Curious About Migraine Surgery?
Migraine patients may be interested to learn there are sometimes surgical options for their Migraine pain. Based on ongoing discussion in the Migraine.com community, we’ve invited Jason Hall, MD, to share his thoughts for patients interested to learn about nerve decompression surgery and Migraine. There are many evolving theories that apply to Migraine pathogenesis and treatment. The article below highlights opinions expressed by Dr. Hall, a plastic & craniofacial surgeon. Do not stop, start or change any treatment program without first discussing the benefits and risks with your health care professional.
Ellen: Thank you so much for joining us, Dr. Hall. We’re very interested in talking to you about some surgical options patients have been bringing up in our forums and conversations. Over the next several months we hope to touch on several surgical options that may potentially apply to some Migraine and headache patients. I know they’ll be very interested in reading what you have to say. We would love it if you could start out this first post of three, by giving us a brief overview of the technique with which you’re having positive results in your practice.
What are some things patients should keep in mind if they’re reading about surgical options for their Migraines for the very first time?
Dr. Hall: Many non-migraineurs are confused when I start talking about migraine surgery. Most have no idea that a surgical option even exists, much less that is as effective as it can be. Unfortunately, this group of non-migraineurs includes many physicians who routinely treat migraine patients.
I start any discussion about surgery for migraines by stating one thing as plainly and clearly as I know how:
While surgery for migraines can work well, it is NOT the treatment for all migraine pain and is just that – a treatment, not a cure.
Ellen: It is safe to say that surgery for Migraine is controversial. Aside from nerve stimulators and closure of PFO – patent foramen ovale (a septal heart defect) which we hope to touch on in future posts, what do you see as the most frequently successful surgery for Migraine?
Dr. Hall: Essentially, there are two different surgical procedures that can be used to treat migraines: nerve decompression and arterial ligation. Both may be effective treatments in their own right based on the scientific data that exists today.
Ellen: Dr Hall, can you give us a little background on decompression surgery for Migraine?
Dr. Hall: Over ten years ago, a plastic surgeon in Cleveland (Dr. Bahman Guyuron) noticed that some of his cosmetic patients casually remarked that their migraine pain had completely disappeared after having undergone a cosmetic brow lift with removal of the corrugator muscles (small muscles in your eyebrows responsible for the “11” lines between the brows). As has been the case throughout medical history, this one observation set off a chain reaction that has led to a number of different research trials and the pioneering of a new set of surgical procedures to treat a disease once thought to be treated by medicine alone (or not treated, depending on where you are on the spectrum of migraines). Dr. Guyuron and his group have since published numerous studies on both anatomy and surgical outcomes, and have validated microsurgical decompression of extracranial branches of the trigeminal nerve and occipital nerves as a treatment for SOME migraineurs. In smaller studies in both the United States and Europe, other groups have shown nerve decompression to be beneficial as well.
Ellen: Do you think this is the most common surgical treatment for Migraine here in the United States?
Dr. Hall: The most common surgical treatment in the United States, regardless of the site of pain, is nerve decompression of various nerves of the head, neck, and face. In this procedure, branches of the trigeminal or the occipital nerve – the main sensory nerves of the head – are freed up from muscle or fascia (a thick, rigid covering of muscle; the equivalent of the “silverskin” on the outside of a steak). What varies in migraine surgery is the location of the nerve decompression and which nerves may be decompressed.
There are four main areas that can sometimes be addressed surgically. These are:
1. Above the inner eyebrows (the supraorbital & supratrochlear nerves)
2. The temples (the zygomaticotemporal nerve)
3. The back of the head (the greater occipital nerve)
4. Inside the nose (the septum and turbinates) This site is somewhat controversial and we’ll address it specifically in another post.
There are a few other “minor” trigger points in the head and neck which have been found and may be decompressed, as well.
To clear up a common misconception, nerve decompression surgery is just that – removing pressure from the sensory nerves themselves. The only nerves that are treated by nerve ligation (“cutting the nerve”) are the zygomaticotemporal nerve and the lesser occipital nerves. Both of these nerves give sensation to very small parts of the side of the face or scalp which “fills in” over time. The areas of temporary numbness are so small and are in such out-of-the-way locations that they go almost totally unnoticed. Also, the ends of these nerves are then buried in surrounding muscle to prevent the formation of a neuroma (an unorganized bundle of nerve fibers that can be terribly painful).
Ellen: This is often misunderstood, so I love that you’ve clarified that the treatment removes potential Migraine triggers or exacerbating factors, not the cause of a patient’s Migraine attacks. If these triggers are not the only ones they have, patients will still have to manage their other triggers. In other words, successful surgery doesn’t necessarily free the patient from continuing with important management strategies. Additionally, triggers can change throughout time, and these changes can have positive as well as negative results on our Migraine attacks. I think that’s really important for patients to understand.
