J Neurosurg 72:866-871, 1990
Surgical treatment of cluster headache JOEL C. MORGENLANDER, M.D., AND ROBERT H . WILKINS, M . D .
Divisions of Neurology and Neurosurgery, Duke University Medical Center, Durham, North Carolina v- 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. 9 cluster headache 9 greater superficial petrosal nerve nervus intermedius 9 trigeminal nerve
KEY WORDS
C
LUSTER headache (also called migrainous neuralgia, Horton's syndrome, and histamine cephalalgia among other terms) is a typical form of cranial pain syndrome that can occur episodically or chronically.7.11,13-16.28.38 It is predominately a disorder of adult men, with reported male to female ratios ranging between 4.5:1 and 6.7:1. The pain is typically unilateral and retro-orbital, oculotemporal or oculofrontal in location, excruciating in severity, and boring and nonthrobbing in character. In association with the pain, the patient m a y exhibit ipsilateral signs o f autonomic dysfunction such as rhinorrhea or nasal congestion, increased lacrimation, ptosis, and miosis. Methysergide, corticosteroid preparations, and ergotamine tartrate are a m o n g the medications given prophylactically to prevent episodic cluster headache. Lithium carbonate, calcium channel blockers such as verapamil, and indomethacin are some o f the drugs that are administered to prevent chronic cluster headache. Histamine desensitization is also used prophylactically with some success. Oxygen inhalation, ergotamine tartrate administration, and local anesthesia of the sphenopalatine fossa region with cocaine or lido866
-
caine are employed to ameliorate an attack of migrainous neuralgia once it has begun. However, the headaches of some patients are or become refractory to such medical management. This has led to the development of surgical strategies designed to interrupt the transmission of nociceptive and autonomic impulses. Partial destruction of the trigeminal nerve and surgical division o f the nervus intermedius are two o f the surgical approaches that have been taken when treating cluster headache. Because some degree of success has been reported for these operations, one of the authors (R.H.W.) performed 15 such procedures on 13 patients with intractable cluster headache. S u m m a r y of C a s e s
Patient Population Data were obtained from chart review and patient interviews. The patient population consisted o f 12 men and one w o m a n (Table 1). All patients had classic symptoms of cluster headache, including unilateral orbital, frontotemporal, or maxillary pain with associated autonomic symptoms. Seven patients were in the epi-
J. Neurosurg. / Volume 72~June, 1990
Surgical treatment of cluster headache TABLE 1 Results in 13 patients treated surgically for cluster headache (CH)* Case Sex, Age Age at No. at Onset Treat(yrs) ment (yrs)
Medications of Benefit#
Symptoms
1
M, 29
36
rt orbit, chronic CH weekly + autonomic sx rt temple, episodic CH 3-4/day + autonomic sx It maxilla, episodic CH several/day + autonomic sx
2
M, 17
23
3
M, 27
32
4
M, 16
24
rt orbit, chronic CH several/day + autonomic sx
5
M, 16
30
6
F, 29
46
7
M, 54
67
It orbit, chronic CH 4-5/mo + autonomic sx, transient hemiparesis with a few headaches It orbit, chronic CH l-9/day + autonomic sx rt orbit, chronic CH 1-3/day + autonomic sx, trauma to forehead
8
M, 35
41
9
M, 26
39
10
M, 16
29
11
M, 31
43
12
M, 33
35
13
M, 32
50
It orbit, chronic CH 4-5/day + autonomic sx, V neuralgia It orbit, episodic CH 2/day + autonomic sx, trauma to face It orbit, episodic CH 3/day + autonomic sx
Return of Autonomic Symptoms
Postop Follow-Up (Mos)
Operation
Results
PSV, SNI
rec, 5 wks
yes
3
PSV, SNI
rec, 2 mos
yes
2
PSV
rec, < l wk
less severe
l0
PSV, SNI
rec, < 1 mo
yes
12
PSV, SNI
rec, > 2 wks
less severe
lithium carbonate (14) lithium carbonate (9)
SNI
rec,> 2 yrs
yes
MVD, SNI PSV, SNI
rec with CH, now none yes
120
none (7)
rec, > 1 wk: less frequent; CHfree for 8 yrs rec, at 2 days
yes no less severe
1 25 20
yes
48
corticosteroid prep (16) corticosteroid prep (ll) hydrocodone bitartrate + acetaminophen (16) lithium carbonate, corticosteroid prep (ll) none (17)
verapamil, corticosteroid prep (2) lithium carbonate (11)
I:PSV, SNI l : r e c < 1 mo 2: PSV, SNI 2: no CH PSV, SNI initial relief; rare mild headache > 1 mo; facial trauma at 18 mos, pain rec It orbit/frontal/occipital, episodic lithium carbonate, PSV, SN1 rec, < 2 wks CH several/day + autonomic sx corticosteroid prep, oxygen ( 1 l) rt orbit, episodic CH several/day + lithium carbonate, l: PSV, SNI 1: rec > 5 mos autonomic sx oxygen (11) 2: PSV, SNI 2: rec at 5 days rt maxilla, episodic CH 3/day + au- lithium carbonate, MVD, SNI rec > 1 yr, retonomic sx corticosteroid prep mission, rec (12) years later; CHfree for 3 yrs
yes yes less severe, now none
3 5l
30
7 12 135
* Abbreviations: SNI = sectioning of the nervus intermedius; MVD = microvascular decompression of the trigeminal nerve; PSV = partial sectioning of the main sensory root of the trigeminal nerve; rec = recurrence; sx = symptoms; V = trigeminal nerve. t Total number of medications tried given in parentheses.
