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.
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