Can migraines be treated surgically? From a serendipitous finding come new surgical decompression techniques that provide relief for select patients with this often-debilitating condition.
Background
Surgery for migraine headaches was first discovered by Cleveland plastic surgeon Bahman Guyuron, MD, who noticed that patients were reporting migraine relief after undergoing cosmetic browlift surgery. Research later showed that release of the supraorbital nerve, which is commonly done during browlift surgery, was the reason for this improvement.
Since that discovery, plastic surgeons and neurologists having been refining surgical options for treating migraines (1). We now know of several other nerves that can trigger migraines. Surgical treatment might include decompression of one or more of these nerves, similar to treatment of carpal tunnel syndrome, cubital tunnel syndrome, or other nerve compression syndromes.
Patient Evaluation
Patients who present with severe headaches must first be diagnosed with migraine disorder by a neurologist or headache specialist. During the surgical evaluation, we will identify the site(s) of pain and determine which nerves are triggering the migraines, possibly confirming this with Botox® injections or a local anesthetic.
Patients whose symptoms are relieved by local injections are the most likely candidates for the surgical procedure. Other factors, such as previous treatments, medications success or failure, medication side effects, and migraine severity and duration, also determine a patient’s suitability for surgery.
How the Procedure Works
The procedure is performed in the outpatient suite, usually under general anesthesia. It usually takes one to two hours, though may take longer if a patient has multiple trigger sites on different areas of the head.
For frontal migraines, we use either an endoscopic approach (through the scalp) or a transpalpebral approach (through the upper eyelid) to resect the corrugator supercilii muscle and decompress the supraorbital and supratrochlear nerves. Our research has shown that both approaches are effective complete muscle resection (2).
The next most common target of nerve decompression is the greater occipital nerve at the back of the scalp. Six different compression points have been described for this nerve, including the trapezius, semispinalis capitis, and the occipital artery.
Other nerves that may trigger migraines are the zygomatico frontal, auriculotemporal, and the lesser and third occipital nerves. In some patients with “rhinogenic” migraines, irritation of the peripheral branches of the trigeminal nerve in the nasal mucosa causes the headache. This can often be improved by a septoplasty or a turbinectomy.
In all cases, the procedure is not intracranial surgery, and the skull bones are never removed.
After surgery, patients may have some slight bruising and swelling, but this is typically gone within two weeks. The incisions are well hidden in the scalp or eyelid. Recovery is quick: most patients can return to work within a few days and resume their usual activities within two weeks.
Outcomes and Complications
Over the last 10 years, multiple studies have consistently shown that surgical decompression of the involved nerve(s) has a beneficial effect on the intensity, duration, and severity of migraine headaches.
The most notable of these studies was a randomized controlled trial from Case Western Reserve University. In this study, patients were randomized into two groups. One group had a surgical decompression of the nerve; the other had a sham surgery (general anesthesia, surgical incision, and exposure of the nerve without a complete decompression). There was a 57% cure rate (defined as complete elimination of migraines) in the surgery group versus a 4% cure rate in the sham surgery group (3).
Retrospective and prospective studies from other institutions have shown success rates (defined as complete elimination of migraines or more than 50% decrease in headache intensity, duration, and frequency) of 70% to 90%, with roughly a third of patients experiencing total relief of their migraines (3-6). A recently published five-year follow-up study showed that the results endure over time (7).
Complications are usually minor and temporary, and include neuropraxia, numbness, alopecia, and incomplete relief of the migraine. Other complications included nerve injury, bleeding, and wound healing problems.
As with cosmetic surgery, many patients notice an aesthetic improvement in the appearance of their forehead, with an elimination of frown lines and forehead wrinkles and a correction of sagging eyebrows.
Consultation and More Information
For more information about migraine surgery, or to contact us, visit our website for patients.
References
- Kung et al. Migraine surgery: a plastic surgery solution for refractory migraine headache. Plast Reconstr Surg. 2011 Jan;127(1):181-9.
- Afifi AM et al. Comparison of the transpalpebral and endoscopic approaches in resection of the corrugator supercilii muscle. Aesthet Surg J. 2012 Feb 1;32(2):151-6.
- Guyuron B et al. A placebo-controlled surgical trial of the treatment of migraine headaches. Plast Reconstr Surg. 2009 Aug;124(2):461-8.
- Dirnberger F et al. Surgical treatment of migraine headaches by corrugator muscle resection. Plast Reconstr Surg. 2004 Sep 1;114(3):652-7.
- Ducic I et al. Indications and outcomes for surgical treatment of patients with chronic migraine headaches caused by occipital neuralgia. Plast Reconstr Surg. 2009 May;123(5):1453-61.
- Poggi JT, Grizzell BE, Helmer SD. Confirmation of surgical decompression to relieve migraine headaches. Plast Reconstr Surg. 2008 Jul;122(1):115-22.
- Guyuron B et al. Five-year outcome of surgical treatment of migraine headaches. Plast Reconstr Surg. 2011 Feb;127(2):603-8.