Surgical Interventions for Cluster Headache, Including Implanted Stimulators

  • Koen Paemeleire
  • Paolo Martelletti
Reference work entry


Refractory cluster headache (rCH) is one of the most devastating conditions known to man. Historically, only destructive procedures were available for these desperate patients in which all drug therapies failed. The surgical interventions were aimed at the sensory trigeminal nerve, including the trigeminal sensory root, Gasserian ganglion, and supra- or infraorbital nerves; or the autonomic pathways involved in cluster headache (CH), including the nervus intermedius, nervus petrosus major, and sphenopalatine ganglion. Especially, trigeminal destructive procedures are associated with potential serious long-term consequences such as anesthesia dolorosa, as well as corneal anesthesia and ulceration. The surgical management of rCH is changing drastically with the advent of neuromodulatory techniques, such as occipital nerve stimulation and hypothalamic deep brain stimulation. These techniques were developed based on the physiology of the trigeminocervical complex and on evidence for a hypothalamic generator in CH, respectively. The potential therapeutic effect of each technique should be carefully balanced against known potential long-term consequences, knowing that long-term data on the rate of recurrence of CH after a procedure are generally lacking. No conclusive recommendations can be formulated at present, but we will suggest some guidelines toward implementing surgical interventions for rCH in clinical practice. We will briefly touch upon greater occipital nerve block as a transitional treatment.


