Migraine surgery

Surgical Treatment of Migraine Headaches have recently been used and innovative surgical techniques have been developed to help patients with migraine headaches. Migraine headaches affect an estimated 10% of the worldwide population annually, and cause significant loss of workdays and billions of dollars in productivity. It is well documented that migraine headaches cause significant disability, and reduce of quality of life that is as dire, if not worse than, debilitating chronic diseases. There have been major pharmacological advances for the treatment of migraine headaches, yet patients must still endure migraine headache symptoms until the medications take effect. Furthermore, often they still experience a poor quality of life despite an aggressive regimen of pharmacotherapy. Elimination of trigger sites (TS) which was introduced to the public after successful clinical trials has been revolutionary in providing significant improvement and/or long lasting relief from symptoms in appropriate candidates.

Trigger Site Release

The proposed theory is that trigger sites exist where sensory nerves are being stimulated by surrounding muscle or specific contact points. As a consequence of irritation of these nerves, a cascade of events is initiated which lead to inflammation of meningeal layers and migraine headaches. Four trigger areas have been identified so far. Three of these are in locations which the nerve passes through a muscle . The fourth trigger point, however, has been identified in the nose of patients who have significant septal deviation with enlargement of the turbinates. The contact between these structures causes the irritation of the trigeminal nerve end branches and thus triggers migraine headaches. Several large series of studies have been conducted to evaluate the efficacy of surgical obliteration of trigger points. Almost all demonstrated more than 90% response, with at least 50% improvement to complete resolution of migraine pain symptoms.

Ohio Plastic Surgeon Dr. Bahman Guyuron Chair of Plastic Surgery at Case Western Reserve University, was the first to explore and describe trigger site surgery to relieve migraines. His serendipitous discovery followed revelation by several of his patients that their migraines had disappeared following cosmetic brow lifts. This prompted a series of retrospective and prospective studies with gratifying results. However, this type of migraine surgery is not offered as a first line of treatment, rather it is used after extensive evaluation and failure of medical treatment. Trials are still ongoing to standardize the procedures of choice for definitive management of migraine headaches, but there have been successful guidelines for surgical therapy , which are being used by several migraine surgery specialists around the globe. Currently this treatment has institutional approval for adults, and trials for the pediatric population are ongoing.

Details of the procedure

Patients have to be screened preoperatively with a full neurological examination, and subsequent Botox injection and/or nasal endoscopy. A positive response to Botox predicts a favorable outcome of surgery. Single or multiple TS could exist and after proper identification, the surgical approach is planned. Migraine headaches can start in one area depending on their corresponding trigger site and spread to the rest of the forehead. It is important to identify the initial trigger sites rather than address all the areas of pain, after the inflammation involves the entire trigeminal tree. The following migraine headaches corresponds to their four separate trigger sites and are addressed individually either with multiple surgeries or more commonly on a single setting. Sometime alleviation of one trigger site results in unmasking a second site.

1) Forehead Migraine Headaches: In the glabellar area the supra-orbital and supra-trochlear nerves are skeletonized by resecting the corrugator and depressor supercilii muscle using an endoscopic approach similar that of used for cosmetic forehead lift.

2) Temporal Migraine Headaches: The temporal area, where the zygomaticotemporal branch of trigeminal nerve passes through the temporalis muscle, is addressed using a similar endoscopic approach but involves removing a segment of the nerve rather than transecting the muscle. The residual sensory defect on the temporal skin area is minimal because of cross innervation from other sensory nerves.

3) Rhinogenic Migraine Headaches: The nasal trigger points where enlarged turbinates are in contact with the nasal septum are addressed with septoplasty and turbinectomy.

4) Occipital Migraine Headaches: The posterior neck area where the greater occipital nerve passes through the semispinals capitis muscle is addressed with an open surgical approach with resection of a small segment of the semispinalis muscle and shielding the nerves with a subcutaneous adipose flap. Migraine pressure points were the key that show me this new idea! 1- migraine pressure points in place # 1 for frontal/ocular migraine headaches.

2- migraine pressure points in place # 3 for occipital (basilar) migraine headaches.

Note; rare cases of frontal migraine headaches need pace # 3 not place # 1.

Other Surgical and invasive approaches in consideration

A) Surgical Ligation of scalp vessels has shown some promise in the treatment of migraine headaches. Ligation of temporal vessels was first described by Al-Zahrawi (936 - 1013 AD) , a Moorish physician. Historically it is reported that Ambroise Paré (1510-1590 AD) father of modern medicine ligated his own temporal vessels for relief of his migraines. This technique however has not been popularized thus far. A recent study however, showed that selected patients with chronic migraine experience a significant reduction in pain levels and significant improvement in their quality of life following the surgery.

B) Patent Foramen ovale (PFO) Correction: Several clinical trials are currently under way in an effort to determine the existence of a causal linkage between PFO and migraine. It has been shown that migraines are reduced in frequency if the foramen is closed.

C) Botulinum toxin A: Various headache specialists report encouraging results for chronic migraines using injection of botulinum toxin A. This treatment is effective in suppressing the trigger site without invasive surgery. However, repeated injections are required to keep the headaches under control and they do not address the headaches which are triggered from the septum and turbinates.

D) Spinal Cord Stimulators: These are medical implant stimulators in the region of the spinal cord. They are sometimes used in cases of severe migraine headache on patients who tend to have multiple attacks in a month.

References

1. Jensen R, Stovner LJ. Epidemiology and comorbidity of headache. Lancet Neurol. 2008 Apr;7(4):354-61.

2. Guyuron B, Kriegler JS, Davis J, Amini SB.Comprehensive surgical treatment of migraine headaches.Plast Reconstr Surg. 2005 Jan;115(1):1-9. PMID: 15622223.

3. Guyuron B, Tucker T, Davis J.Surgical treatment of migraine headaches. Plast Reconstr Surg. 2002 Jun;109(7):2183-9. PMID: 12045534. 4. Totonchi A, Pashmini N, Guyuron B.The zygomaticotemporal branch of the trigeminal nerve: an anatomical study.

5. Abu Qasim Al-Zahrawi (936 - 1013 AD), Al-Tasrif. Cordoba , Spain.

6. Shevel E. Vascular Surgery for Chronic Migraine. Therapy 2007; 4: 451-456.

7. Elliot Shevel, Migraine Disorders Research Trends , Clarke Laura B., Nova Science Publishers,September 19, 2007, Page 166.

8. Fan Z, Fan Z, Wang H. New surgical approach for migraine. Otol Neurotol. 2006 Aug;27(5):713-5.

9. Chwerzmann M, Wiher S, Nedeltchev K, Mattle HP, Wahl A, Seiler C, Meier B, Windecker S (2004). "Percutaneous closure of patent foramen ovale reduces the frequency of migraine attacks". Neurology 62 (8): 1399-401. PMID 15111681.

10. Samton JB and Mauskop A. The treatment of headaches with Botulinum Toxin. Expert Review of Neurotherapeutics March 2006, Vol. 6, No. 3, Pages 313–322.

11. Matharu MS, Bartsch T, Ward N, Frackowiak RS, Weiner R, Goadsby PJ (2004). "Central neuromodulation in chronic migraine patients with suboccipital stimulators: a PET study". Brain 127 (Pt 1): 220-30. PMID 14607792. 12. Dr sultaneh .Migraine: New Surgical Treament, 2001 San Diego American neurological Congerss