s o d i c p h a s e a n d six p a t i e n t s w e r e i n t h e c h r o n i c p h a s e o f h e a d a c h e . O n e p a t i e n t ( C a s e 8) h a d c o n c u r r e n t trig e m i n a l n e u r a l g i a (a c l u s t e r - t i c s y n d r o m e 6 . l.0. .12 31 36 ). T h e p a t i e n t s ' age a t o n s e t o f s y m p t o m s r a n g e d f r o m 16 t o 5 4 y e a r s ( m e a n 2 8 years). T h e d u r a t i o n o f s y m p t o m s b e f o r e o p e r a t i o n r a n g e d f r o m 1 t o 13 y e a r s ( m e a n 7 years). The patients had been treated with a wide range of medical therapies, an average of I 1 therapies per patient. Most frequently used were ergot preparations, carbamazepine, beta receptor blockers, calcium channel blockers, lithium carbonate, corticosteroid preparations, oxygen, methysergide maleate, antidepressant drugs, and narcotic agents. The best results had been o b t a i n e d w i t h c o r t i c o s t e r o i d p r e p a r a t i o n s ( i n six o f n i n e
J. Neurosurg. / Volume 72~June, 1990
p a t i e n t s s o t r e a t e d ) , l i t h i u m c a r b o n a t e ( i n s e v e n o f 12 patients), and oxygen (in two of four patients). All patients had become refractory to medical treatment before operative treatment was undertaken. Bet w e e n 1 9 7 6 a n d 1987, 15 r e t r o m a s t o i d c r a n i e c t o m i e s w e r e p e r f o r m e d o n t h e s e 13 p a t i e n t s . N i n e p a t i e n t s underwent partial sectioning of the main sensory root of the trigeminal nerve (the caudal one-half to twot h i r d s ) a n d s e c t i o n i n g o f as m a n y n e r v e r o o t l e t s o f t h e i p s i l a t e r a l n e r v u s i n t e r m e d i u s as c o u l d b e s e e n t h r o u g h the operative microscope. One patient had only partial sectioning of the main sensory root; one patient had only sectioning of the nervus intermedius; and two p a t i e n t s ( t h e first t w o i n t h e series) h a d n e r v u s i n t e r medius sectioning plus microvascular decompression 867
J. C. Morgenlander and R. H. Wilkins o f the ipsilateral trigeminal nerve. The postoperative follow-up period ranged from 1 to 135 months (average 37 months). Results o f Surgery Partial sectioning of the main sensory root of the trigeminal nerve plus sectioning of the nervus intermedius was performed 1 1 times in nine patients (Table 1). Two patients (Cases 8 and 1 1) noted the return of headache within 2 weeks after the first operation; the remainder experienced relief for 2 weeks to 5 months postoperatively. A second similar procedure in two of these patients resulted in relief in one for the 2-year follow-up period, but the other patient experienced the return o f pain on the 5th postoperative day. All patients in this group had return of their autonomic symptoms with recurrence of their headaches. The sole patient who had headache relief through the 2-year follow-up period also remained free of autonomic symptoms. The two patients who underwent either partial sectioning o f the main sensory root or nervus intermedius sectioning experienced recurrence o f headache and autonomic symptoms. This occurred within one week in Case 3 (partial main sensory root sectioning alone), but did not occur until after 2 years in Case 6 (nervus intermedius sectioning alone). Although the two patients (Cases 7 and 13) who had microvascular decompression o f the trigeminal nerve plus nervus intermedius sectioning noted recurrence of headache and autonomic symptoms after 1 week and after 1 year, respectively, each had a subsequent remission. At the time o f the last follow-up assessment 120 and 135 months postoperatively, these two patients had been pain-flee and without related autonomic dysfunction 8 and 3 years, respectively. Overall, when symptoms returned postoperatively they were often less severe initially than the preoperative symptoms had been. But with time they tended to return to their preoperative level. All patients who had partial main sensory root sectioning had some degree of trigeminal sensory loss postoperatively; however, dense hypalgesia in the upper face was not produced. Two patients had cerebrospinal fluid (CSF) rhinorrhea postoperatively which was treated successfully by a short course o f external lumbar CSF drainage. The one patient who was treated by nervus intermedius sectioning alone had ipsilateral postoperative deafness. Discussion
The nervus intermedius ordinarily consists of a series of filaments that lie between, and communicate with, the facial and vestibular nerves. 25,27 The greater superficial petrosal nerve leaves the nervus intermedius within the temporal bone at the geniculate ganglion and enters the cranial cavity through the hiatus of the facial canal. It runs forward on the floor of the middle fossa, passing under the gasserian ganglion and lateral 868
to the internal carotid artery. It is joined by the deep petrosal nerve from the sympathetic plexus around the internal carotid artery to form the vidian nerve, which passes forward through the pterygoid canal to the sphenopalatine ganglion. Preganglionic parasympathetic fibers from the lacrimal nucleus travel through the nervus intermedius and greater superficial petrosal nerve to reach the sphenopalatine ganglion. 22 Postganglionic fibers mediate secretory impulses to the lacrimal gland via the zygomatic nerve and its anastomosis with the lacrimal nerve. Other postganglionic fibers carry secretory and vasodilatory impulses to the mucous glands and vessels of the nasal epithelium. 22,29 Additional preganglionic parasympathetic fibers, leaving the medulla with the fibers mentioned above, pass through the nervus intermedius but leave the greater superficial petrosal nerve to join the internal carotid artery plexus. Within this plexus are neurons that give rise to vasodilatory postganglionic fibers that pass to the cerebral arteries. 4'22'29 The nervus intermedius also contains afferent fibers, 4,29,34,37and there is some evidence that nociceptive impulses from deep facial structures may pass to the brain through the greater superficial petrosal nerve and nervus intermedius. 32 According to Solomon, 29 "many neuroanatomists believe that deep sensation from the face is carried by neurons whose cell bodies are in the geniculate ganglion . . . . Afferent pathways from the internal carotid artery and from the dura are carried via the [greater superficial petrosal nerve] to the geniculate ganglion . . . . The [nervus intermedius] carries all of the afferent impulses from the geniculate ganglion to the brain stem, where some fibers synapse in the nucleus of the tractus solitarius and somatic sensory pathways end in the nucleus of the descending tract of the trigeminal nerve." Beginning in 1940, Gardner and his associates 9 treated cluster headache by resecting the greater superficial petrosal nerve in an attempt to interrupt abnormal parasympathetic discharges responsible for dilation of the cerebral, meningeal, and nasal mucosal blood vessels, the pain resulting from which was being transmitted over the trigeminal nerve. However, they also thought it possible that the operation interrupted painful impulses coming over the geniculate somatic afferent fibers from the dura mater, internal carotid artery, and vidian nerve. By the time of their report in 1947, Gardner, et al., had performed this procedure on 13 patients. The results were excellent in 25% and fair to good in 50%; 25% of the patients experienced no relief. Other surgeons subsequently performed this same procedure for cluster headache. L5'23'24'33-35'38Beginning in 1948, White and Sweet 38 treated periodic migrainous neuralgia by greater superficial petrosal nerve sectioning, either alone or in association with sectioning of the lesser superficial petrosal nerve, the external nerve, or the middle and accessory middle meningeal arteries. The results were quite varied. One o f their nine patients noted no improvement; all of the others experienced J. Neurosurg. / Volume 72/June, 1990
