Surgical Interventions

The management of frequent headaches primarily employs a number of effective pharmacologic and non-pharmacologic therapies. Tricyclic antidepressants, topiramate, valproic acid, onabotulinumtoxinA injections, CGRP monoclonal antibodies, as well as cognitive behavioral therapy and biofeedback therapies, among others, are all part of the standard armamentarium of headache management. There exists, however, a substantial population of patients for whom these first-line therapies are not satisfactory. Refractory chronic migraine, for example, affects approximately 4% of the population worldwide or up to one-third of all migraine sufferers. Surgical therapies for refractory headache, the focus of this chapter, can be broadly categorized into two groups: ablative or neurostimulatory. Neurostimulation relates to various treatment modalities employing electrical stimulation directly or indirectly, to peripheral nerves or to brain parenchyma itself. Among the multiple modalities of neurostimulation, occipital nerve stimulation, transcutaneous supraorbital nerve stimulation, sphenopalatine ganglion stimulation, deep brain stimulation, and transcranial magnetic stimulation are discussed. Ablative techniques discussed will include supraorbital nerve decompression, glycerol and radiofrequency rhizotomy, and gamma knife radiosurgery. Microvascular decompression surgery, which does not neatly fall into an “ablative” or “stimulatory” heading, are also discussed.