, fair in 1 and poor in 6. Complications were anesthesia dolorosa, stabbing pain over the vertex, ice-pick like pain over the ipsilateral eye, transient corneal infection, transient diplopia, localized dermatosis, and recurrent stye. Complications were mild and transient in the majority of the patients, and the benefits from the surgery far outweighed the discomfort from the complications. The reasons for poor results in some patients were analyzed.

It is concluded that radiofrequency trigeminal gangliorhizolysis is a reasonable alternative in patients with chronic cluster headache 1) who are totally resistant to medical treatment, 2) with a history of strictly unilateral headache, and 3) with stable personality profile and low addiction proneness.

http://www.blackwell-synergy.com/doi/abs/10.1111/j.1526-4610.1988.hed2805328.x

----------

Page Last Updated:  02/26/2008