Surgical treatment of cluster headache recurrence of symptoms, but there were often significant periods of relief. In 1953, Trowbridge, e t a/., 34 reported four patients with cluster headache treated by dividing the greater superficial petrosal nerve. One patient had complete relief and two had marked improvement, but the longest follow-up period was only 8 months. Aubin, et al., 2 in 1953 and Ponti and Valerio 23 in 1960 reported surgical sectioning of the greater superficial petrosal nerve as treatment of post-otitic cephalalgia. Ponti and Valerio described seven patients who received this type of treatment for what were probably cluster headaches. In 1970, Stowel133 reported 36 patients so treated for cluster headache over a 20-year period. Of these, 32 had complete relief, but 15 subsequently experienced recurrence of headache (eight by 1 year, three more by 2 years, and four more by 3 years). Alvarez Garijo, et al., 1 published in 1975 an account of nine patients whom they had treated for cluster headache by greater superficial petrosal neurectomy plus division of the superficial temporal and middle meningeal arteries. The results were excellent in four cases, fair to good in two, and a failure in three. In 1977, Denecke 5 presented three patients who had had cluster headache for a period of 10 to 20 years and who were relieved by resection of the greater superficial petrosal nerve; however, the follow-up period was less than 1 year in all three cases. Among the patients reported in 1983 by Watson, et al., 35 four were treated for chronic cluster headache by greater superficial petrosal neurectomy. One of the patients had no improvement, one experienced pain relief for 12 months before recurrence, and two were still pain-free at 4 and 5 years after operation, respectively. From the foregoing, it seems that the main drawback to the treatment of cluster headache by greater superficial petrosal neurectomy is the incidence of headache recurrence, which in some cases may result from nerve regeneration. Because of the relatively high failure and recurrence rates associated with this type of surgical treatment, other approaches have been tried. Two o f these approaches involve interruption of the same neural system, either peripheral to the greater superficial petrosal nerve (the sphenopalatine ganglion) or central to it (the nervus intermedius). In 1962, Brown 3 reported that the injection of alcohol into the sphenopalatine ganglion of 28 patients with cluster headache did not reliably stop the headache. Meyer, et al., 19 in 1970, presented 13 patients with intractable cluster headache who were treated by sphenopalatine ganglionectomy; seven obtained little relief, four were improved, and only two had complete relief (for more than 1 year). Beginning in 1952, Sachs 27 divided the nervus intermedius for intractable face and head pain, and in 1968 reported four patients who had been treated successfully in this way; at least one of these patients had cluster headache. By 1969, he had performed this procedure on two more patients with cluster headache. 26 As of that date, all six patients had been relieved of pain. J. Neurosurg. / Volume 7 2 / J u n e , 1990
A variation on the surgical approach to the nervus intermedius was tried by Apfelbaum and his associates. 1o,29-3tIn 1986, they reported their experience with decompressing the facial nerve at the brain stem in five patients with chronic cluster headache. 3~ Two o f these patients also had decompression of the trigeminal nerve at its entry zone into the pons; one of them experienced improvement in the severity of the cluster headache, but the other did not. O f the remaining three patients, two noted improvement. However, none o f the five patients achieved complete relief. Kunkel and Dohn 17 reported in 1974 that since 1970 they had treated 12 patients with chronic migrainous neuralgia by sectioning the greater superficial petrosal nerve and neurolysis of the sensory root of the trigeminal nerve. Three of the patients continued to have similar headaches, but without parasympathetic manifestations. O f the nine patients with immediate relief, three later experienced recurrence o f headache, again without parasympathetic dysfunction. The remaining six patients (50%) were free of headache at their last follow-up examination. Four of the 12 patients experienced postoperative facial weakness that resolved completely. Procedures designed to interrupt pain transmission in the trigeminal system have been employed for some 80 years to treat cluster headache. 8'l~ White and Sweet 38 summarized the various approaches taken prior to 1969 and this information was updated by Maxwell in 1982. is In 1936, Harris ~ noted that "since 1909 I have treated a considerable n u m b e r of migrainous neuralgias with alcohol injection, of either the supra-orbital or the infraorbital nerves, being guided by the principal location of the pain. O f late years I have, instead, in several cases injected the inner portion of the Gasserian ganglion so as to obtain a permanent anaesthesia and a lasting cure." In 1970, Stowel133 stated that 16 o f his 21 patients were relieved by a block or avulsion o f the supraorbital nerve and that all of five patients obtained relief after sectioning the first trigeminal division. In more recent years, the trigeminal sensory root has been divided surgically or injured by a percutaneous radiofrequency trigeminal gangliorhizolysis. Onofrio and Campbell 2~ noted excellent pain relief in 54% of 26 patients so treated and fair to good relief in another 15%. These authors stressed "the absolute need to achieve either corneal anesthesia or dense analgesia to accomplish relief of cluster headaches . . . . " O ' B r i e n and MacCabe 2~ reached a similar conclusion based on their experience with three patients. Watson, et al., 35 performed radiofrequency lesioning on 27 occasions in 13 patients; only 12 of these 27 procedures provided significant pain relief for at least 5 months. In another eight patients, they performed nine intracranial trigeminal sensory root sections; good results were obtained following five o f the nine operations, lasting a median of 44 months (range 24 months to 8 years). MaxwelP 8 achieved better results than these with percutaneous radiofrequency trigeminal gangliorhizo869
J. C. Morgenlander and R. H. Wilkins lysis, probably because of more refined patient selection for the procedure. In addition to the usual selection criteria based on an accurate diagnosis and the failure o f adequate medical therapy, Maxwell also tested the patient's response to a lidocaine injection of the ipsilateral gasserian ganglion. O f 23 patients so tested, eight experienced immediate but transient relief. These eight patients were then treated by gangliorhizolysis and all received prolonged relief. With this background information about the interruption o f aspects o f the nervus intermedius and trigeminal systems for the treatment o f cluster headache, we elected to treat the patients in the present series by sectioning the nervus intermedius, either alone (one patient) or in combination with partial sectioning of the trigeminal sensory root (nine patients) or decompression of the trigeminal sensory root (two patients). One additional patient was treated by partial trigeminal sensory root sectioning alone. The initial results were gratifying, but the recurrence rate has been disappointing. It is interesting that the two patients who were treated by microvascular decompression o f the trigeminal nerve and sectioning of the nervus intermedius had a distinctly better outcome than the other 11 patients. If this represents a true difference rather than a chance occurrence, the reason is not obvious to us. At least two factors m a y explain the recurrence of headache and autonomic symptoms in our patients. First, the caudal portion of the main trigeminal sensory root was cut. Perhaps a better result would follow sectioning of the cephalad portion, which should contain more of the sensory fibers from the upper face. Second, because of the variable and extensive branching o f the nervus intermedius, it is difficult to identify and section all of its components. Perhaps sectioning of the greater superficial petrosal nerve would give a more complete effect. Finally, because o f the relatively short time to recurrence of symptoms in most of our patients, it does not seem likely that such recurrence resulted from regeneration of the nervus intermedius. Addendum
The interested reader should also consult Gybels JM, Sweet WH: Neurosurgical Treatment of Persistent Pain."
