|Dr Elliot Shevel|
Dr Elliot Shevel – Migraine Surgery Pioneer
|Alma mater||University of the Witwatersrand|
|Occupation||Founder and Medical Director of The Headache Clinic South Africa|
Dr Elliot Shevel BDS, DipMFOS, MBBCh (born 3 January 1943 ) is a South African maxillo-facial and oral surgeon, best known for his contribution to understanding of the underlying processes involved in the pain of migraine. He is, inter alia, a tireless campaigner to bring to the attention of migraine specialists the importance of the extracranial (outside the skull) structures in migraine. The importance of these structures in migraine is not generally appreciated by most migraine specialists. The anatomical structures that have been proven to be important in migraine are a) the pericranial (around the head) muscles, and b) the extracranial terminal branches of the external carotid artery. The reason for the lack of awareness among migraine specialists of the importance of the pericranial muscles and the extracranial arteries in migraine, is that these structures are not mentioned in the diagnostic criteria for migraine laid down by the Headache Classification Committee of the International Headache Society (IHS). The IHS Classification does not require the examining physician to examine the muscles or the arteries when diagnosing migraine. Shevel maintains that progress in the understanding of migraine pain has been materially retarded by this, and has published a number of papers on the subject. Shevel has shown that the universally accepted diagnostic criteria for migraine, as laid down by the IHS, are not supported by data, and are unscientific. At the Congress for Controversies in Neurology in Vienna in 2012, Shevel debated the validity of the IHS classification criteria of migraine with the chairman of the IHS classification committee, and, after presenting conclusive evidence that the criteria had no scientific validity, was adjudged the winner of the debate.
Shevel has practised as a Maxillo-Facial and Oral Surgeon in Johannesburg, South Africa, since 1973. In 1999 he was awarded an honorary fellowship by the International College of Craniomandibular Orthopedics, and he is a peer reviewer for "The European Journal of Neurology", the "International Journal of Clinical Practice", "Headache", the official journal of the American Headache Society, and "Cephalalgia", the official journal of the International Headache Society.
His first contribution to medical science was the development of an atraumatic method of removing impacted wisdom teeth, which significantly reduces the amount of post-operative swelling and pain. His major contributions have however been in the field of migraine and other primary headaches – these are expanded upon below.
Arteries and migraine pain
In 1995, Shevel observed that in some migraine patients the frontal branch of the superficial temporal artery throbbed visibly during a migraine attack. Digital compression of this artery sometimes resulted in the pain being reduced or eliminated while the pressure was maintained. When the pressure was removed, the pain returned. As a Maxillo-Facial Surgeon, he knew that this vessel could be tied off without any untoward side effects. Encouraged by the results of the surgery, he decided to publish a description of the procedure. At that stage, Shevel was unaware of the work of Harold Wolff, but when he studied the published literature, he was astounded to find that the involvement of the extracranial terminal branches of the external carotid artery in migraine pain had been recognised and proven by Wolff as long ago as 1934. Wolff's theory has since been confirmed many times.
Arterial surgery for migraine – The Shevel Procedure
Armed with this knowledge, Shevel developed a protocol for the accurate identification of the painful vessels, using a combination of history, clinical examination, Doppler flowmetry, and 3 Dimensional Computer Tomograph Angiograms. The Shevel procedure consists of minimally invasive surgical exposure and cauterisation of the painful arteries. The results of the Shevel procedure for surgical cauterisation in selected patients were excellent, particularly as all the patients undergoing the surgery were suffering from 'refractory migraine' – migraine that had not responded to any other form of treatment.
Historical perspective of arterial surgery for migraine
A search of the literature brought to light a number of previously published papers describing either ligation or cryotherapeutic ablation of the terminal branches of the external carotid artery for migraine and migraine-like headaches. The first mention in the literature of arterial migraine surgery was by Abu Qasim al-Zahrawi, the personal physician to Al-Hakam II, Caliph of Cordoba, in Al-Andalus (936–1013). Since then there have been numerous reports of this procedure from many countries, but they have been largely unnoticed or ignored by mainstream headache scientists. Painful dilatation of the extracranial terminal branches of the external carotid artery is not a diagnostic criterion for migraine in the International Headache Classification, and most headache specialists are unaware that is an important component of migraine pain. Harold Wolff, and his co-workers showed conclusively as far back as the 1940s that the terminal branches of the external carotid artery are a source of pain in migraine, but his work has been forgotten, and most migraine researchers today are unaware of its importance. On the contrary, some have, notwithstanding the evidence, made a concerted attempt to discredit Wolff's findings, even though no one has been able to provide evidence that disproves Wolff's theory. Shevel has devoted himself to resuscitating Wolff's ideas, and to this end has published a number of articles in peer-reviewed medical journals, while writing a constant stream of letters to the editors of the important headache journals.
