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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.

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.

Comments

  • Dr Hutchinson author
    7 years ago

    I agree there is a subset of migraine patients who may benefit from surgery if there is a specific problem with, for example, a nerve or blood vessel being constricted. Sadly, however, many migraine patients have had high hopes that surgery would “cure” their headaches and found they were not better off after the surgery. In my practice, I have found this to be particularly true with “sinus” surgery. For most patients, migraine is a centrally-mediated condition in that the cerebral cortex, thalamus, and brain-stem get activated and having a peripheral nerve procedure or sinus surgery will not “cure” their headaches. I remain optimistic, however, and have referred at least 2 patients in recent weeks for consideration of nerve decompression surgery. Are there any readers who would like to comment on surgical procedures they have had for their migraines that were not successful?

  • jhallmd
    6 years ago

    I agree with you. I think that the peripheral trigger theory and the centrally-mediated theory go hand-in-hand in some patients. By eliminating the peripheral nerve input from pathologically compressed sensory nerves, the brainstem/cortical activation can be more easily controlled with standard preventatives which may not have been very effective before. I still have patients who I have operated on who get migraines, but the severity, intensity, or duration (often all three) are much less and more easily controlled.
    I would also love to hear from readers who have had surgery that has not lived up to expectations.

  • jhallmd
    7 years ago

    Headache Mama, I couldn’t agree more, especially with your appendicitis analogy. Anytime surgical treatments are proposed, especially for conditions typically thought of as ones treated with medicines alone, both doctors and patients are right to be weary. However, there is over 10 years of good data (including sham surgery studies, which are almost unheard of in surgical studies anymore) which validate trigeminal decompressions as effective treatment for specific patients with chronic migraine headaches. The data clearly shows that surgery works in that subset of patients. I have links to the important papers on the migraine section of my own website if you are interested.
    Whether you as a migraineur are a candidate for surgery is something that should be discussed with your surgeon. It is not a “first line” treatment for all migraines, but for patients with specific anatomic trigger points who have failed maximal medical therapy. I and other migraine surgeons do, however, have a growing number of patients who have “gotten their life back (their words, not mine)” after surgery…they are, by far, the happiest and most grateful patients in my practice.

  • Headache Mama
    7 years ago

    Dr Bahman Guyuron has published formal studies on five-year outcomes for nerve decompression surgery. People with severe migraine that does not respond to other treatment should consider being evaluated by a surgeon experienced in diagnosing and treating neuralgia. It is far too difficult to find a neurologist even willing to consider that severe migraine symptoms are actually being caused by occipital neuralgia or trigeminal neuralgia. After nearly two years of medications, hospitalizations, physical therapy, and many other less traditional treatments, my daughter was diagnosed with occipital neuralgia. Nerve decompression surgery has freed her from the constant, debilitating pain that had stolen her life. Look at it this way: an appendectomy is not for everyone with abdominal pain, but it is the best solution for someone with appendicitis. Nerve decompression surgery is for individuals whose pain is caused by neuralgia. Just because a surgery isn’t for everyone doesn’t mean it should not be considered or explored.

  • Dr Hutchinson author
    7 years ago

    It is wonderful to hear some positive success stories for nerve stimulators and nerve decompression surgery for the treatment of refractory migraine. Thank you for sharing your story with us. Although these procedures are not for everyone, it is an avenue of treatment to consider. As a headache provider, I continue to learn…
    Posted by:
    Susan Hutchinson, MD
    Director-Orange County Migraine & Headache Center

  • juliannealley
    7 years ago

    I got a peripheral nerve stimulator in 2009. It has been amazing, and given me more relief than any other treatment I’ve tried in the last 17 years. My doctor never claimed it would be a cure, and it isn’t, but it has greatly reduced my pain. If I had to give it a number I’d say 80%.

    I had a wonderful surgeon but I’d heard horror stories from other people. Some of the surgeons doing these surgeries aren’t doing a very good job because it’s such a new treatment when it comes to headaches. If you are considering doing any kind of surgical procedure to treat your headaches, DO YOUR RESEARCH. Don’t just stick with your doctor because they are the most convenient one. I traveled 1200 miles to have my surgery and it was completely worth it.

    Also, this treatment is not yet FDA approved. It is hard to get insurance to cover it although people seem to be having more and more success with that. If insurance won’t cover a PNS, it’s very cost-prohibitive to the patient ($50,000 and up).

    There are some good blogs out there detailing personal experiences as well as a very active Facebook group (entitled Occipital Nerve Stimulation) if anyone wants more info.

  • Achinghead
    7 years ago

    Hi,

    I had Occipital Nerve Decompression surgery 11/3/2010. It took 16 months for the full benefit of the surgery to be realized. I have had an 85-90% decrease in migraines on the back of my head.

    I had Frontal Nerve Decompression surgery on 8/1/2012. So far I have gone from having migraines almost daily, to having 3-4 days a week without a migraine. The migraines I do get are not as severe and don’t last as long as they did prior to surgery.

    I see a Neurologist who only sees patients with headaches. She is a Headache Specialist in Houston who works with a Plastic Surgeon to determine if you are qualified for the surgery. We worked together to try numerous preventatives as well as an abortive and pain medication. We then tried Botox as well as Nerve Blocks. The nerve blocks provided great relief, which indicated that the surgery would offer relief.

    Prior to surgery I had tried medication, acupuncture, relaxation therapy, heat, ice therapy, physical therapy, going off of all pain medication for 2 months to be sure I wasn’t suffering from medication overuse headaches, avoiding triggers and nothing was helping with my chronic daily migraines.

    As you stated in your article, this surgery is not for everyone. This is my experience with nerve decompression surgery, and I just wanted to give everyone details of my experience.

    Thanks, Nancy

  • mjsymonds
    7 years ago

    Thanks Dr. H. for a very informative article. Are there any statistics available on what percentage of migraineurs have found substantial relief from their refractory pain after undergoing these procedures? Or can you offer any anecdotal numbers from your own practice?

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