Physiological and Pathological Mechanisms of Human Pain. Basel: Karger, 1989, pp 70-87.
References
1. Alvarez Garijo JA, Bordes Vails C, Vila Mengual M: Tratamiento quirfirgico de la cefalea facial vegetativa. Rev Esp Oto Neuro Oftalmol 33:7-11, 1975 2. Aubin A, Clerc P, Nahon R: R6sultants obtenus dans les c6phal6es post-otitiques par la section du grand neff 196treux superficiel (27 observations). Sere Hop Paris 29: 1687-1692, 1953 3. Brown LA: Mythical sphenopalatine ganglion neuralgia. South Med J 55:670-672, 1962 870
4. Chorobski J, Penfield W: Cerebral vasodilator nerves and their pathway from the medulla oblongata. With observations on the pial and intracerebral vascular plexus. Arch Neurol Psychiatry 28:1257-1289, 1932 5. Denecke H J: Zur Chirurgie des N. petros major bei langj~ihrigem Gesichts- und Kopfschmerz. HNO 25: 48-50, 1977 6. Diamond S, Freitag FG, Cohen JS: Cluster headache with trigeminal neuralgia. An uncommon association that may be more than coincidental. Postgrad Med 75:165-172, 1984 7. Diamond S, Freitag FG, Prager J, et al: Treatment of intractable cluster. Headache 26:42-46, 1986 8. Dott NM: Facial pain. Proe R Soc Med 44:1034-1037, 1951 9. Gardner WJ, Stowell A, Dutlinger R: Resection of the greater superficial petrosal nerve in the treatment of unilateral headache. J Neurosurg 4:105-114, 1947 10. Green MW, Apfelbaum RI: Cluster-tic syndrome. Headache 18:112, 1978 (Abstract) 11. Harris W: Ciliary (migrainous) neuralgia and its treatment. Br Med J 1:457-460, 1936 12. Klimek A: Cluster-tic syndrome. Cephalalgia 7: 161-162, 1987 13. Krabbe AA: Cluster headache: a review. Acta Neurol Scand 74:1-9, 1988 14. Kudrow L: Cluster Headache: Mechanisms and Managemeat. Oxford: Oxford University Press, 1980 15. Kudrow L: Cluster headache: new concepts. Neurol Clin 1:369-383, 1983 16. Kunkel RS: Classification of cluster headache: clinical features of episodic duster headache, in Mathew NT (ed): Cluster Headache. New York: SP Medical & Scientific, 1984, pp 15-20 17. Kunkel RS, Dohn DF: Surgical treatment of chronic migrainous neuralgia. Cleve Clin Q 41:189-192, 1974 18. Maxwell RE: Surgical control of chronic migrainous neuralgia by trigeminal ganglio-rhizolysis. J Neurosarg 57: 459-466, 1982 19. Meyer JS, Binns PM, Ericsson AD, et at: Sphenopalatine ganglionectomy for cluster headache. Arch Otolaryngol 92:475-484, 1970 20. O'Brien MD, MacCabe J J: Trigeminal nerve section for unremitting migrainous neuralgia, in Rose FC, Zilkha KJ (eds): Progress in Migraine Research 1. London: Pitman, 1981, pp 185-187 21. Onofrio BM, Campbell JK: Surgical treatment of chronic cluster headache. Mayo Clin Proc 61:537-544, 1986 22. Peele TL: The Neuroanatomic Basis for Clinical Neurology, ed 3. New York: McGraw-Hill, 1977, pp 210-213 23. Ponti L, Valerio M: [Results of resection of the greater superficial petrosal nerve in several cases of post-otitis headache and of cranio-facial neuralgia.] Clin Otorinolaringol 12:409-418, 1960 (It) 24. Ray BS: The surgical treatment of headache and atypical facial neuralgia. J Neurosurg 11:596-606, 1954 25. Rhoton AL Jr, Kobayashi S, Hollinshead WH: Nervus intermedius. J Neurosurg 29:609-618, 1968 26. Sachs E Jr: Further observations on surgery of the nervus intermedius. Headache 9:159-161, 1969 27. Sachs E Jr: The role of the nervus intermedius in facial neuralgia. Report of four cases with observations on the pathways for taste, lacrimation, and pain in the face. J Neurosurg 28:54-60, 1968 28. Saper JR: Drug treatment of headache: changing concepts and treatment strategies. Semin Neurol 7:178-191, 1987 29. Solomon S: Cluster headache and the nervus intermedius. Headache 26:3-8, 1986
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Surgical treatment of cluster headache 30. Solomon S, Apfelbaum RI: Surgical decompression of the facial nerve in the treatment of chronic cluster headache. Arch Neurol 43:479-482, 1986 31. Solomon S, Apfelbaum RI, Guglielmo KM: The clustertic syndrome and its surgical therapy, Cephalalgia 583-89, 1985 32. Stookey B, Ransohoff J: Trigeminal Neuralgia: Its History and Treatment. Springfield, Ill: Charles C Thomas, 1959, pp 114-120 33. Stowell A: Physiologic mechanisms and treatment of histaminic or petrosal neuralgia. Headache 9:187-194, 1970 34. Trowbridge WV, French JD, Bayless AE: Greater superficial petrosal neurectomy for orbitofacial pain: preliminary report. Neurology 3:707-713, 1953 35. Watson CP, Morley TP, Richardson JC, et al: The surgical
J. Neurosurg. / Volume 72/June, 1990
treatment of chronic cluster headache. Headache 23: 289-295, 1983 36. Watson P, Evans R: Cluster-tic syndrome. Headache 25: 123-126, 1985 37. Wegner W: Nervus intermedius (Hunt's) neuralgia, in Vinken PJ, Bruyn G W (eds): Handbook of Clinical Neurology. Vol 5: Headaches and Cranial Neuralgias. Amsterdam: North-Holland, 1968, pp 337-344 38. White JC, Sweet WH: Pain and the Neurosurgeon: A Forty-Yeur Experience. Springfield, I11: Charles C Thomas, 1969, pp 257-265,345-372, 622-627 Manuscript received October 3, 1989. Address reprint requests to: Robert H. Wilkins, M.D., P.O. Box 3807, Duke University Medical Center, Durham, North Carolina 27710.
