Intractable headache is a common presenting symptom of the thoracic outlet syndrome (TOS). We followed thirty patients for at least six months after transaxillary first rib resection. Prior to surgery, twenty-six reported recurring headache before the appearance of neck and shoulder pain; headache was lateralized in 21 and continual in 14. In 11, intensification of TOS symptoms accompanied headache. After surgery, 11 previously disabled patients returned to work; 13 became head-ache-free. Eleven others reported benefit from vaso-active drugs that had been ineffective pre-operatively.