Muscles and migraine pain
In 1992, he developed an intra-oral appliance (called the Posture Modifying Appliance or PMA) for the treatment of the myofascial pain dysfunction syndrome (MPDS). When some of his patients reported that wearing the PMA had reduced or eliminated their migraines, he realised that there must be a muscle tension component to the pain of migraine. This was confirmed in a literature search, which revealed that the presence of pericranial muscle tenderness in migraine had been extensively documented, and that there is focal pericranial (masticatory and cervical) muscle tenderness with associated referred symptoms that reproduce the headache pain. As the migraine headache increases in intensity, there is increasing tenderness of the pericranial muscles. The literature search also revealed that various intra-oral appliances designed to reduce muscle tension, are effective in the treatment of migraine. Shevel started restricting his practice to the treatment of migraine and tension-type headaches. The results of muscle tension treatment with the PMA for tension-type headache and for the muscle tension component of migraine are excellent, particularly as the medication with its side-effects is eliminated or reduced in successfully treated migraineurs. Although the treatment of muscle tension has been shown to be effective in some migraine sufferers, this form of treatment has not been recognised by the vast majority of migraine specialists, and muscle pain is not listed as a symptom of migraine in the official headache classification of the International Headache Society.
- Olesen J (2004). "The International Classification of Headache Disorders". Cephalalgia 24: 1–160. PMID 14979299.
- Shevel E (2009). "Middle meningeal artery dilatation in migraine". Headache 49 (10): 1541–3. doi:10.1111/j.1526-4610.2009.01495.x. PMID 19656222.
- Shevel E (2011). "The extracranial vascular theory of migraine: an artificial controversy". J Neural Transm 118 (4): 525–30. doi:10.1007/s00702-010-0517-1. PMID 21207080.
- Shevel E (2007). "Vascular surgery for chronic migraine". Therapy 4 (4): 451–456. doi:10.2217/14750708.4.4.451.
- Shevel E (2007). "Migraine pain – intracranial or extracranial?". Headache 47 (10): 1458. doi:10.1111/j.1526-4610.2007.00942.x. PMID 18052959.
- Shevel E; Spierings, EH (2004). "The role of extra cranial arteries in migraine headache: A review". Cranio – the Journal of Craniomandibular Practice 22 (2): 132–136. doi:10.1179/crn.2004.017. PMID 15134413.
- Shevel E (2007). "The Role of the External Carotid Vasculature in Migraine". In Laura B Clarke. Migraine Disorder Research Trends. New York: Nova Biomedical. pp. 165–182.
- Shevel E, Koepp W, Butow K-W. (2001). "A subjective assessment of pain and swelling following the surgical removal of impacted third molar teeth using two different surgical techniques". SADJ 56 (5): 238–241. PMID 11490696.
- Clark D, Hough H, Wolff HG (1934). "Experimental studies on headache". A Research Nerv. and Ment. Dis 15: 417.
- Graham JR, Wolff HG (1938). "Mechanism of migraine headache and action of ergotamine tartrate". Arch. Neurol. Psychiat 39: 737–763. doi:10.1001/archneurpsyc.1938.02270040093005.
- Schumacher GA, Wolff HG (1941). "Experimental studies on headache: A. Contrast of histamine headache with the headache of migraine and that associated with hypertension. B. Contrast of vascular mechanisms in pre-headache and in headache phenomena of migraine". Arch. Neurol. Psychiat 45: 199–214. doi:10.1001/archneurpsyc.1941.02280140009001.
- Wolff HG, Tunis MM (1952). "Analysis of cranial artery pressure pulse waves in patients with vascular headache of the migraine type". Trans. Assn. Am. Phys 65 (5): 240–244. PMID 13005666.
- Wolff HG, Tunis MM, Goodell H (1953). "Evidence of tissue damage and changes in pain sensitivity in subjects with vascular headaches of the migraine type". Arch. Int. Med 92: 332–341. PMID 13136278.
- Tunis MM, Wolff HG (1953). "Long term observations on the reactivity of the cranial arteries in subjects with vascular headaches of the migraine type". Arch. Neurol. Psychiat 70 (5): 551–557. doi:10.1001/archneurpsyc.1953.02320350003001. PMID 13091503.
