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Migraine: Choosing Surgical Nerve Decompression Candidates

After Dr Hall’s last post “Curious About Migraine Surgery?” patients are wondering if they might be a candidate for nerve decompression surgery.  Dr Hall explains more here.

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.

A common question is: Who is a good candidate for migraine surgery?   I’ll start by saying that this is a growing field – we are learning more about surgical options for migraine every day, so what I say now will likely change with time. First of all, anyone who is contemplating surgery for migraine needs to be under the care of a migraine and headache specialist.  Secondly, a diagnosis of migraine should be established by your treating migraine specialist.  Until a patient carries a definitive diagnosis of migraine, it is difficult (if not impossible) to come up with a treatment plan that has any chance of working.While plastic surgeons are good diagnosticians and good physicians, they are not trained medical migraine and headache specialists.  There are lots of potential reasons for a person to have migraine pain, and surgery can only address a small number of those patients.  It must be emphasized that current standard of care is to treat migraine with preventative and abortive medications as a first line of therapy.  Indeed, many patients improve with medication alone.It is when medications don’t work that surgery enters the picture.The initial studies of microsurgical nerve decompression for migraine were done in patients who met the following criteria:

  1. Carried a diagnosis of chronic migraine (or Chronic Daily Headache)
  2. Failed medical management with traditional preventive and abortive therapy
  3. Had trigger points which were identifiable and reproducible on physical examination
  4. Had a positive response to Botox® injection

In this study, with follow-up extending out at least 5 years, the positive response rates from surgery was 88%, with almost 30% reporting complete elimination of symptoms at 5 years1.

These criteria have since been revised, but are used by most board-certified plastic surgeons who perform nerve decompression surgery.  More recently, the selection criteria for nerve decompression have been modified.   Dr. Guyuron’s group has found that a constellation of physical signs and symptoms are equally as predictive as a trial of Botox with regards to who will or will not respond to surgical treatment2.

The following tables are the symptoms (not diagnoses) that are predictive of positive responders to surgical nerve decompression, and are directly adapted from Dr. Guyuron’s research.

Frontal Headache

  • Pain above the brows
  • Pain usually in the afternoon
  • Strong corrugator muscles
  • Tenderness at the supraorbital notch
  • Unilateral eyelid drooping associated with headache
  • “imploding” type of head pain
  • Stress is a trigger

Temporal Headache (side of the head)

  • Pain in the front part of the temple
  • Tender temporalis or masseter muscle
  • Pain common in the morning
  • Wear on the teeth indicative of grinding
  • “imploding” type of head pain
  • Stress is a trigger

Occipital Headache (back of the head)

  • Tender over the occipital nerves
  • No specific time of pain onset
  • History of whiplash or neck trauma
  • Tight neck muscles
  • Heavy exercise is a trigger
  • Stress is a trigger

Rhinogenic Headache (nasal headache)

  • Pain behind the eyes
  • Awake with pain or pain in the evening
  • Weather changes trigger pain
  • Runny nose accompanies pain
  • Pain can be related to seasonal allergies
  • Pain is related to changes in menstrual cycle
  • “exploding” character of pain
  • CT scan findings of concha bullosa, septal bullosa, or septal/turbinate contact points

This, in my mind, is important for several reasons.  First, Botox injections are technically “medical procedures”, meaning they depend on human beings to administer them correctly.  Using a set of symptoms and signs instead of a response to a test can eliminate what is known as “operator error” from the equation.  Even with a defined set of instructions, which most headache specialists use to administer Botox, a small needle can easily be placed in the wrong position if the angle of the injection is incorrect, which could render the injections useless in someone who would otherwise have a positive response.  Secondly, it gives a more detailed set of historical questions to answer with regards to the headache, and puts them together in more of a “cause and effect” fashion than has been done in the past.

Most importantly, though, if the new set of selection criteria are more widely adopted it could save the time, financial cost, and discomfort of a Botox trial prior to surgery (Botox, if you’ve never had it, stings…and the sheer number of injection sites most patients have is substantial).  If you have the right set of symptoms, surgery has a chance at helping relieve your headaches; if you don’t meet those criteria, you are not a surgical candidate for nerve decompression.

The second surgical treatment, which is not discussed as much in the US as it is overseas, is deactivation of arterial triggers in the scalp.  Unlike nerve decompression candidates in whom direct pressure over a trigger site tends to exacerbate their pain, patients who are a candidate for arterial surgery experience temporary pain relief with direct pressure over the offending arteries.  Obviously, this diagnostic maneuver can only be performed when you’re having pain, and since the procedure is not discussed as a potential treatment in the US, the diagnostic test is almost always omitted from the routine physical examination.  Sometimes, complete resolution requires pressure on multiple scalp arteries simultaneously.  It has been my experience that this most often occurs in unilateral pain and often involves some combination of the supraorbital, superficial temporal, and occipital arteries.

