Expert Review: Surgery and Migraine

I am skeptical of anyone who claims to be able to cure migraines with a surgical approach. At the same time, I want to be open to new treatment options, including surgical, that could potentially help my refractory migraine patients. Surgical procedures involving nerve decompression or resection (removal) of muscles or nerves thought to be involved in the migraine process have largely been viewed with skepticism by leading Headache Experts. What are these procedures and could they make sense for the patient for whom nothing else seems to be working?

The rationale behind nerve decompression procedures is that muscles in the scalp and neck are “entrapping” nerves and that, in releasing this constriction of the nerve, the headaches will be relieved. In some cases, the nerve is simply re-positioned and tucked under an adjacent structure; in other cases, it may be removed. Another surgical procedure is to remove part of the muscle that is believed to be putting pressure on the nerve. Complications of removing part of the muscles can include eyelid sagging, temple hollowing, and neck weakness.

Often, nerve blocks are done to help determine if a patient is a surgical candidate. For example, if a patient consistently experiences pain in the back of their head in the occipital region, then a nerve block with a local anesthetic can be done to see if a dramatic improvement in headache occurs. If the nerve block fails to bring relief, then it would not make sense to proceed with decompression of the nerve in that area. Nerve blocks can be done in the doctor’s office and in fact, occipital nerve blocks are often done to treat prolonged headaches or to help prevent migraine for 1-2 weeks. It is an easy procedure and patients can drive themselves home afterwards.

Another surgical approach involves peripheral nerve stimulators. The most common type used for migraine is the occipital nerve stimulator. This involves placement of a small battery-operated generator in the low back that sends a weak electrical current to the occipital nerve involved in migraine. Patients may experience a tingling sensation that one of my patients told me is not uncomfortable at all and preferable than her previous severe head pain from her migraines. Complications include migration of the generator; incomplete relief of headaches; and high cost of the procedure. Highly recommended would be a trial with an external stimulator device before proceeding with the surgery to put in the device.

Plastic surgeons and Otolaryngologists (ENT) are usually the types of doctors performing the nerve decompression and removal of muscle surgeries for refractory migraine. Pain Specialists are usually the ones who put in occipital nerve stimulators. My advice is to consult with your primary treating headache provider before considering or proceeding with any surgical approaches to migraine. For most migraine sufferers, having a procedure is not going to be “miracle” they were hoping for. Complications can occur including infection, worsening of headache, and adverse cosmetic effects in parts of muscle are removed.

For the majority of migraine individuals, the best treatment remains non-surgical. Identification and avoidance of migraine triggers, adherence to a healthy life-style, developing an effective acute and preventive treatment plan, and identification/treatment of underlying causes or contributing factors such as neck tightness, work stress, marital issues, hormonal factors, and medication overuse remains the mainstay of treatment.

In my opinion, surgical options are not “mainstream” accepted treatment for migraine and need to be approached very cautiously. More research needs to be done in this area of treatment before definitive conclusions can be made.

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