Jump to content

Migraine surgery: Difference between revisions

From Wikipedia, the free encyclopedia
Browse history interactively
← Previous editNext edit →
Content deleted Content added
VisualWikitext
→Minimally Invasive Arterial Surgery (MIAS): fix pmid, remove incorrect PMC
YingYang2 (talk | contribs)
341 edits
←Replaced content with '{{POV|date=May 2011}} '''Migraine surgery''' is any surgical operation undertaken with the goal of reducing or preventing migraines.'
Line 1: Line 1:
{{POV|date=May 2011}}
{{POV|date=May 2011}}


'''Migraine surgery''' is any [[surgery operation|surgical operation]] undertaken with the goal of reducing or preventing [[migraine]]s.
'''Migraine surgery''' is any [[surgery operation|surgical operation]] undertaken with the goal of reducing or preventing [[migraine]]s. Innovative [[surgical technique]]s have been developed to help patients with migraine headaches. Migraines affect an estimated 10% of the worldwide population annually{{Citation needed|date=September 2009}} and cause significant loss of workdays and billions of dollars in productivity.{{Citation needed|date=September 2009}} It is well documented{{By whom|date=September 2009}} that migraine headaches cause significant disability, and reduce of quality of life that is as dire, if not worse than, debilitating chronic diseases.{{Citation needed|date=September 2009}} There have been major [[pharmacological]] advances for the treatment of migraine headaches, yet patients must still endure symptoms until the medications take effect. Furthermore, often they still experience a poor quality of life despite an aggressive regimen of pharmacotherapy.<ref name="Jensen 2008">{{cite pmid|18339350}}</ref> For these reasons, surgical solutions to migraines are actively being researched, particularly those involving the surgical cauterization of the superficial blood vessels of the scalp (the terminal branches of the external carotid artery), the removal of muscles or nerves in areas known as "[[trigger sites]]", and those involving the correction of a [[congenital heart defect]].

