• Robert Belvis, Rodrigo Rodríguez, Marina Guasch, María Jesús Álvarez, Joan Molet, and Carles Roig.
• Unidad de Cefaleas y Neuralgias, Servicio de Neurología, Hospital de la Santa Creu i Sant Pau, Barcelona, España. Electronic address: rbelvis@santpau.cat.
• Med Clin (Barc). 2020 Feb 14; 154 (3): 75-79.

Background And ObjectivesCluster headache (CR) is the most severe human headache and is chronic in 10%-20% of patients, and 10% can become refractory to all effective drugs. In this scenario, surgical procedures are indicated: radiofrequencies of the sphenopalatine ganglion ipsilateral to pain (RF-SPG), bilateral stimulation of the occipital nerves (NOM-S) and deep brain stimulation (DBS) of the ipsilateral posterior hypothalamus. The efficacy and safety of each of these procedures has been specifically analyzed, but the progress of a series of patients following this surgical route in order of aggressiveness has not been described.PatientsPatients with chronic and refractory CR according to the criteria of the European Headache Federation. The patients underwent RF-SPG, NOM-S sequentially if the previous procedure had been ineffective, and DBS if the previous procedure had been ineffective.ResultsWe prospectively included 44 patients between November 2003 and June 2018 with an average age of 38.3 years; 70% were men. The mean follow-up was 87.4 months. Nineteen patients responded to 74 procedures of RF-SPG (33.3%). Of the remaining 25 patients, a NOM-S device was implanted in 22, showing an efficacy of 50%. Finally, 9 patients underwent ECP of the ipsilateral lower-posterior hypothalamus with an efficacy of 88.8%. No serious complications were found following any of these 3 procedures.ConclusionsThe sequential application of these three surgical procedures succeeded in reversing the serious situation of chronic CR refractory to an episodic CR in 93% of patients with acceptable surgical morbidity.Copyright © 2019 Elsevier España, S.L.U. All rights reserved.

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