Other than a confirmed history of migraine, a good physical examination performed during a headache can determine whether or not you are a candidate for arterial surgery.  Sometimes a CT scan can help to identify the exact course of the involved arteries (which are located in the skin of the scalp); a small, handheld ultrasound can be used to accomplish the same thing.  Surgery involves division of the offending arteries, which is done as an outpatient procedure under light sedation and local anesthesia.

In my own practice, I am starting to incorporate the newer symptom-based selection of nerve decompression candidates into my practice.  I discuss the research with my patients and whether or not I feel that they are a surgical candidate.  If they’re not sure whether or not they’d like to proceed with nerve decompression surgery or have lingering doubts, I suggest a confirmatory trial of Botox with or without an injection of local anesthetic.   For migraine with arterial triggers, the physical examination is convincing enough – no further testing is needed.  In both cases, however, I don’t have any problem with patients not “jumping” to surgery of any kind – I actually ask that they think about it and research it (if they haven’t already) before making the decision to move forward with surgery.  Most migraineurs I see are at the end of their proverbial rope, and the last thing I want is someone making an “impulse buy” when it comes to their health and well-being.

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

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The Migraine.com team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

1. Guyuron B, Kriegler JS, Davis J, Amini SB. Five-year outcome of surgical treatment of migraine headaches. Plast Reconstr Surg. 2011;127:603-8 Available at: http://www.migrainesurgery.co.uk/uk/assets/downloads/international_publications/Five_Year_Outcome_of_Surgical_Treatment_of.14.pdf?PHPSESSID=9b5f7c5db21ba4e63d9d06af26871fe1 2. Liu MT, Armijo BS, Guyuron B.  A Comparison of Outcome of Surgical Treatment of Migraine Headaches Using a Constellation of Symptoms versus Botulinum Toxin Type A to Identify Trigger Sites.  Plas Recon Surg 129; 2.  413 -  419 3. Shevel E.  Vascular surgery for chronic migraine. Therapy 2007; 4: 451-456. Available at: http://www.headclin.co.za/uploads/ftp/DrShevelPublications/therapy2007.pdf

Comments

  • mo
    6 years ago

    Dr. Hall: I have chronic, daily migraines which have not responded to any preventative/abortive method which started 22 years ago. I am on morphine 24/7. I have been accepted by Dr. Peled in San Francisco as a potential candidate for the surgical nerve decompression, and have had one very successful Botox test in my right temporal (in front of ear) region. My result was fabulous; after the first 4 days I was free of all pain on that side of my head and the intensity and occurance of headaches decreased significantly.(My pain was now at the top of my head and, to a lesser degree, on the left side.) At my next visit, as I was still having headaches, although less intense & less frequent, Dr. Peled suggested a Botox test of the other nerve on the right side to determine if that would even further decrease the occurance/intensity of headaches. Ever since that treatment, my daily intense headaches have returned with a very high intensity and occurance, primarily in the temporal area, and bi-laterally. We were all so thrilled with the results obtained with the first injection; do you feel that the reversal of improvement with the second injection is indicative of results I might see with surgery? Is there some other factor involved? Should I continue with Botox testing on the left side? What are some of the possibilities of what’s going on?

  • nursemcdonald
    3 years ago

    MO,

    Per comments, it seems that you are now 4 years post nerve decompression surgery. I must know your current status. Please provide this forum with a follow-up report…

  • jhallmd author
    6 years ago

    mo:
    Very happy for you that you were able to connect with Dr. Peled and that surgery worked is working so well for you! Keep us all posted with respect to both you and your daughter’s progress!

  • mo
    6 years ago

    I am three weeks post-surgery, having had the nerve decompression surgery done by Dr. Peled. He located two potential problem nerves, located in my right temple area, which is where most of my migraine pain starts. He started with an intensive physical and migraine history, then asked a few specific questions about the location, quality and quantity of my pain. He then did an unusual physical exam of my head, pushing on specific points and asking for my responses. Once he had decided which point he wanted to evaluate further, he injected that point with Botox and asked me to keep a headache journal. He had asked me to keep a journal from when I had made the appointment weeks ago, so he would have something to compare. (Since I have daily headaches, it wasn’t very hard to do!) We continued in this fashion, using various nerve blocks in addition to the Botox, until the second nerve was pinpointed. I have two 2-inch incisions near my hairline; the stitches come out tomorrow. So far the results are mixed, although he says it’s much too soon to judge. I was headache free for nine days following the surgery. Since then I have about 2 days on and 2 days off (headache free). Since I was 100% headache every day, already I’m 50% better! Nothing was covered by insurance, and realistically I would say that it cost $5500-6000. A second blessing to come from all of this is that my 28- year old daughter is also going through this process; she’s suffered with daily intractable headaches for about three years. It took me 22 years to find Dr. Peled and his surgery–she can get relief without all of those intervening years! Her younger sister also gets migraines, but she hasn’t tried all of the preventative medications yet, and so far only gets them a few days around her period . Of course, that’s the way mine started, too.