== Surgical procedures ==
===Arterial surgery===

The rationale for arterial surgery for the treatment of migraine is based upon the work done by [[Harold Wolff]] and his co-workers in the 1940s. Wolff first subjected the condition of migraine to rigorous scientific experimentation, and showed convincingly that in some migraine sufferers the pain originates in the distended terminal branches of the external carotid artery.<ref>{{Cite journal
|journal=A Research Nerv. and Ment. Dis
|author=Clark D, Hough H, Wolff HG
|title=Experimental studies on headache
|volume=15
|pages=417
|year=1934}}</ref><ref>{{Cite journal
|journal=Arch. Neurol. Psychiat
|author=Graham JR, Wolff HG
|title=Mechanism of migraine headache and action of ergotamine tartrate
|volume=39
|pages=737–763
|year=1938}}</ref><ref>{{Cite journal
|journal=Arch. Neurol. Psychiat
|author=Schumacher GA, Wolff HG
|title=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
|volume=45
|pages=199–214
|year=1941}}</ref><ref>{{Cite journal
|journal=Trans. Assn. Am. Phys
|author=Wolff HG, Tunis MM
|title=Analysis of cranial artery pressure pulse waves in patients with vascular headache of the migraine type
|volume=65
|issue=5
|pages=240–244
|year=1952
|pmid=12985578}}</ref><ref>{{Cite journal
|journal=Arch. Int. Med
|author=Wolff HG, Tunis MM, Goodell H
|title=Evidence of tissue damage and changes in pain sensitivity in subjects with vascular headaches of the migraine type
|volume=92
|pages=332–341
|year=1953
|pmid=13136278}}</ref><ref>{{Cite journal
|journal=Arch. Neurol. Psychiat
|author=Tunis MM, Wolff HG
|title=Long term observations on the reactivity of the cranial arteries in subjects with vascular headaches of the migraine type
|volume=70
|issue=5
|pages=551–557
|year=1953
|pmid=13091503}}</ref> Wolff’s theory has since been confirmed many times.<ref>{{Cite journal
|journal=Neurology
|author=Brazil P, Friedman AP
|title=Craniovascular studies in headache; a report and analysis of pulse volume tracings
|volume=6
|issue=2
|pages=96–102
|year=1956
|pmid=13288761}}</ref><ref>{{Cite journal
|journal=Psychosom Med
|author=Ostfeld AM, Chapman LF, Goodell H, Wolff HG
|title=Studies in headache; summary of evidence concerning a noxious agent active locally during migraine headache
|volume=19
|issue=3
|pages=199–208
|year=1957
|pmid=13432093}}</ref><ref>{{Cite journal
|doi=10.1016/0140-6736(90)92339-J
|journal=Lancet
|author=Iversen HK, Nielsen TH, Olesen J, Tfelt-Hansen P
|title=Arterial responses during migraine headache
|volume=336
|issue=8719
|pages=837–839
|year=1990
|pmid=1976878}}</ref><ref>{{Cite journal
|journal=Neurology
|author=Elkind AH, Friedman AP, Grossman J
|title=Cutaneous Blood Flow in Vascular Headaches of the Migraine Type
|volume=14
|pages=24–30
|year=1964
|pmid=14112444}}</ref><ref>{{Cite journal
|doi=10.1111/j.1526-4610.1978.hed1803122.x
|journal=Headache
|author=Sakai F, Meyer JS
|title=Regional cerebral hemodynamics during migraine and cluster headaches measured by the 133Xe inhalation method
|volume=18
|issue=3
|pages=122–132
|year=1978
|pmid=669942}}</ref><ref>{{Cite journal
|doi=10.1111/j.1526-4610.1979.hed1905257.x
|journal=Headache
|author=Sakai F, Meyer JS
|title=Abnormal cerebrovascular reactivity in patients with migraine and cluster headache
|volume=19
|issue=5
|pages=257–266
|year=1979
|pmid=468531}}</ref><ref>{{Cite journal
|doi=10.1016/0196-9781(94)00165-0
|journal=Peptides
|author=Olesen IJ, Gulbenkian S, Valenca A
|title=The peptidergic innervation of the human superficial temporal artery: immunohistochemistry, ultrastructure, and vasomotility
|volume=16
|issue=2
|pages=275–287
|year=1995
|pmid=7540293}}</ref><ref>{{Cite journal
|doi=10.1002/ana.410330109
|journal=Ann Neurol
|author=Goadsby PJ, Edvinsson L
|title=The trigeminovascular system and migraine: studies characterizing cerebrovascular and neuropeptide changes seen in humans and cats
|volume=33
|issue=1
|pages=48–56
|year=1993
|pmid=8388188}}</ref><ref>{{Cite journal
|doi=10.1002/ana.410280213
|journal=Ann Neurol
|author=Goadsby PJ, Edvinsson L, Ekman R
|title=Vasoactive peptide release in the extracerebral circulation of humans during migraine headache
|volume=28
|issue=2
|pages=183–187
|year=1990
|pmid=1699472}}</ref><ref>{{Cite journal
|doi=10.1046/j.1468-2982.1992.1204202.x
|journal=Cephalalgia
|author=Jansen I, Edvinsson L, Mortensen A, Olesen J
|title=Sumatriptan is a potent vasoconstrictor of human dural arteries via a 5-HT1-like receptor
|volume=12
|issue=4
|pages=202–205
|year=1992
|pmid=1326402}}</ref><ref>{{Cite journal
|doi=10.1016/j.clpt.2004.10.001
|journal=Clin Pharmacol Ther
|author=Petersen KA, Lassen LH, Birk S, Lesko L, Olesen J
|title=BIBN4096BS antagonizes human alpha-calcitonin gene related peptide-induced headache and extracerebral artery dilatation
|volume=77
|issue=3
|pages=202–213
|year=2005
|pmid=15735614}}</ref><ref>{{Cite journal
|doi=10.1046/j.1468-2982.1981.0104223.x
|journal=Cephalalgia
|author=Ostergaard JR, Mikkelsen E, Voldby B
|title=Effects of 5-hydroxytryptamine and ergotamine on human superficial temporal artery
|volume=1
|issue=4
|pages=223–228
|year=1981
|pmid=7347625}}</ref><ref>{{Cite journal
