Long-Term Results of Radiosurgery for Refractory Cluster Headache

 

Shearwood McClelland III M.D.¹, Gene H. Barnett M.D.², Gennady Neyman Ph.D.³, John H. Suh M.D.³

 

¹Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN; Departments of ²Neurosurgery and ³Radiation Oncology, The Cleveland Clinic Foundation, Cleveland, OH.

 

 

Introduction:

Medically refractory cluster headache (CH) is a debilitating condition for which few surgical modalities have proven effective.  Previous reports (1, 2) involving short-term follow-up of CH patients have reported modest degrees of pain relief following radiosurgery of the trigeminal nerve ipsilateral to symptom onset.  Given the recent success of deep brain stimulation as a surgical modality for these patients (3), 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 reported series of patients undergoing radiosurgery for CH with extended follow-up.

 

Methods:

Between 1997 and 2001, ten 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.  Mean age at radiosurgery was 40.3 years (range: 26-62), and average CH duration was 11.3 years (range: 2-21).  Patients received 75 Gy to the 100% isodose line delivered to the proximal trigeminal nerve, with mean follow-up of 39.7 months (range: 5-88).  Pain relief was defined as: excellent (free of CH with minimal/no medications), good (50% reduction of CH severity/frequency with medications), fair (25% reduction), or poor (less than 25% reduction). 

 

Results:

Following radiosurgery, pain relief was poor in 9 patients, and fair in 1.  Six patients with poor/fair relief initially experienced excellent/good relief (range: 2 weeks to 2 years post treatment) before regressing.  Five patients experienced trigeminal nerve dysfunction, manifesting predominantly as facial numbness post-treatment. 

 

Conclusion:

Although some patients may experience short-term pain relief, no patient had relief sustainable for more than two years.  The results from this series indicate that radiosurgery of the trigeminal nerve does not provide long-term pain relief for medically refractory CH.

 

 

 

Keywords:

Refractory Cluster Headache, Gamma Knife Radiosurgery, Trigeminal Nerve, Long-Term Follow-Up

 

Objectives:

1. To recognize the clinical criteria for radiosurgical treatment of cluster headache

2. To be familiar with the anatomic target and radiation dosing in radiosurgery for refractory cluster headache

3. To understand the efficacy of Gamma Knife radiosurgery in providing long-term pain relief for patients with refractory cluster headache

 

References:

1. Ford RG, Ford KT, Swaid S, Young P, Jennelle R. Gamma knife treatment of refractory cluster headache. Headache. 1998;38:3-9.

2. Donnet A, Valade D, Regis J. Gamma knife treatment for refractory cluster headache: prospective open trial. J Neurol Neurosurg Psychiatry. 2005;76:218-221.

3. Franzini A, Ferroli P, Leone M, Broggi G. Stimulation of the posterior hypothalamus for treatment of chronic intractable cluster headaches: first reported series. Neurosurgery. 2003;52:1095-1101.