871
Surgical treatment of cluster headache JOEL C. MORGENLANDER, M.D., AND ROBERT H . WILKINS, M . D .
Divisions of Neurology and Neurosurgery, Duke University Medical Center, Durham, North Carolina v- 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. 9 cluster headache 9 greater superficial petrosal nerve nervus intermedius 9 trigeminal nerve
KEY WORDS
C
LUSTER headache (also called migrainous neuralgia, Horton's syndrome, and histamine cephalalgia among other terms) is a typical form of cranial pain syndrome that can occur episodically or chronically.7.11,13-16.28.38 It is predominately a disorder of adult men, with reported male to female ratios ranging between 4.5:1 and 6.7:1. The pain is typically unilateral and retro-orbital, oculotemporal or oculofrontal in location, excruciating in severity, and boring and nonthrobbing in character. In association with the pain, the patient m a y exhibit ipsilateral signs o f autonomic dysfunction such as rhinorrhea or nasal congestion, increased lacrimation, ptosis, and miosis. Methysergide, corticosteroid preparations, and ergotamine tartrate are a m o n g the medications given prophylactically to prevent episodic cluster headache. Lithium carbonate, calcium channel blockers such as verapamil, and indomethacin are some o f the drugs that are administered to prevent chronic cluster headache. Histamine desensitization is also used prophylactically with some success. Oxygen inhalation, ergotamine tartrate administration, and local anesthesia of the sphenopalatine fossa region with cocaine or lido866
-
caine are employed to ameliorate an attack of migrainous neuralgia once it has begun. However, the headaches of some patients are or become refractory to such medical management. This has led to the development of surgical strategies designed to interrupt the transmission of nociceptive and autonomic impulses. Partial destruction of the trigeminal nerve and surgical division o f the nervus intermedius are two o f the surgical approaches that have been taken when treating cluster headache. Because some degree of success has been reported for these operations, one of the authors (R.H.W.) performed 15 such procedures on 13 patients with intractable cluster headache. S u m m a r y of C a s e s
Patient Population Data were obtained from chart review and patient interviews. The patient population consisted o f 12 men and one w o m a n (Table 1). All patients had classic symptoms of cluster headache, including unilateral orbital, frontotemporal, or maxillary pain with associated autonomic symptoms. Seven patients were in the epi-
J. Neurosurg. / Volume 72~June, 1990
Surgical treatment of cluster headache TABLE 1 Results in 13 patients treated surgically for cluster headache (CH)* Case Sex, Age Age at No. at Onset Treat(yrs) ment (yrs)
Medications of Benefit#
Symptoms
1
M, 29
36
rt orbit, chronic CH weekly + autonomic sx rt temple, episodic CH 3-4/day + autonomic sx It maxilla, episodic CH several/day + autonomic sx
2
M, 17
23
3
M, 27
32
4
M, 16
24
rt orbit, chronic CH several/day + autonomic sx
5
M, 16
30
6
F, 29
46
7
M, 54
67
It orbit, chronic CH 4-5/mo + autonomic sx, transient hemiparesis with a few headaches It orbit, chronic CH l-9/day + autonomic sx rt orbit, chronic CH 1-3/day + autonomic sx, trauma to forehead
8
M, 35
41
9
M, 26
39
10
M, 16
29
11
M, 31
43
12
M, 33
35
13
M, 32
50
It orbit, chronic CH 4-5/day + autonomic sx, V neuralgia It orbit, episodic CH 2/day + autonomic sx, trauma to face It orbit, episodic CH 3/day + autonomic sx
Return of Autonomic Symptoms
Postop Follow-Up (Mos)
Operation
Results
PSV, SNI
rec, 5 wks
yes
3
PSV, SNI
rec, 2 mos
yes
2
PSV
rec, < l wk
less severe
l0
PSV, SNI
rec, < 1 mo
yes
12
PSV, SNI
rec, > 2 wks
less severe
lithium carbonate (14) lithium carbonate (9)
SNI
rec,> 2 yrs
yes
MVD, SNI PSV, SNI
rec with CH, now none yes
120
none (7)
rec, > 1 wk: less frequent; CHfree for 8 yrs rec, at 2 days
yes no less severe
1 25 20
yes
48
corticosteroid prep (16) corticosteroid prep (ll) hydrocodone bitartrate + acetaminophen (16) lithium carbonate, corticosteroid prep (ll) none (17)
verapamil, corticosteroid prep (2) lithium carbonate (11)
I:PSV, SNI l : r e c < 1 mo 2: PSV, SNI 2: no CH PSV, SNI initial relief; rare mild headache > 1 mo; facial trauma at 18 mos, pain rec It orbit/frontal/occipital, episodic lithium carbonate, PSV, SN1 rec, < 2 wks CH several/day + autonomic sx corticosteroid prep, oxygen ( 1 l) rt orbit, episodic CH several/day + lithium carbonate, l: PSV, SNI 1: rec > 5 mos autonomic sx oxygen (11) 2: PSV, SNI 2: rec at 5 days rt maxilla, episodic CH 3/day + au- lithium carbonate, MVD, SNI rec > 1 yr, retonomic sx corticosteroid prep mission, rec (12) years later; CHfree for 3 yrs
yes yes less severe, now none
3 5l
30
7 12 135
* Abbreviations: SNI = sectioning of the nervus intermedius; MVD = microvascular decompression of the trigeminal nerve; PSV = partial sectioning of the main sensory root of the trigeminal nerve; rec = recurrence; sx = symptoms; V = trigeminal nerve. t Total number of medications tried given in parentheses.
