|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.
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- 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.
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- 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.