- Brazil P, Friedman AP (1956). "Craniovascular studies in headache; a report and analysis of pulse volume tracings". Neurology 6 (2): 96–102. doi:10.1212/wnl.6.2.96. PMID 13288761.
- Ostfeld AM, Chapman LF, Goodell H, Wolff HG (1957). "Studies in headache; summary of evidence concerning a noxious agent active locally during migraine headache". Psychosom Med 19 (3): 199–208. PMID 13432093.
- Iversen HK, Nielsen TH, Olesen J, Tfelt-Hansen P (1990). "Arterial responses during migraine headache". Lancet 336 (8719): 837–839. doi:10.1016/0140-6736(90)92339-J. PMID 1976878.
- Elkind AH, Friedman AP, Grossman J (1964). "Cutaneous Blood Flow in Vascular Headaches of the Migraine Type". Neurology 14: 24–30. doi:10.1212/wnl.14.1.24. PMID 14112444.
- Sakai F, Meyer JS (1978). "Regional cerebral hemodynamics during migraine and cluster headaches measured by the 133Xe inhalation method". Headache 18 (3): 122–132. doi:10.1111/j.1526-4610.1978.hed1803122.x. PMID 669942.
- Sakai F, Meyer JS (1979). "Abnormal cerebrovascular reactivity in patients with migraine and cluster headache". Headache 19 (5): 257–266. doi:10.1111/j.1526-4610.1979.hed1905257.x. PMID 468531.
- Olesen IJ, Gulbenkian S, Valenca A (1995). "The peptidergic innervation of the human superficial temporal artery: immunohistochemistry, ultrastructure, and vasomotility". Peptides 16 (2): 275–287. doi:10.1016/0196-9781(94)00165-0. PMID 7540293.
- Goadsby PJ, Edvinsson L (1993). "The trigeminovascular system and migraine: studies characterizing cerebrovascular and neuropeptide changes seen in humans and cats". Annals of Neurology 33 (1): 48–56. doi:10.1002/ana.410330109. PMID 8388188.
- Goadsby PJ, Edvinsson L, Ekman R (1990). "Vasoactive peptide release in the extracerebral circulation of humans during migraine headache". Annals of Neurology 28 (2): 183–187. doi:10.1002/ana.410280213. PMID 1699472.
- Jansen I, Edvinsson L, Mortensen A, Olesen J (1992). "Sumatriptan is a potent vasoconstrictor of human dural arteries via a 5-HT1-like receptor". Cephalalgia 12 (4): 202–205. doi:10.1046/j.1468-2982.1992.1204202.x. PMID 1326402.
- Petersen KA, Lassen LH, Birk S, Lesko L, Olesen J (2005). "BIBN4096BS antagonizes human alpha-calcitonin gene related peptide-induced headache and extracerebral artery dilatation". Clin Pharmacol Ther 77 (3): 202–213. doi:10.1016/j.clpt.2004.10.001. PMID 15735614.
- Ostergaard JR, Mikkelsen E, Voldby B (1981). "Effects of 5-hydroxytryptamine and ergotamine on human superficial temporal artery". Cephalalgia 1 (4): 223–228. doi:10.1046/j.1468-2982.1981.0104223.x. PMID 7347625.
- Ferrari MD, Saxena PR (1993). "Clinical and experimental effects of sumatriptan in humans". Trends Pharmacol Sci 1993 (4): 129–133. doi:10.1016/0165-6147(93)90084-w. PMID 8390743.
- Doods H (2001). "Development of CGRP antagonists for the treatment of migraine". Current Opinion in Investigational Drugs 2 (9): 1261–1268. PMID 11717813.
- Olesen J, Diener HC, Husstedt IW (2004). "Calcitonin gene-related peptide receptor antagonist BIBN 4096 BS for the acute treatment of migraine". N Engl J Med 350 (11): 1104–1110. doi:10.1056/NEJMoa030505. PMID 15014183.
- Petersen KA, Birk S, Lassen LH (2005). "The CGRP-antagonist, BIBN4096BS does not affect cerebral or systemic haemodynamics in healthy volunteers". Cephalalgia 25 (2): 139–147. doi:10.1111/j.1468-2982.2004.00830.x. PMID 15658951.
- Verheggen R, Bumann K, Kaumann AJ (2002). "BIBN4096BS is a potent competitive antagonist of the relaxant effects of alpha-CGRP on human temporal artery: comparison with CGRP(8–37)". Br J Pharmacol 136 (1): 120–126. doi:10.1038/sj.bjp.0704682. PMC 1762122. PMID 11976276.
