Endocrine Abstracts

Headaches associated with acromegaly are common even after hypophysectomy. Medical treatment with dopamine agonists and Somatostatin analogues often help. We report two cases when pharmacological therapy failed but further surgical removal of residual pituitary tissue cured the headaches.

A 38 year-old lady presented with an eight year history of headaches, unresponsive to simple analgesia. Acromegaly was confirmed by a raised serum growth hormone (GH) 33 mU/l, not suppressed by an oral glucose tolerance test (OGTT). A magnetic resonance imaging scan (MRI) showed a right pituitary macroadenoma. She underwent a hypophysectomy, but two weeks later the headaches reappeared. She was treated with adjuvant external beam radiotherapy but the headaches continued. An MRI scan showed residual tumour in the right side of the pituitary fossa. Further pituitary surgery was performed. Within 20 hours there was complete remission of headaches. Histology failed to demonstrate a growth hormone secreting tumour. An OGTT confirmed biochemical cure. The patient remains symptom free for the past seven years.

A 40 year-old man presented with a five year history of headaches, not relieved by simple analgesia. Acromegaly was confirmed by a raised GH 10.1 mU/l not suppressed by an OGTT. A MRI scan showed a right pituitary macroadenoma. He underwent surgery, one day post operatively GH was less than 0.5 mU/l and the headaches had resolved. Three months on the headaches returned. Octreotide relieved the headache but he soon developed tolerance. Further surgery was carried out a year later, with immediate post operative resolution of the headache. Histology of the pituitary tissue confirmed sparsely granulated somatrophic cells. Eight months on, he remains symptom free.

These cases provide further evidence that the mechanism of the headache associated with acromegaly is complex and in patients in whom all other therapies fail, further pituitary surgery may be of benefit.