We’ll talk a little more about deciding if surgery might be an option for patients in a later post, but, in a nutshell – how do you know if this surgery might help a particular patient?
Dr. Hall: A good physical examination by both your surgeon and your migraine/headache specialist can guide potential patients as to which surgeries may be most effective. Some imaging may also be helpful as well. However it’s important that your surgeon look at those scans personally and that none of your doctors rely on a written report. CT scan findings which may be significant in migraineurs and other head pain patients are viewed by most radiologists as “normal variants” and will not be accurately reported.
Ellen: In a future post we’re going to discuss which subset of patients in your experience typically do best with this type of surgical intervention, but for now, can we talk for a moment about the research that underlies your belief decompression is a potentially viable treatment for some patients?
Dr. Hall: There are a number of high quality scientific papers that prove (with very little doubt) that nerve decompression for migraine pain is beneficial IN THE PROPER PATIENTS.
What the current literature shows is that:
1. Surgery to decompress migraine trigger points works in approximately 90% of properly chosen patients, and approximately half of those patients find that their migraines are completely eliminated. (citation 1)
2. Surgery ends up costing patients, their employers, and their insurance companies less over the long run than a lifetime of medication and lost days at work. (citation2)
Dr. Guyuron and his group even went so far as to conduct a sham surgery trial – patients underwent surgery without having nerve decompression – and found that patients who underwent surgery with nerve decompression had a significant improvement in their pain than those who did not (and these patients were all followed for over a year after their surgeries). (citation 3)
Ellen: Acting as the devil’s advocate can be difficult, but I think it’s important. Can you discuss if there has been any research that hasn’t been favorable regarding this type of surgery, and why?
Dr. Hall: To my knowledge, there are no studies that show that migraine surgery doesn’t work or is not a valid treatment option or that it “doesn’t work”. The thing to remember is that the patients for the migraine studies – whether they are the American studies out of Cleveland, or the studies from Austria, Africa, or Germany – were all carefully selected for participation based on their constellation of symptoms, physical examination, and, in most, their response to Botox treatments. Common arguments against surgery as a valid treatment option have nothing to do with the effectiveness of surgery for this disease, but instead center around the feeling there is not “enough” data to support its use. My question in response is: How much is enough? There are studies from 5 countries and 3 continents demonstrating surgery’s efficacy in selected patients, including a study in which patients underwent sham surgery – which is almost unheard of in modern surgical trials. Old habits, especially in medicine, die hard. This, I feel, is one of them. I saw the same debate when I was a general surgeon and surgery for esophageal reflux was being discussed. It takes time, but the more people have successful surgery, the more it will be accepted by patients and physicians as a standard treatment option. More than anything, though, is that for surgery to have a chance at being successful, a correct diagnosis and proper patient selection are paramount.
Ellen: Surgeries that do not involve the placement of a medical device, like those we’re discussing here, do not have to be FDA approved, so some consider that a good thing because it frees both patients and doctors to consider it without years of expensive testing and the lengthy approval process. Others consider it a detriment because FDA approval is like the golden seal that makes a treatment widely acceptable and more likely to be covered by insurance. Surgical procedures continue to be mentioned at scientific meetings and conferences, and Dr. Guyuron himself will be there debating the pros and cons of Migraine surgery at the International Headache Society’s 2013 Headache Congress in Boston this June. I’m eager to sit in on that myself! Many Migraine and headache specialists still consider all types of Migraine surgery to be experimental, and I wish there was more data spanning a longer period of time and more conference presentations and case studies to get doctors discussing surgery for Migraine.
Dr. Hall: Interestingly, these procedures are being increasingly covered by insurance carriers, as the cost- effectiveness of surgery for migraine has been established (see citation 3).
Ellen: We are a new site and still trying to cover topics that may not come up as frequently as others. As mentioned earlier, we’re eventually going to have some posts about PFO closure and stimulator surgery for Migraine pain as well. These surgeries utilize devices. There are a couple of different stimulator surgeries being used in the US and gaining a bit of popularity, and others that are currently being researched. Until then, are there any other surgical options you’d like to talk about that are happening outside the United States?
Dr. Hall: There is another migraine procedure I’m aware of that is not commonly performed in the US. This involves the division of blood vessels in the skin of the head to treat (again) PROPERLY SELECTED PATIENTS (citation 4).
A physician named Harold Wolff published a theory back in the 1940’s that blamed dilation of the arteries of the head and brain as the cause of migraine, which quickly became the accepted theory until the “neurogenic” migraine theory displaced it. Commonly cited works today show that the arteries within the brain do not always change (enlarge) during a migraine attack (studied with equipment not dreamt about in the 1940’s), which disproved the first part of Wolff’s theory. However, the vessels outside the head were arguably not well studied, which some might say was the main thrust of the original work. Interestingly, a recent paper in “the” headache journal showed that migraine pain worsened when patients were given medication to stimulate the dilation or enlargement of vessels in the skin of the scalp (citation 5). This work adds more fuel to the fire that migraine pain is, indeed, multifactorial and that there may be different treatment options depending on the patient, their examination, and the nature of their pain.