Deep Brain Stimulation Cluster Headache Chronic Cluster Headache Cluster Headache Patient Great Occipital Nerve 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Afridi SK, Shields KG, Bhola R, Goadsby PJ (2006) Greater occipital nerve injection in primary headache syndromes – prolonged effects from a single injection. Pain 122:126–129PubMedCrossRefGoogle Scholar
  2. Ambrosini A (2007) Occipital nerve stimulation for intractable cluster headache. Lancet 369:1063–1065PubMedCrossRefGoogle Scholar
  3. Ambrosini A, Schoenen J (2010) Commentary on Fontaine et al.: “Safety and efficacy of deep brain stimulation in refractory cluster headache: a randomized placebo-controlled double-blind trial followed by a 1-year open extension”. J Headache Pain 11:21–22PubMedCrossRefGoogle Scholar
  4. Ambrosini A, Vandenheede M, Rossi P, Aloj F, Sauli E, Pierelli F, Schoenen J (2005) Suboccipital injection with a mixture of rapid- and long-acting steroids in cluster headache: a double-blind placebo-controlled study. Pain 118:92–96PubMedCrossRefGoogle Scholar
  5. Anthony M (1985) Arrest of attacks of cluster headache by local steroid injection of the occipital nerve. In: Rose FC (ed) Migraine: clinical and research advances. Karger, London, pp 169–173Google Scholar
  6. Anthony M (1987) The role of the occipital nerve in unilateral headache. In: Advances in headache research. Proceedings of the sixth international migraine symposium 1986, London. John Libbey & Co Ltd, London, pp 257–262Google Scholar
  7. Bartsch T, Goadsby PJ (2003) The trigeminocervical complex and migraine: current concepts and synthesis. Curr Pain Headache Rep 7:371–376PubMedCrossRefGoogle Scholar
  8. Bartsch T, Paemeleire K, Goadsby PJ (2009) Neurostimulation approaches to primary headache disorders. Curr Opin Neurol 22:262–268PubMedCrossRefGoogle Scholar
  9. Burns B, Watkins L, Goadsby PJ (2009) Treatment of intractable chronic cluster headache by occipital nerve stimulation in 14 patients. Neurology 72:341–345PubMedCrossRefGoogle Scholar
  10. Busch V, Jakob W, Juergens T, Schulte-Mattler W, Kaube H, May A (2006) Functional connectivity between trigeminal and occipital nerves revealed by occipital nerve blockade and nociceptive blink reflexes. Cephalalgia 26:50–55PubMedCrossRefGoogle Scholar
  11. Campbell JK (2000) Surgical and ablative management of cluster headache. In: Olesen J, Goadsby PJ (eds) Cluster headache and related conditions. Oxford University Press, Oxford, pp 264–270Google Scholar
  12. Constantoyannis C, Kagadis G, Chroni E (2008) Percutaneous balloon compression for trigeminal neuralgias and autonomic cephalalgia. Headache 48:130–134PubMedGoogle Scholar
  13. Denecke HJ (1977) Greater petrosal nerve surgery in long-term cluster headache (author’s transl). HNO 25:48–50PubMedGoogle Scholar
  14. Dodick DW (2005) Chronic cluster headache. In: Goadsby PJ, Silberstein SD, Dodick DW (eds) Chronic daily headache for clinicians. BC Decker, London, pp 65–80Google Scholar
  15. Donnet A, Valade D, Regis J (2005) Gamma knife treatment for refractory cluster headache: prospective open trial. J Neurol Neurosurg Psychiatry 76:218–221PubMedCrossRefGoogle Scholar
  16. Ekbom K, Lindgren L, Nilsson BY, Hardebo JE, Waldenlind E (1987) Retro-Gasserian glycerol injection in the treatment of chronic cluster headache. Cephalalgia 7:21–27PubMedCrossRefGoogle Scholar
  17. Felisati G, Arnone F, Lozza P, Leone M, Curone M, Bussone G (2006) Sphenopalatine endoscopic ganglion block: a revision of a traditional technique for cluster headache. Laryngoscope 116:1447–1450PubMedCrossRefGoogle Scholar
  18. Fontaine D, LaMertens P, Blond S, Geraud G, Fabre N, Navez M, Lucas C, Dubois F, Gonfrier S, Paq Zorthes Y, Uis P, Lanteri-Minet M (2010) Safety and efficacy of deep brain stimulation in refractory cluster headache: a randomized placebo-controlled double-blind trial followed by a 1-year open extension. J Headache Pain 11:23–31PubMedCrossRefGoogle Scholar
  19. Ford RG, Ford KT, Swaid S, Young P, Jennelle R (1998) Gamma knife treatment of refractory cluster headache. Headache 38:3–9PubMedCrossRefGoogle Scholar
  20. Franzini A, Ferroli P, Leone M, Broggi G (2003) Stimulation of the posterior hypothalamus for treatment of chronic intractable cluster headaches: first reported series. Neurosurgery 52:1095–1099PubMedCrossRefGoogle Scholar
  21. Franzini A, Messina G, Leone M, Cecchini AP, Broggi G, Bussone G (2009) Feasibility of simultaneous vagal nerve and deep brain stimulation in chronic cluster headache: case report and considerations. Neurol Sci 30(Suppl 1):S137–S139PubMedCrossRefGoogle Scholar