  • mo
    6 years ago

    How do we find a qualified doctor in our area? I live in the San Francisco Bay Area.

  • Ellen Schnakenberg
    6 years ago

    Hi Mo, that’s the subject of Dr Hall’s next post, so stay tuned!

  • mo
    6 years ago

    I looked into this procedure a few years ago, but wasn’t too sure I wanted to go through the “face lift” process that was being used then. Here’s an update on the treatment:
    http://abclocal.go.com/kgo/story?section=news/health&id=8662760

  • Ellen Schnakenberg
    6 years ago

    The paper discussed here is one of Dr Hall’s sources, so those wanting to see for themselves what the 5 yr research said, can check out the resources pages for Dr Hall’s posts for more information.

  • silvermoon
    6 years ago

    This was a very interesting, upcoming treatment option for migraine! I have suffered migraines for most of my life (58 yr. now) and have been diagnosed with chronic migraines for probably at least 15 years. My migraines occur on the right side of my head above my ear in the temporal area, that seem to either initiate or migrate down the right side of my neck. I currently take a preventive med, rescue, Botox, physical therapy, a gluten free diet (I do not have gluten disease, but physically feel better), and cranial-sacral therapy. The Botox has been helpful in reducing overall pain and increasing tolerance of migraines. They have decreased from approximately 14/15 a month to 10/11. Would I make a good candidate for this type of surgery?

  • jhallmd author
    6 years ago

    Without examining you and going through your migraine history, it’s hard to tell whether or not you would be a surgical candidate. The auriculotemporal nerve (which runs in front of your ear) is a known trigger that can be surgically released. I’d imagine that since you have been a Botox responder, you would likely get a similar response with surgery…I (or anyone else) could really only tell by examining you.

  • LBellando
    6 years ago

    Wonderful news on migraine surgery! I have been a migraine sufferer for most of my whole life (I’m 54). I’ve had good years and bad years having migraines – but always having some. They are ALWAYS in the same spot above my right eye, inside corner. I have been fortunate that taking rizatriptan takes the pain away. I am completely happy and healthy, exercise and eat well. When I went through menopause (starting at age 43), I had debilitating almost daily migraines and sought medical attention with many different maintenance drugs but still had migraines. Luckily, I made it through that bad period instilling a healthier lifestyle and now only having 4 to 5 per month. As I am not considered a chronic migraine sufferer, could I still be a candidate for this surgery? Thanks!

  • jhallmd author
    6 years ago

    It sounds like you may have compression of the supraorbital and supratrochlear nerves. A Botox trial may help to determine if you would get long-term relief of your headaches with decompression of that nerve(s). If you did, it would be a very candid risk/benefit discussion between you and your surgeon as to whether or not you would want to proceed.

  • stacysillen
    6 years ago

    Botox has been working pretty good for me!! Am I a candidate? We never hear about migraine surgery in the U.S. though. How safe is it? What are the side effects? Will my forehead still be sooth like with the botox? 🙂

  • marlenerossman
    6 years ago

    Botox did not work for me. And, after three different Radiofrequency ablations of the C2, C3 and C4, I am still suffering from terrible migraines. I have tried 22 different medications, some of which gave me terrible reactions. I got eretheyma multiforme minore from Topamax and after taking Gabapentin for a few days started falling. On one fall, I broke my finger.

    NOTHING WORKS, NOTHING HELPS, I am a slave to migraine. I might add that I have had MRIs and there is no pathology. I have been recommended to Transcranial Magnetic Stimulation. But it is a daily treatment that I would have to take EVERY DAY for a month.

  • jhallmd author
    6 years ago

    If you are having a good response to Botox, it is likely that you would get a similar benefit from surgical nerve decompression. Surgery for migraine has been increasingly discussed for the past 10 years, but there are many migraineurs and physicians alike who do not know that a surgical treatment option exists. As far as side effects and other outcomes from surgery, that is a topic of an upcoming post, so stay tuned!
    Glad to hear Botox is helping!

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