|journal=Trends Pharmacol Sci
|author=Ferrari MD, Saxena PR
|title=Clinical and experimental effects of sumatriptan in humans
|volume=1993
|issue=4
|pages=129–133
|year=1993
|pmid=8390743}}</ref><ref>{{Cite journal
|journal=Curr Opin Investig Drugs
|author=Doods H
|title=Development of CGRP antagonists for the treatment of migraine
|volume=2
|issue=9
|pages=1261–1268
|year=2001
|pmid=11717813}}</ref><ref>{{Cite journal
|doi=10.1056/NEJMoa030505
|journal=N Engl J Med
|author=Olesen J, Diener HC, Husstedt IW
|title=Calcitonin gene-related peptide receptor antagonist BIBN 4096 BS for the acute treatment of migraine
|volume=350
|issue=11
|pages=1104–1110
|year=2004
|pmid=15014183}}</ref><ref>{{Cite journal
|doi=10.1111/j.1468-2982.2004.00830.x
|journal=Cephalalgia
|author=Petersen KA, Birk S, Lassen LH
|title=The CGRP-antagonist, BIBN4096BS does not affect cerebral or systemic haemodynamics in healthy volunteers
|volume=25
|issue=2
|pages=139–147
|year=2005
|pmid=15658951}}</ref><ref>{{Cite journal
|doi=10.1038/sj.bjp.0704682
|journal=Br J Pharmacol
|author=Verheggen R, Bumann K, Kaumann AJ
|title=BIBN4096BS is a potent competitive antagonist of the relaxant effects of alpha-CGRP on human temporal artery: comparison with CGRP(8-37)
|volume=136
|issue=1
|pages=120–126
|year=2002
|pmid=11976276
|pmc=1762122}}</ref><ref>{{Cite journal
|doi=10.1111/j.1526-4610.1981.hed2103087.x
|journal=Headache
|author=Louis S
|title=A bedside test for determining the sub-types of vascular headache
|volume=21
|issue=3
|pages=87–88
|year=1981
|pmid=7263221}}</ref><ref>{{Cite journal
|doi=10.1046/j.1468-2982.1981.0103143.x
|journal=Cephalalgia
|author=Blau JN, Dexter SL
|title=The site of pain origin during migraine attacks
|volume=1
|issue=3
|pages=143–147
|year=1981
|pmid=7346182}}</ref><ref>{{Cite journal
|doi=10.1002/ana.410130108
|journal=Ann Neurol
|author=Drummond PD, Lance JW
|title=Extracranial vascular changes and the source of pain in migraine headache
|volume=13
|issue=1
|pages=32–37
|year=1983
|pmid=6830162}}</ref><ref>{{Cite journal
|doi=10.1002/ana.410190521
|journal=Ann Neurol
|author=Lipton SA
|title=Prevention of classic migraine headache by digital massage of the superficial temporal arteries during visual aura
|volume=19
|issue=5
|pages=515–516
|year=1986
|pmid=3717913}}</ref><ref>{{Cite journal
|doi=10.1111/j.1526-4610.1993.hed3301040.x
|journal=Headache
|author=Vijayan N
|title=Head band for migraine headache relief
|volume=33
|issue=1
|pages=40–42
|year=1993
|pmid=8436498}}</ref><ref name="Shevel2004">{{Cite journal
|journal=Cranio
|author=Shevel E, Spierings EH
|title=Role of the extracranial arteries in migraine headache: a review
|volume=22
|issue=2
|pages=132–136
|year=2004
|pmid=15134413}}</ref> There have been attempts to debunk Wolff's vascular theory,<ref>{{Cite journal
|journal= Brain
|author= Goadsby PJ
|title= The vascular theory of migraine--a great story wrecked by the facts
|volume=132
|issue= Pt 1
|pages=6–7
|year=2009
|pmid=19098031
|doi= 10.1093/brain/awn321}}</ref><ref>{{Cite journal
|doi= 10.1097/WCO.0b013e32833821c1
|journal= Curr Opin Neurol
|author= Brennan KC, Charles A
|title= An update on the blood vessels in migraine
|volume=23
|issue= 3
|pages=266–74
|year=2010
|pmid=20216215}}</ref><ref>{{Cite journal
|doi= 10.1136/bmj.332.7532.25
|journal= BMJ
|author= Goadsby PJ
|title= Recent advances in the diagnosis and management of migraine
|volume=332
|issue= 7532
|pages=25–29
|year=2006
|pmid= 16399733
|pmc= 1325129 }}</ref><ref>{{Cite journal
|journal= Neuroscience
|author= Goadsby PJ, Charbit AR, Andreou AP, Akerman S, Holland PR
|title= Neurobiology of migraine
|volume=161
|issue= 2
|pages=327–41
|year=2009
|pmid=19303917
|doi= 10.1016/j.neuroscience.2009.03.019}}</ref><ref>{{Cite journal
|doi= 10.1016/j.ncl.2008.11.012
|journal= Neurol Clin
|author= Goadsby PJ
|title= Pathophysiology of migraine
|volume=27
|issue= 2
|pages=335–360
|year=2009
|pmid= 19289219 }}</ref> and for years it has been out of favor. Recently however, there has been renewed interest in Wolff's vascular theory of migraine led by [[Elliot Shevel]], a South African headache specialist, who has published a number of articles providing compelling evidence that Wolff was in fact correct.<ref name="Shevel2004" /><ref>{{Cite journal
|journal= Headache
|author= Shevel E
|title= Middle meningeal artery dilatation in migraine
|volume=49
|issue= 10
|pages=1541–3
|year=2009
|pmid=19656222
|doi= 10.1111/j.1526-4610.2009.01495.x}}</ref><ref>{{Cite journal
|journal= J Neural Transm
|series= Jan
|author= Shevel E
|title= The extracranial vascular theory of migraine: an artificial controversy
|volume= 5
|pages= Epub ahead of print
|year=2011
|pmid=21207080
|doi= 10.1007/s00702-010-0517-1}}</ref><ref>{{Cite journal
|doi= 10.2217/14750708.4.4.451
|journal= Therapy
|author= Shevel E
|title= Vascular Surgery for Chronic Migraine
|volume=4
|issue= 4
|pages=451–456
|year=2007}}</ref><ref>{{Cite journal
|doi= 10.1111/j.1526-4610.2011.01844.x
|journal= Headache
|author= Shevel E
|title= The Extracranial Vascular Theory of Migraine – A Great Story Confirmed by the Facts
|volume=51
|issue= 3
|pages=409–417
|year=2011
|pmid= 21352215}}</ref>