  22. Grover PJ, Pereira EA, Green AL, Brittain JS, Owen SL, Schweder P, Kringelbach ML, Davies PT, Aziz TZ (2009) Deep brain stimulation for cluster headache. J Clin Neurosci 16:861–866PubMedCrossRefGoogle Scholar
  23. Hassenbusch SJ, Kunkel RS, Kosmorsky GS, Covington EC, Pillay PK (1991) Trigeminal cisternal injection of glycerol for treatment of chronic intractable cluster headaches. Neurosurgery 29:504–508PubMedCrossRefGoogle Scholar
  24. Jarrar RG, Black DF, Dodick DW, Davis DH (2003) Outcome of trigeminal nerve section in the treatment of chronic cluster headache. Neurology 60:1360–1362PubMedGoogle Scholar
  25. Kirkpatrick PJ, O’Brien MD, MacCabe JJ (1993) Trigeminal nerve section for chronic migrainous neuralgia. Br J Neurosurg 7:483–490PubMedCrossRefGoogle Scholar
  26. Leone M, Franzini A, Bussone G (2001) Stereotactic stimulation of posterior hypothalamic gray matter in a patient with intractable cluster headache. N Engl J Med 345:1428–1429PubMedCrossRefGoogle Scholar
  27. Leone M, May A, Franzini A, Broggi G, Dodick D, Rapoport A, Goadsby PJ, Schoenen J, Bonavita V, Bussone G (2004) Deep brain stimulation for intractable chronic cluster headache: proposals for patient selection. Cephalalgia 24:934–937PubMedCrossRefGoogle Scholar
  28. Leone M, Proietti Cecchini A, Franzini A, Broggi G, Cortelli P, Montagna P, May A, Juergens T, Cordella R, Carella F, Bussone G (2008) Lessons from 8 years’ experience of hypothalamic stimulation in cluster headache. Cephalalgia 28:787–797PubMedCrossRefGoogle Scholar
  29. Leone M, Franzini A, Cecchini AP, Mea E, Broggi G, Bussone G (2009) Costs of hypothalamic stimulation in chronic drug-resistant cluster headache: preliminary data. Neurol Sci 30(Suppl 1):S43–S47PubMedCrossRefGoogle Scholar
  30. Lovely TJ, Kotsiakis X, Jannetta PJ (1998) The surgical management of chronic cluster headache. Headache 38:590–594PubMedCrossRefGoogle Scholar
  31. Magis D, Schoenen J (2008) Neurostimulation in chronic cluster headache. Curr Pain Headache Rep 12:145–153PubMedCrossRefGoogle Scholar
  32. Magis D, Allena M, Bolla M, De Pasqua V, Remacle JM, Schoenen J (2007) Occipital nerve stimulation for drug-resistant chronic cluster headache: a prospective pilot study. Lancet Neurol 6:314–321PubMedCrossRefGoogle Scholar
  33. Manzoni GC, Micieli G, Granella F, Tassorelli C, Zanferrari C, Cacallini (1991) A cluster headache – course over ten years in 189 patients. Cephalalgia 11:169–174PubMedCrossRefGoogle Scholar
  34. Matharu MS, Goadsby PJ (2002) Persistence of attacks of cluster headache after trigeminal nerve root section. Brain 125:976–984PubMedCrossRefGoogle Scholar
  35. Matharu M, Goadsby PJ (2008) Trigeminal autonomic cephalalgias: diagnosis and management. In: Silberstein SD, Lipton RB, Dodick DW (eds) Wolff’s headache. Oxford University Press, Oxford, pp 379–430Google Scholar
  36. Mathew NT, Hurt W (1988) Percutaneous radiofrequency trigeminal gangliorhizolysis in intractable cluster headache. Headache 28:328–331PubMedCrossRefGoogle Scholar
  37. Mauskop A (2005) Vagus nerve stimulation relieves chronic refractory migraine and cluster headaches. Cephalalgia 25:82–86PubMedCrossRefGoogle Scholar
  38. May A (2005) Cluster headache: pathogenesis, diagnosis, and management. Lancet 366:843–855PubMedCrossRefGoogle Scholar
  39. May A (2008) Hypothalamic deep-brain stimulation: target and potential mechanism for the treatment of cluster headache. Cephalalgia 28:799–803PubMedCrossRefGoogle Scholar
  40. May A, Bahra A, Buchel C, Frackowiak RS, Goadsby PJ (1998) Hypothalamic activation in cluster headache attacks. Lancet 352:275–278PubMedCrossRefGoogle Scholar
  41. May A, Leone M, Afra J, Linde M, Sandor PS, Evers S (2006) EFNS guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalalgias. Eur J Neurol 3:1066–1077CrossRefGoogle Scholar
  42. McClelland S III, Barnett GH, Neyman G, Suh JH (2007) Repeat trigeminal nerve radiosurgery for refractory cluster headache fails to provide long-term pain relief. Headache 47:298–300PubMedCrossRefGoogle Scholar
  43. Meyer JS, Binns PM, Ericsson AD, Vulpe M (1970) Sphenopalatine gangionectomy for cluster headache. Arch Otolaryngol 92:475–484PubMedGoogle Scholar
  44. Morgenlander JC, Wilkins RH (1990) Surgical treatment of cluster headache. J Neurosurg 72:866–871PubMedCrossRefGoogle Scholar
  45. Narouze SN, Kapural L (2007) Supraorbital nerve electric stimulation for the treatment of intractable chronic cluster headache: a case report. Headache 47:1100–1102PubMedCrossRefGoogle Scholar
  46. Narouze S, Kapural L, Casanova J, Mekhail N (2009) Sphenopalatine ganglion radiofrequency ablation for the management of chronic cluster headache. Headache 49:571–577PubMedCrossRefGoogle Scholar
