The term cluster-tic syndrome (CTS) is used to designate a clinical pain pattern in which symptoms of cluster headache (CH) and tic douloureux (TD) coexist. The TD elements of the attack occur in paroxysms of many seconds or minutes, always affect the maxillary or mandibular divisions of the trigeminal nerve, with spread into the ophthalmic division in some cases, and may be triggered by slight superficial stimuli. These features may occur independent of CH elements but more often the two blend together. Four patients with CTS unresponsive to medication underwent surgery. Blood vessels were found to cross compress the trigeminal nerve in all four patients and the nerve was decompressed. A similar condition was found affecting the facial nerve in two of the three patients in whom that nerve was explored and the facial nerve was decompressed in these two. The TD component of the CTS disappeared after surgery in all four patients. The CH component of the syndrome returned after surgery but in a modified form. In three patients, the CH changed from what had been chronic cluster to infrequent episodic cluster periods; additionally in two patients, the duration of cluster was shorter and the pain was of lesser severity.