Surgical management of refractory trigeminal autonomic cephalalgias: A review of interventions and outcomes

Objective To evaluate surgical interventions for medically refractory trigeminal autonomic cephalalgias (TACs), focusing on efficacy, recurrence, and complications. Background TACs are severe, unilateral headaches with autonomic features. While pharmacologic therapies are first-line, a subset of patients requires surgical approaches, including microvascular decompression (MVD), Gamma Knife radiosurgery (GK), neuromodulation (ONS, DBS, VNS), and rhizotomy (PBC, GR, RFT). Methods A narrative review of the literature was conducted to evaluate surgical and neuromodulatory interventions for medically refractory trigeminal autonomic cephalalgias (TACs). A systematic literature search was performed across three databases: PubMed, Embase, and Primo (University of Colorado Anschutz Medical Campus Library). Search terms included combinations of condition-specific and intervention-specific terminology, including “trigeminal autonomic cephalalgia,” “cluster headache,” “SUNCT,” “SUNA,” “paroxysmal hemicrania,” “hemicrania continua,” “microvascular decompression,” “radiosurgery,” “occipital nerve stimulation,” “deep brain stimulation,” “vagus nerve stimulation,” “rhizotomy,” and “neuromodulation.” English-language, human studies were included. Case reports and small series were prioritized from the past 15 years; older literature was included where more recent data were unavailable for a given intervention. Given the narrative design and the predominantly observational, small-series nature of the available evidence, formal PRISMA-style screening was not employed. Instead, studies were selected based on relevance to the clinical question, quality of outcome reporting, and representativeness across TAC subtypes and surgical modalities. The narrative format was chosen to reflect the heterogeneous and largely non-systematic evidence base in this area, and findings are interpreted accordingly throughout. Where possible, findings from larger prospective or retrospective cohort studies were prioritized over smaller case series and isolated case reports. Given the limited evidence base in this area, case reports and single-center series are included where they represent the best or only available data for a given intervention; in such instances, the limited evidentiary weight is explicitly acknowledged in the text. This review was conducted in accordance with the SANRA guidelines for narrative reviews. As no patient data were collected or analyzed, ethical approval was not required. Results MVD demonstrated the highest efficacy, with 78.7% of patients achieving good to excellent outcomes and recurrence of 23.4% at 5 years; outcomes were superior in patients with radiographic trigeminal nerve compression. Smaller case series reported 60–70% symptom resolution. GK provided partial relief in select patients with cluster headache or SUNCT. ONS and DBS were effective in refractory cases but were associated with hardware-related complications. VNS showed modest benefit in resistant cluster headache. Rhizotomy outcomes were variable, with PBC showing some efficacy, GR offering short-lived benefit, and RFT requiring further investigation. Overall, major complications occurred in approximately 6% of patients. Conclusion MVD represents a promising surgical option for medically refractory SUNCT and SUNA, particularly when trigeminal neurovascular compression is evident on preoperative imaging. Its applicability to other TAC subtypes remains less established. Further studies are needed to clarify the role of MVD and other interventions across the full spectrum of TACs, especially in patients without demonstrable compression or as first-line surgical therapy.