  47. Nilsson Remahl AI, Laudon Meyer E, Cordonnier C, Goadsby PJ (2003) Placebo response in cluster headache trials: a review. Cephalalgia 23:504–510PubMedCrossRefGoogle Scholar
  48. Onofrio BM, Campbell JK (1986) Surgical treatment of chronic cluster headache. Mayo Clin Proc 61:537–544PubMedGoogle Scholar
  49. Owen SL, Green AL, Davies P, Stein JF, Aziz TZ, Behrens T, Voets NL, Johansen-Berg H (2007) Connectivity of an effective hypothalamic surgical target for cluster headache. J Clin Neurosci 14:955–960PubMedCrossRefGoogle Scholar
  50. Paemeleire K, Bartsch T (2010) Occipital nerve stimulation for headache disorders. Neurotherapeutics 7(2):213–219PubMedCrossRefGoogle Scholar
  51. Peres MF, Stiles MA, Siow HC, Rozen TD, Young WB, Silberstein SD (2002) Greater occipital nerve blockade for cluster headache. Cephalalgia 22:520–522PubMedCrossRefGoogle Scholar
  52. Pieper DR, Dickerson J, Hassenbusch SJ (2000) Percutaneous retrogasserian glycerol rhizolysis for treatment of chronic intractable cluster headaches: long-term results. Neurosurgery 46:363–368PubMedCrossRefGoogle Scholar
  53. Pinsker MO, Bartsch T, Falk D, Volkmann J, Herzog J, Steigerwald F, Diener HC, Deuschl G, Mehdorn M (2008) Failure of deep brain stimulation of the posterior inferior hypothalamus in chronic cluster headache – report of two cases and review of the literature. Zentralbl Neurochir 69:76–79PubMedCrossRefGoogle Scholar
  54. Piovesan EJ, Kowacs PA, Tatsui CE, Lange MC, Ribas LC, Wenneck LC (2001) Referred pain after painful stimulation of the greater occipital nerve in humans: evidence of convergence of cervical afferences on trigeminal nuclei. Cephalalgia 21:107–109PubMedCrossRefGoogle Scholar
  55. Rothrock J (2006) Cluster: a potentially lethal headache disorder. Headache 46:327PubMedCrossRefGoogle Scholar
  56. Rowed DW (1990) Chronic cluster headache managed by nervus intermedius section. Headache 30:401–406PubMedCrossRefGoogle Scholar
  57. Sanders M, Zuurmond WW (1997) Efficacy of sphenopalatine ganglion blockade in 66 patients suffering from cluster headache: a 12- to 70-month follow-up evaluation. J Neurosurg 87:876–880PubMedCrossRefGoogle Scholar
  58. Schoenen J, Di Clemente L, Vandenheede M, Fumal A, De Pasqua V, Mouchamps M, Remacle JM, de Noordhout AM (2005) Hypothalamic stimulation in chronic cluster headache: a pilot study of efficacy and mode of action. Brain 128:940–947PubMedCrossRefGoogle Scholar
  59. Schwedt TJ, Dodick DW, Hentz J, Trentman TL, Zimmerman RS (2007) Occipital nerve stimulation for chronic headache – long-term safety and efficacy. Cephalalgia 27:153–157PubMedCrossRefGoogle Scholar
  60. Sillay KA, Sani S, Starr PA (2009) Deep brain stimulation for medically intractable cluster headache. Neurobiol Dis 38(3):361–368PubMedCrossRefGoogle Scholar
  61. Solomon S, Apfelbaum RI (1986) Surgical decompression of the facial nerve in the treatment of chronic cluster headache. Arch Neurol 43:479–482PubMedGoogle Scholar
  62. Sprenger T, Boecker H, Tolle TR, Bussone G, May A, Leone M (2004) Specific hypothalamic activation during a spontaneous cluster headache attack. Neurology 62:516–517PubMedGoogle Scholar
  63. Sweet WH (1988) Surgical treatment of chronic cluster headache. Headache 28:669–670PubMedCrossRefGoogle Scholar
  64. Taha JM, Tew JM Jr (1995) Long-term results of radiofrequency rhizotomy in the treatment of cluster headache. Headache 35:193–196PubMedCrossRefGoogle Scholar
  65. Trentman TL, Rosenfeld DM, Vargas BB, Schwedt TJ, Zimmerman RS, Dodick DW (2009) Greater occipital nerve stimulation via the Bion microstimulator: implantation technique and stimulation parameters. Clinical trial: NCT00205894. Pain Physician 12:621–628PubMedGoogle Scholar
  66. van Kleef M, Lataster A, Narouze S, Mekhail N, Geurts JW, van Zundert J (2009) Evidence-based interventional pain medicine according to clinical diagnoses. 2. Cluster headache. Pain Pract 9:435–442PubMedCrossRefGoogle Scholar
  67. Weiner R, Reed K (1999) Peripheral neurostimulation for control of intractable occipital neuralgia. Neuromodulation 2:217–222CrossRefGoogle Scholar
  68. Wolter T, Kaube H, Mohadjer M (2008) High cervical epidural neurostimulation for cluster headache: case report and review of the literature. Cephalalgia 28:1091–1094PubMedCrossRefGoogle Scholar

Copyright information

© Lifting The Burden 2011

Authors and Affiliations

  1. 1.Department of NeurologyGhent University HospitalGhentBelgium
  2. 2.Department of Medical and Molecular Sciences, School of Health SciencesSchool of Health Sciences, Sapienza University of RomeRomeItaly

Personalised recommendations