Experiences of Headaches Successfully Treated by Surgery

—Especially in Headaches related to Occipital and/or Trigeminal Neuralgias—

Abstract

We experienced 325 cases of patients who had headaches as a chief complaint at our out-patient clinic from January, 1977 to September, 1979. Occipital and trigeminal neuralgias consist 149 cases (46%) as a main cause of headache followed by vascular headache (19%), subarachnoid hemorrhage (18%), increased intracranial pressure (15%) and others (2%). Classification of headache in our clinic is much different from that of Ad Hoc Committee, because we need to represent basic mechanism of headache from surgical points of view. So-called muscle-contraction headache of nuchal or temporal muscles is included in occipital and trigeminal neuralgias, as far as tenderness is present on greater occipital, smaller occipital and/or trigeminal nerves, and nerve blocking by local anesthetics eliminates the pain temporarily.
Twenty-one out of 149 cases (14%) were operated to relieve the headaches related to occipital and, /or trigeminal neuralgias, in which the main cause of headache was trigeminal neuralgia in 8 cases and occipital neuralgia in 13 cases. In trigeminal neuralgias, one case of tic douloureux was treated by Frazier's gasserian ganglionectomy and seven cases of symptomatic trigeminal neuralgias (giant IC cavernous aneurysm 1, unruptured MCA aneu-rysm 1, pituitary tumor extended into sphenoid sinus 1, cerebello-pontine-angle tumor 2, metastatic craniobasal tumor 2) were respectively treated by trapping or clipping of aneu-rysms, total removal of tumors or trigeminal rhizotomy. Over-all effects of surgery were disappearance of the headache in 5 cases and improvement in 3 cases. Out of 13 cases of occipital neuralgias, 4 had cervical spinal lesions(cervical spondylosis 2, cervical disc herni-ation 2), one had dural AVM and the other 8 had posttraumatic or nontraumatic thoracic outlet syndromes (TOS). Anterior body fusion with full removal of osteophytes abolished the headache in all 4 cases of cervical spinal lesions. Total removal of the AVM got the headache disappeared. After division of the anterior scalene muscle with hypertrophic, fibrous or tendinous portions through supraclavicular approach, various symptoms and signs such as occipital and/or trigeminal pain, visual disturbances, stiffness of neck and shoulder muscles and restriction of neck movements were disappeared in 5, improved in one and unchanged in 2 cases. We would like to emphasize an importance of TOS as a cause of occipital neuralgia, because TOS is encountered more frequently than expected in post-traumatic soft tissue neck injuries and furthermore treated successfully by the division of the anterior scalene muscle.
As far as surgical treatment of troublesome headaches gives dramatic and long-lasting relief to many patients, neurosurgeons must examine patients carefully to find real causes of headache intracranially and extracranially for the best treatment.