In my opinion, both vascular and neurogenic theories have merit and may apply in different patients. The trick is figuring out if and which pain mechanism may be at work in an individual patient, and tailoring potential surgical treatment to the individual patient.
As far as nerve stimulators are concerned, I try to reserve them for patients who have failed everything else. The technology is good, but we must all remember with a stimulator, we are relying on a man-made device with a number of “moving parts” to function properly to provide relief. When a stimulator is placed, it is activating (or quieting) the same nerves that are decompressed in a nerve decompression, and so my feeling is that it may be used after surgery if patients are either still having chronic pain or to alleviate what pain is left. If a patient may benefit from surgery, a stimulator is not (right now, anyway) my go-to option; a nerve decompression is.
Ellen: Patients need something new to try when medications, other treatments and management strategies have failed or are contraindicated. Unique and different treatments are very slow in being discovered and accepted however.
“The translation of medical discovery to practice has thankfully improved substantially. But a 2003 report from the Institute of Medicine found that the lag between significant discovery and adoption into routine patient care still averages 17 years” (6)
This is the natural course of science when the lives of patients are at stake. But some patients believe they can’t or don’t want to wait for their current doctors to adopt a treatment into routine care. Some specialists agree surgery might be considered in a specific subset of patients once these other options have failed. Do you agree or do you have a different opinion?
Dr. Hall: In my opinion, surgery for migraines has been scientifically shown to benefit a certain group of migraineurs. The counter-argument is that not “enough” research has been done, and that the majority of the work has come out of one center; this argument neglects work on the same nerve decompression procedure that has come out of Europe, as well as some work out of Africa with respect to arterial surgery. An important thing to remember is that nerve decompression surgery for migraines is, essentially, an adaptation of a cosmetic surgery for forehead wrinkles which was performed by plastic surgeons more than 44,000 times in 2012. Complications from these surgeries are fortunately very rare, and when they occur are mostly cosmetic in nature. Probably the most worrisome complication is performing a surgery and not seeing any benefit – this is a very real concern. That is why proper patient selection is so important – to do everything possible to ensure that the patient who has surgery will see a positive benefit.
Ellen: As patients, we need the hope that more and different options give us. But we also have to educate ourselves and be smart in making these treatment decisions for ourselves and our families. This doesn’t just pertain to surgical intervention, but all of our choices and decisions. Everything that has the potential to be helpful, also has the potential to hurt us. When it hurts us, it hurts those we love too.
Patients need to realize that while this is an interesting and appropriate subject for them to discuss with their specialists, many doctors consider these procedures experimental and don’t have sufficient information about them. As the subject is more frequently discussed in conference presentations and scientific meetings, this is likely to change. Without those formal presentations and a chance for useful conversation and debate between doctors, I don’t think most specialists are comfortable recommending surgery to their Migraine patients.
Dr. Hall: I think that is true and is something that will only change with time, which is one of many reasons forum like this are so important. A few take home points, if I may:
1. Neither procedure nor set of procedures can be applied to every migraineur. It is imperative that these procedures are done in the properly selected patients who are most likely to benefit from them.
2. The word “cure” is not applicable. These procedures are, like medications, treatments for your migraines and head pain. Remember, though, that these treatments are meant to lessen the impact that migraine pain will have on your social, professional, and personal life. Be wary of anyone who tells you otherwise or offers any “guarantee” of success – they either don’t know what they’re doing or are not being honest with you.
Ellen: Thank you very much Dr. Hall, for helping patients understand nerve decompression surgery for Migraine from a plastic & craniofacial surgeon’s perspective. I look forward to the next two posts where we’ll learn a little more about how patients are chosen, etc.
Dr. Jason Hall is a plastic & craniofacial surgeon with practices in Knoxville, Tennessee and Houston, Texas. He trained in both general and plastic surgery in Texas, followed by a fellowship in craniofacial surgery at Stanford University. A major focus of his practice is the surgical treatment of migraines. He is a Fellow of the American College of Surgeons, as well as a member of both the American Society of Plastic Surgeons and the American Society of Maxillofacial Surgeons. He is board-certified by both the American Board of Plastic Surgery and the American Board of Surgery. When he is not working, he enjoys spending time with his wife and children, yoga, and doing pretty much anything outdoors. You can learn more about Dr. Hall and his practice at www.drjasonhall.com or schedule an online consultation with him at www.healthtap.com/drhallplasticsurgery