s o d i c p h a s e a n d six p a t i e n t s w e r e i n t h e c h r o n i c p h a s e o f h e a d a c h e . O n e p a t i e n t ( C a s e 8) h a d c o n c u r r e n t trig e m i n a l n e u r a l g i a (a c l u s t e r - t i c s y n d r o m e 6 . l.0. .12 31 36 ). T h e p a t i e n t s ' age a t o n s e t o f s y m p t o m s r a n g e d f r o m 16 t o 5 4 y e a r s ( m e a n 2 8 years). T h e d u r a t i o n o f s y m p t o m s b e f o r e o p e r a t i o n r a n g e d f r o m 1 t o 13 y e a r s ( m e a n 7 years). The patients had been treated with a wide range of medical therapies, an average of I 1 therapies per patient. Most frequently used were ergot preparations, carbamazepine, beta receptor blockers, calcium channel blockers, lithium carbonate, corticosteroid preparations, oxygen, methysergide maleate, antidepressant drugs, and narcotic agents. The best results had been o b t a i n e d w i t h c o r t i c o s t e r o i d p r e p a r a t i o n s ( i n six o f n i n e
J. Neurosurg. / Volume 72~June, 1990
p a t i e n t s s o t r e a t e d ) , l i t h i u m c a r b o n a t e ( i n s e v e n o f 12 patients), and oxygen (in two of four patients). All patients had become refractory to medical treatment before operative treatment was undertaken. Bet w e e n 1 9 7 6 a n d 1987, 15 r e t r o m a s t o i d c r a n i e c t o m i e s w e r e p e r f o r m e d o n t h e s e 13 p a t i e n t s . N i n e p a t i e n t s underwent partial sectioning of the main sensory root of the trigeminal nerve (the caudal one-half to twot h i r d s ) a n d s e c t i o n i n g o f as m a n y n e r v e r o o t l e t s o f t h e i p s i l a t e r a l n e r v u s i n t e r m e d i u s as c o u l d b e s e e n t h r o u g h the operative microscope. One patient had only partial sectioning of the main sensory root; one patient had only sectioning of the nervus intermedius; and two p a t i e n t s ( t h e first t w o i n t h e series) h a d n e r v u s i n t e r medius sectioning plus microvascular decompression 867
J. C. Morgenlander and R. H. Wilkins o f the ipsilateral trigeminal nerve. The postoperative follow-up period ranged from 1 to 135 months (average 37 months). Results o f Surgery Partial sectioning of the main sensory root of the trigeminal nerve plus sectioning of the nervus intermedius was performed 1 1 times in nine patients (Table 1). Two patients (Cases 8 and 1 1) noted the return of headache within 2 weeks after the first operation; the remainder experienced relief for 2 weeks to 5 months postoperatively. A second similar procedure in two of these patients resulted in relief in one for the 2-year follow-up period, but the other patient experienced the return o f pain on the 5th postoperative day. All patients in this group had return of their autonomic symptoms with recurrence of their headaches. The sole patient who had headache relief through the 2-year follow-up period also remained free of autonomic symptoms. The two patients who underwent either partial sectioning o f the main sensory root or nervus intermedius sectioning experienced recurrence o f headache and autonomic symptoms. This occurred within one week in Case 3 (partial main sensory root sectioning alone), but did not occur until after 2 years in Case 6 (nervus intermedius sectioning alone). Although the two patients (Cases 7 and 13) who had microvascular decompression o f the trigeminal nerve plus nervus intermedius sectioning noted recurrence of headache and autonomic symptoms after 1 week and after 1 year, respectively, each had a subsequent remission. At the time o f the last follow-up assessment 120 and 135 months postoperatively, these two patients had been pain-flee and without related autonomic dysfunction 8 and 3 years, respectively. Overall, when symptoms returned postoperatively they were often less severe initially than the preoperative symptoms had been. But with time they tended to return to their preoperative level. All patients who had partial main sensory root sectioning had some degree of trigeminal sensory loss postoperatively; however, dense hypalgesia in the upper face was not produced. Two patients had cerebrospinal fluid (CSF) rhinorrhea postoperatively which was treated successfully by a short course o f external lumbar CSF drainage. The one patient who was treated by nervus intermedius sectioning alone had ipsilateral postoperative deafness. Discussion
The nervus intermedius ordinarily consists of a series of filaments that lie between, and communicate with, the facial and vestibular nerves. 25,27 The greater superficial petrosal nerve leaves the nervus intermedius within the temporal bone at the geniculate ganglion and enters the cranial cavity through the hiatus of the facial canal. It runs forward on the floor of the middle fossa, passing under the gasserian ganglion and lateral 868
to the internal carotid artery. It is joined by the deep petrosal nerve from the sympathetic plexus around the internal carotid artery to form the vidian nerve, which passes forward through the pterygoid canal to the sphenopalatine ganglion. Preganglionic parasympathetic fibers from the lacrimal nucleus travel through the nervus intermedius and greater superficial petrosal nerve to reach the sphenopalatine ganglion. 22 Postganglionic fibers mediate secretory impulses to the lacrimal gland via the zygomatic nerve and its anastomosis with the lacrimal nerve. Other postganglionic fibers carry secretory and vasodilatory impulses to the mucous glands and vessels of the nasal epithelium. 22,29 Additional preganglionic parasympathetic fibers, leaving the medulla with the fibers mentioned above, pass through the nervus intermedius but leave the greater superficial petrosal nerve to join the internal carotid artery plexus. Within this plexus are neurons that give rise to vasodilatory postganglionic fibers that pass to the cerebral arteries. 4'22'29 The nervus intermedius also contains afferent fibers, 4,29,34,37and there is some evidence that nociceptive impulses from deep facial structures may pass to the brain through the greater superficial petrosal nerve and nervus intermedius. 32 According to Solomon, 29 "many neuroanatomists believe that deep sensation from the face is carried by neurons whose cell bodies are in the geniculate ganglion . . . . Afferent pathways from the internal carotid artery and from the dura are carried via the [greater superficial petrosal nerve] to the geniculate ganglion . . . . The [nervus intermedius] carries all of the afferent impulses from the geniculate ganglion to the brain stem, where some fibers synapse in the nucleus of the tractus solitarius and somatic sensory pathways end in the nucleus of the descending tract of the trigeminal nerve." Beginning in 1940, Gardner and his associates 9 treated cluster headache by resecting the greater superficial petrosal nerve in an attempt to interrupt abnormal parasympathetic discharges responsible for dilation of the cerebral, meningeal, and nasal mucosal blood vessels, the pain resulting from which was being transmitted over the trigeminal nerve. However, they also thought it possible that the operation interrupted painful impulses coming over the geniculate somatic afferent fibers from the dura mater, internal carotid artery, and vidian nerve. By the time of their report in 1947, Gardner, et al., had performed this procedure on 13 patients. The results were excellent in 25% and fair to good in 50%; 25% of the patients experienced no relief. Other surgeons subsequently performed this same procedure for cluster headache. L5'23'24'33-35'38Beginning in 1948, White and Sweet 38 treated periodic migrainous neuralgia by greater superficial petrosal nerve sectioning, either alone or in association with sectioning of the lesser superficial petrosal nerve, the external nerve, or the middle and accessory middle meningeal arteries. The results were quite varied. One o f their nine patients noted no improvement; all of the others experienced J. Neurosurg. / Volume 72/June, 1990
