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Migraine and cluster headaches can both activate the trigeminovascular system including the superior salivatory nucleus, causing autonomic symptoms that can present in 50% of migraine patients, and induce dilation of intracranial vessels and sensitization of the trigeminovascular system leading to pain. Randomized controlled trials support peripheral nerve simulator (PNS) utilization in refractory cases with moderate evidence for cluster headaches and strong evidence for migraines. There are no PNS trials of patients having diagnoses of both chronic cluster headache (CH) and chronic migraine (CM).

A 51-year-old male with history of CM, chronic CH, and relapse remitting multiple sclerosis presented with severe refractory right retroorbital, scalp and V1 pain for 12 years after optic neuritis. Exam showed decreased temperature sensation of right trigeminal V1 and right ptosis. MRI did not show vascular compression. He failed numerous migraine and CH preventative and abortive medications. He underwent trigeminal nerve blocks, retrobulbar thorazine and steroid injections, transection of supraorbital and supratrochlear nerves, sphenopalatine ganglion blocks, and auriculotemporal nerve blocks without sustained improvement. Poor pain control led to a suicide attempt. Upon recovery, he was referred to neurosurgery for a right V1 PNS via a right-sided subtemporal craniotomy.

Post-surgical complications included ear and jaw pain and numbness with higher device settings. Patient reported >50% pain reduction and >80% improvement in quality of life two months after PNS placement with sustained effects after 12 months.  He was able to decrease the dose of gabapentin and baclofen and was more responsive to his abortive treatments.

Trigeminal PNS may be effective in reducing refractory pain and improving quality of life in patients with CM and chronic CH. Future studies are needed to evaluate duration of benefit with PNS, particularly in CM and chronic CH unresponsive to various medications, treatments, and procedures.