- Louis S (1981). "A bedside test for determining the sub-types of vascular headache". Headache 21 (3): 87–88. doi:10.1111/j.1526-4610.1981.hed2103087.x. PMID 7263221.
- Blau JN, Dexter SL (1981). "The site of pain origin during migraine attacks". Cephalalgia 1 (3): 143–147. doi:10.1046/j.1468-2982.1981.0103143.x. PMID 7346182.
- Drummond PD, Lance JW (1983). "Extracranial vascular changes and the source of pain in migraine headache". Annals of Neurology 13 (1): 32–37. doi:10.1002/ana.410130108. PMID 6830162.
- Lipton SA (1986). "Prevention of classic migraine headache by digital massage of the superficial temporal arteries during visual aura". Annals of Neurology 19 (5): 515–516. doi:10.1002/ana.410190521. PMID 3717913.
- Vijayan N (1993). "Head band for migraine headache relief". Headache 33 (1): 40–42. doi:10.1111/j.1526-4610.1993.hed3301040.x. PMID 8436498.
- Shevel E, Spierings EH (2004). "Role of the extracranial arteries in migraine headache: a review". Cranio 22 (2): 132–136. doi:10.1179/crn.2004.017. PMID 15134413.
- Shevel E (2007). "Vascular Surgery for Chronic Migraine". Therapy 4 (4): 451–456. doi:10.2217/14750708.4.4.451.
- Abu al-Qasim al-Zahrawi. Al-Tasrif.
- Nadler SB (1945). "Paroxysmal temporal headache". JAMA. Sept 29: 334–335. doi:10.1001/jama.1945.02860390020005.
- Murillo CA (1968). "Resection of the temporal neurovascular bundle for control of migraine headache". Headache 8 (3): 112–117. doi:10.1111/j.1526-4610.1968.hed0803112.x. PMID 5730120.
- Cook N (1973). "Cryosurgery of migraine". Headache 12 (4): 143–150. doi:10.1111/j.1526-4610.1973.hed1204143.x. PMID 4682552.
- Bouche J, Freche C, Chaix G, Dervaux JL (1974). "[Surgery by cryotherapy of the superficial temporal artery in temporo-parietal neuralgia] French". Ann Otolaryngol Chir Cervicofac 91 (1): 56–9. PMID 4603862.
- Florescu V, Florescu R (1975). "[Value of resection of the superficial temporal vasculo-nervous bundle in some cases of vascular headache.] Romanian". Rev Chir Oncol Radiol O R L Oftalmol Stomatol Otorinolaringol 20 (2): 113–117. PMID 127294.
- Holland JT (1976). "Three cases of vascular headache treated by surgery". Proc Aust Assoc Neurol 13: 51–54. PMID 1029006.
- Rapidis AD (1976). "The therapeutic result of excision of the superficial temporal artery in atypical migraine". J Maxillofac Surg 4 (3): 182–188. doi:10.1016/S0301-0503(76)80029-X. PMID 1066419.
- Cook N (1978). "Cryosurgery of headache". Res Clin Stud Headache 5: 86–101. PMID 674810.
- Sacristán HD, Ramírez AB (1980). "[Tratamiento Quirurgico de las Jaquecas] Spanish". Annales de la Real. X Sesion Cientifica: 29 Abril.
- Hankemeier U (1985). "[Therapy of pulsating temporal headache. Resection of the superficial temporal artery.] German". Fortschr Med 103 (35): 822–4. PMID 4054803.
- Shi FY (1989). "[Morphological studies of extracranial arteries in patients with migraine] Chinese". Zhonghua Bing Li Xue Za Zhi 18 (4): 271–3. PMID 2636957.
- Goadsby P (2009). "The vascular theory of migraine – a great story wrecked by the facts". Brain 132 (Pt 1): 6, 7. doi:10.1093/brain/awn321. PMID 19098031.
- Shevel E (2007). "Migraine pain—intracranial or extracranial?". Headache 47 (10): 1458. doi:10.1111/j.1526-4610.2007.00942.x. PMID 18052959.
- Shevel E (2008). "Headache education for the medical students: Wolff's postulates". Headache 48 (4): 638–9. doi:10.1111/j.1526-4610.2007.01035.x. PMID 18194295.
- Shevel E (2009). "A comment on remarks regarding Schoonman et al. 'Migraine headache is not associated with cerebral or meningeal vasodilatation—a 3T magnetic resonance angiography study'". Headache 49 (10): 1548–9. doi:10.1111/j.1526-4610.2009.01480.x. PMID 19549157.
