Repeat Trigeminal Nerve Radiosurgery for Refractory Cluster Headache Fails To Provide Long-Term Pain Relief

 

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 ²Radiation Oncology, The Cleveland Clinic Foundation, Cleveland, OH.

 

 

Introduction:

Medically refractory cluster headache (CH) is a debilitating condition that has proven resistant to many modalities.  Previous reports have indicated that radiosurgery for CH 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 CH.

 

Methods:

Two patients with medically refractory CH 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 CH 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 proximal trigeminal nerve, and was evaluated post-retreatment.  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 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 post-retreatment, while patient 1 experienced no morbidity.

 

Conclusion:

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

 

 

 

Keywords:

Refractory Cluster Headache, Repeat Gamma Knife Radiosurgery, Trigeminal Nerve, Pain Relief