Surgical treatment of cluster headache recurrence of symptoms, but there were often significant periods of relief. In 1953, Trowbridge, e t a/., 34 reported four patients with cluster headache treated by dividing the greater superficial petrosal nerve. One patient had complete relief and two had marked improvement, but the longest follow-up period was only 8 months. Aubin, et al., 2 in 1953 and Ponti and Valerio 23 in 1960 reported surgical sectioning of the greater superficial petrosal nerve as treatment of post-otitic cephalalgia. Ponti and Valerio described seven patients who received this type of treatment for what were probably cluster headaches. In 1970, Stowel133 reported 36 patients so treated for cluster headache over a 20-year period. Of these, 32 had complete relief, but 15 subsequently experienced recurrence of headache (eight by 1 year, three more by 2 years, and four more by 3 years). Alvarez Garijo, et al., 1 published in 1975 an account of nine patients whom they had treated for cluster headache by greater superficial petrosal neurectomy plus division of the superficial temporal and middle meningeal arteries. The results were excellent in four cases, fair to good in two, and a failure in three. In 1977, Denecke 5 presented three patients who had had cluster headache for a period of 10 to 20 years and who were relieved by resection of the greater superficial petrosal nerve; however, the follow-up period was less than 1 year in all three cases. Among the patients reported in 1983 by Watson, et al., 35 four were treated for chronic cluster headache by greater superficial petrosal neurectomy. One of the patients had no improvement, one experienced pain relief for 12 months before recurrence, and two were still pain-free at 4 and 5 years after operation, respectively. From the foregoing, it seems that the main drawback to the treatment of cluster headache by greater superficial petrosal neurectomy is the incidence of headache recurrence, which in some cases may result from nerve regeneration. Because of the relatively high failure and recurrence rates associated with this type of surgical treatment, other approaches have been tried. Two o f these approaches involve interruption of the same neural system, either peripheral to the greater superficial petrosal nerve (the sphenopalatine ganglion) or central to it (the nervus intermedius). In 1962, Brown 3 reported that the injection of alcohol into the sphenopalatine ganglion of 28 patients with cluster headache did not reliably stop the headache. Meyer, et al., 19 in 1970, presented 13 patients with intractable cluster headache who were treated by sphenopalatine ganglionectomy; seven obtained little relief, four were improved, and only two had complete relief (for more than 1 year). Beginning in 1952, Sachs 27 divided the nervus intermedius for intractable face and head pain, and in 1968 reported four patients who had been treated successfully in this way; at least one of these patients had cluster headache. By 1969, he had performed this procedure on two more patients with cluster headache. 26 As of that date, all six patients had been relieved of pain. J. Neurosurg. / Volume 7 2 / J u n e , 1990
A variation on the surgical approach to the nervus intermedius was tried by Apfelbaum and his associates. 1o,29-3tIn 1986, they reported their experience with decompressing the facial nerve at the brain stem in five patients with chronic cluster headache. 3~ Two o f these patients also had decompression of the trigeminal nerve at its entry zone into the pons; one of them experienced improvement in the severity of the cluster headache, but the other did not. O f the remaining three patients, two noted improvement. However, none o f the five patients achieved complete relief. Kunkel and Dohn 17 reported in 1974 that since 1970 they had treated 12 patients with chronic migrainous neuralgia by sectioning the greater superficial petrosal nerve and neurolysis of the sensory root of the trigeminal nerve. Three of the patients continued to have similar headaches, but without parasympathetic manifestations. O f the nine patients with immediate relief, three later experienced recurrence o f headache, again without parasympathetic dysfunction. The remaining six patients (50%) were free of headache at their last follow-up examination. Four of the 12 patients experienced postoperative facial weakness that resolved completely. Procedures designed to interrupt pain transmission in the trigeminal system have been employed for some 80 years to treat cluster headache. 8'l~ White and Sweet 38 summarized the various approaches taken prior to 1969 and this information was updated by Maxwell in 1982. is In 1936, Harris ~ noted that "since 1909 I have treated a considerable n u m b e r of migrainous neuralgias with alcohol injection, of either the supra-orbital or the infraorbital nerves, being guided by the principal location of the pain. O f late years I have, instead, in several cases injected the inner portion of the Gasserian ganglion so as to obtain a permanent anaesthesia and a lasting cure." In 1970, Stowel133 stated that 16 o f his 21 patients were relieved by a block or avulsion o f the supraorbital nerve and that all of five patients obtained relief after sectioning the first trigeminal division. In more recent years, the trigeminal sensory root has been divided surgically or injured by a percutaneous radiofrequency trigeminal gangliorhizolysis. Onofrio and Campbell 2~ noted excellent pain relief in 54% of 26 patients so treated and fair to good relief in another 15%. These authors stressed "the absolute need to achieve either corneal anesthesia or dense analgesia to accomplish relief of cluster headaches . . . . " O ' B r i e n and MacCabe 2~ reached a similar conclusion based on their experience with three patients. Watson, et al., 35 performed radiofrequency lesioning on 27 occasions in 13 patients; only 12 of these 27 procedures provided significant pain relief for at least 5 months. In another eight patients, they performed nine intracranial trigeminal sensory root sections; good results were obtained following five o f the nine operations, lasting a median of 44 months (range 24 months to 8 years). MaxwelP 8 achieved better results than these with percutaneous radiofrequency trigeminal gangliorhizo869
J. C. Morgenlander and R. H. Wilkins lysis, probably because of more refined patient selection for the procedure. In addition to the usual selection criteria based on an accurate diagnosis and the failure o f adequate medical therapy, Maxwell also tested the patient's response to a lidocaine injection of the ipsilateral gasserian ganglion. O f 23 patients so tested, eight experienced immediate but transient relief. These eight patients were then treated by gangliorhizolysis and all received prolonged relief. With this background information about the interruption o f aspects o f the nervus intermedius and trigeminal systems for the treatment o f cluster headache, we elected to treat the patients in the present series by sectioning the nervus intermedius, either alone (one patient) or in combination with partial sectioning of the trigeminal sensory root (nine patients) or decompression of the trigeminal sensory root (two patients). One additional patient was treated by partial trigeminal sensory root sectioning alone. The initial results were gratifying, but the recurrence rate has been disappointing. It is interesting that the two patients who were treated by microvascular decompression o f the trigeminal nerve and sectioning of the nervus intermedius had a distinctly better outcome than the other 11 patients. If this represents a true difference rather than a chance occurrence, the reason is not obvious to us. At least two factors m a y explain the recurrence of headache and autonomic symptoms in our patients. First, the caudal portion of the main trigeminal sensory root was cut. Perhaps a better result would follow sectioning of the cephalad portion, which should contain more of the sensory fibers from the upper face. Second, because of the variable and extensive branching o f the nervus intermedius, it is difficult to identify and section all of its components. Perhaps sectioning of the greater superficial petrosal nerve would give a more complete effect. Finally, because o f the relatively short time to recurrence of symptoms in most of our patients, it does not seem likely that such recurrence resulted from regeneration of the nervus intermedius. Addendum
The interested reader should also consult Gybels JM, Sweet WH: Neurosurgical Treatment of Persistent Pain."