- Shevel E (2009). "The trigeminovascular system—quo vadis?". Headache 49 (5): 785–6. doi:10.1111/j.1526-4610.2009.01415.x. PMID 19456890.
- Shevel E (2009). "Comments on Schoonman et al.: Migraine headache is not associated with cerebral or meningeal vasodilatation: a 3 T magnetic resonance angiography study (Brain 2008; 131:2192–2200)". J Headache Pain 10 (4): 307–8. doi:10.1007/s10194-009-0123-5. PMID 19407929.
- Shevel E (2009). "Headache education for medical students: Wolff's postulates—further communication". Headache 49 (4): 611. doi:10.1111/j.1526-4610.2009.01366.x. PMID 19245389.
- Hay KM (1979). "Pain thresholds in migraine". Practitioner 222 (1332): 827–833. PMID 482233.
- Jensen K, Tuxen C, Olesen J (1988). "Pericranial muscle tenderness and pressure-pain threshold in the temporal region during common migraine". Pain 35 (1): 65–70. doi:10.1016/0304-3959(88)90277-1. PMID 3200599.
- Lous I, Olesen J. (1982). "Evaluation of pericranial tenderness and oral function in patients with common migraine, muscle contraction headache and 'combination headache". Pain. 12 (4): 385–393. doi:10.1016/0304-3959(82)90183-X. PMID 7048208.
- Olesen J (1978). "Some clinical features of the acute migraine attack. An analysis of 750 patients". Headache 18 (5): 268–271. doi:10.1111/j.1526-4610.1978.hed1805268.x. PMID 721459.
- Tfelt-Hansen P, Lous I, Olesen J. (1981). "Prevalence and significance of muscle tenderness during common migraine attacks". Headache 21 (2): 49–54. doi:10.1111/j.1526-4610.1981.hed2102049.x. PMID 7239900.
- Jensen K, Bulow P, Hansen H (1985). "Experimental toothclenching in common migraine". Cephalalgia 5 (4): 245–251. doi:10.1046/j.1468-2982.1985.0504245.x. PMID 4084979.
- Langemark M, Olesen J (1987). "Pericranial tenderness in tension headache. A blind, controlled study". Cephalalgia 7 (4): 249–255. doi:10.1046/j.1468-2982.1987.0704249.x. PMID 3427625.
- Lapeer GL (1988). "Reduction of the painful sequelae of migraine headache by use of the occlusal diagnostic appliance: an hypothesis". Journal of Craniomandibular Practice 6 (1): 82–86. PMID 3282687.
- Quayle AA, Gray RJM, Metcalfe RJ, Guthrie E, Wastell D (1990). "Soft occlusal splint therapy in the treatment of migraine and other headaches". Journal of Dentistry 18 (3): 123–129. doi:10.1016/0300-5712(90)90048-J. PMID 2401762.
- Lamey PJ, Steele JG, Aitchison T. (1996). "Migraine: the effect of acrylic appliance design on clinical response". British Dental Journal 180 (4): 137–140. doi:10.1038/sj.bdj.4809001. PMID 8850287.
- Shevel E (2005). "Craniomandibular muscles, intraoral orthoses and migraine". Expert Rev Neurother 5 (3): 371–377. doi:10.1586/14737184.108.40.2061. PMID 15938670.
- de Tommaso M, Shevel E, Libro G, Guido M, Di Venere D, Genco S, Monetti C, Serpino C, Barile G, Lamberti P, Livrea P. (2005). "Effects of amitriptyline and intra-oral device appliance on clinical and laser-evoked potentials features in chronic tension-type headache". Neurol Sci 26: S152–S154. doi:10.1007/s10072-005-0432-7. PMID 15926017.
- de Tommaso M, Shevel E, Pecoraro C, Sardaro M, Divenere D, Di Fruscolo O, Lamberti P, Livrea P. (2006). "Intra-oral orthosis vs amitriptyline in chronic tension-type headache: a clinical and laser evoked potentials study". Head Face Med 2: 15. doi:10.1186/1746-160X-2-15. PMC 1484471. PMID 16725028.
- de Tommaso M, Shevel E, Pecoraro C, Sardaro M, Losito L, Lamberti P, Livrea P. (2006). "Topographic analysis of laser evoked potentials in chronic tension-type headache: Correlations with clinical features". Int Psychophysiol 62 (1): 38–45. doi:10.1016/j.ijpsycho.2005.12.002. PMID 16503063.