Physiological and Pathological Mechanisms of Human Pain. Basel: Karger, 1989, pp 70-87.
References
1. Alvarez Garijo JA, Bordes Vails C, Vila Mengual M: Tratamiento quirfirgico de la cefalea facial vegetativa. Rev Esp Oto Neuro Oftalmol 33:7-11, 1975 2. Aubin A, Clerc P, Nahon R: R6sultants obtenus dans les c6phal6es post-otitiques par la section du grand neff 196treux superficiel (27 observations). Sere Hop Paris 29: 1687-1692, 1953 3. Brown LA: Mythical sphenopalatine ganglion neuralgia. South Med J 55:670-672, 1962 870
4. Chorobski J, Penfield W: Cerebral vasodilator nerves and their pathway from the medulla oblongata. With observations on the pial and intracerebral vascular plexus. Arch Neurol Psychiatry 28:1257-1289, 1932 5. Denecke H J: Zur Chirurgie des N. petros major bei langj~ihrigem Gesichts- und Kopfschmerz. HNO 25: 48-50, 1977 6. Diamond S, Freitag FG, Cohen JS: Cluster headache with trigeminal neuralgia. An uncommon association that may be more than coincidental. Postgrad Med 75:165-172, 1984 7. Diamond S, Freitag FG, Prager J, et al: Treatment of intractable cluster. Headache 26:42-46, 1986 8. Dott NM: Facial pain. Proe R Soc Med 44:1034-1037, 1951 9. Gardner WJ, Stowell A, Dutlinger R: Resection of the greater superficial petrosal nerve in the treatment of unilateral headache. J Neurosurg 4:105-114, 1947 10. Green MW, Apfelbaum RI: Cluster-tic syndrome. Headache 18:112, 1978 (Abstract) 11. Harris W: Ciliary (migrainous) neuralgia and its treatment. Br Med J 1:457-460, 1936 12. Klimek A: Cluster-tic syndrome. Cephalalgia 7: 161-162, 1987 13. Krabbe AA: Cluster headache: a review. Acta Neurol Scand 74:1-9, 1988 14. Kudrow L: Cluster Headache: Mechanisms and Managemeat. Oxford: Oxford University Press, 1980 15. Kudrow L: Cluster headache: new concepts. Neurol Clin 1:369-383, 1983 16. Kunkel RS: Classification of cluster headache: clinical features of episodic duster headache, in Mathew NT (ed): Cluster Headache. New York: SP Medical & Scientific, 1984, pp 15-20 17. Kunkel RS, Dohn DF: Surgical treatment of chronic migrainous neuralgia. Cleve Clin Q 41:189-192, 1974 18. Maxwell RE: Surgical control of chronic migrainous neuralgia by trigeminal ganglio-rhizolysis. J Neurosarg 57: 459-466, 1982 19. Meyer JS, Binns PM, Ericsson AD, et at: Sphenopalatine ganglionectomy for cluster headache. Arch Otolaryngol 92:475-484, 1970 20. O'Brien MD, MacCabe J J: Trigeminal nerve section for unremitting migrainous neuralgia, in Rose FC, Zilkha KJ (eds): Progress in Migraine Research 1. London: Pitman, 1981, pp 185-187 21. Onofrio BM, Campbell JK: Surgical treatment of chronic cluster headache. Mayo Clin Proc 61:537-544, 1986 22. Peele TL: The Neuroanatomic Basis for Clinical Neurology, ed 3. New York: McGraw-Hill, 1977, pp 210-213 23. Ponti L, Valerio M: [Results of resection of the greater superficial petrosal nerve in several cases of post-otitis headache and of cranio-facial neuralgia.] Clin Otorinolaringol 12:409-418, 1960 (It) 24. Ray BS: The surgical treatment of headache and atypical facial neuralgia. J Neurosurg 11:596-606, 1954 25. Rhoton AL Jr, Kobayashi S, Hollinshead WH: Nervus intermedius. J Neurosurg 29:609-618, 1968 26. Sachs E Jr: Further observations on surgery of the nervus intermedius. Headache 9:159-161, 1969 27. Sachs E Jr: The role of the nervus intermedius in facial neuralgia. Report of four cases with observations on the pathways for taste, lacrimation, and pain in the face. J Neurosurg 28:54-60, 1968 28. Saper JR: Drug treatment of headache: changing concepts and treatment strategies. Semin Neurol 7:178-191, 1987 29. Solomon S: Cluster headache and the nervus intermedius. Headache 26:3-8, 1986
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Surgical treatment of cluster headache 30. Solomon S, Apfelbaum RI: Surgical decompression of the facial nerve in the treatment of chronic cluster headache. Arch Neurol 43:479-482, 1986 31. Solomon S, Apfelbaum RI, Guglielmo KM: The clustertic syndrome and its surgical therapy, Cephalalgia 583-89, 1985 32. Stookey B, Ransohoff J: Trigeminal Neuralgia: Its History and Treatment. Springfield, Ill: Charles C Thomas, 1959, pp 114-120 33. Stowell A: Physiologic mechanisms and treatment of histaminic or petrosal neuralgia. Headache 9:187-194, 1970 34. Trowbridge WV, French JD, Bayless AE: Greater superficial petrosal neurectomy for orbitofacial pain: preliminary report. Neurology 3:707-713, 1953 35. Watson CP, Morley TP, Richardson JC, et al: The surgical
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treatment of chronic cluster headache. Headache 23: 289-295, 1983 36. Watson P, Evans R: Cluster-tic syndrome. Headache 25: 123-126, 1985 37. Wegner W: Nervus intermedius (Hunt's) neuralgia, in Vinken PJ, Bruyn G W (eds): Handbook of Clinical Neurology. Vol 5: Headaches and Cranial Neuralgias. Amsterdam: North-Holland, 1968, pp 337-344 38. White JC, Sweet WH: Pain and the Neurosurgeon: A Forty-Yeur Experience. Springfield, I11: Charles C Thomas, 1969, pp 257-265,345-372, 622-627 Manuscript received October 3, 1989. Address reprint requests to: Robert H. Wilkins, M.D., P.O. Box 3807, Duke University Medical Center, Durham, North Carolina 27710.
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