==== Minimally Invasive Arterial Surgery (MIAS) ====
There is compelling evidence to show that migraine pain often originates in the terminal branches of the external carotid artery.<ref name="Shevel 2007b">{{cite book |last1= Shevel|first1= Elliot |authorlink1= |editor1-first= Laura B |editor1-last= Clarke |editor1-link= |title= Migraine Disorders Research Trends |series= |volume= |date= September 19, 2007 |publisher= [[Nova Science Publishers]] |location= [[New York, New York]], [[USA]] |isbn= 9781600215537 |pages= 165–183|chapter= The Role of the External Carotid Vasculature in Migraine}} {{Google books with page|j-TgnRFVVm8C|Preview the chapter|165}}</ref><ref>{{Cite journal
|journal=Cranio:the Journal of Craniomandibular Practice
|author=Shevel E, Spierings E
|title=Role of the Extracranial Arteries in Migraine Headache: a Review
|volume=22
|issue=1
|pages=132–6
|year=2004
|pmid=15134413
|doi=}}</ref><ref>{{Cite journal
|journal=Transactions of the Association of American Physicians
|author=Wolff HG, Tunis MM, Goodell H.
|title=Studies on headache: evidence of tissue damage and changes in pain sensitivity in subjects with vascular headaches of the migraine type.
|volume=66
|pages=332–341
|year=1953
|pmid=13091465
|issue=4}}</ref><ref>{{Cite journal
|journal=British Medical Journal
|author=Pickering GW
|title=Experimental Observations on Headache
|volume=1
|issue=4087
|pages=907–912
|year=1939
|pmid=13306341
|pmc=2209487
|doi=10.1136/bmj.1.4087.907}}</ref><ref>{{Cite journal
|journal=American Journal of Medical Science
|author=Tunis MM, Wolff HG.
|title=Analysis of Arterial Pulse Waves in Patients with Vascular Headache of the Migraine Type
|volume=224
|pages=121–123
|year=1953
|pmid=12985578
|issue=5}}</ref> In migraine sufferers with extracranial vascular pain, and in whom digital compression of the relevant artery reduces or abolishes the pain, surgical ligation or cauterization of the relevant vessel or vessels provides permanent relief from not only the pain of migraine, but also the associated symptoms such as the aura, light sensitivity (photophobia), sensitivity to sound (phonophobia), nausea, and vomiting.<ref>{{Cite journal
|journal=Future Medicine
|author=Shevel E
|title=Vascular Surgery for Chronic Migraine
|volume=4
|issue=4
|pages=451–456
|year=2007
|doi=10.2217/14750708.4.4.451}}</ref> MIAS is highly successful in migraine sufferers where a definite positive diagnosis has been made, by examining the patient while they are experiencing migraine pain. The terminal branches of the external carotid artery are systematically compressed against the underlying tissues to determine exactly which vessels are responsible for the pain. When the relevant vessels are compressed, the pain either diminishes significantly or disappears completely. In this way, a positive diagnosis is made.

Ligation of temporal vessels was first described by Abu al-Qasim al-Zahrawi (936 – 1013 AD), a Moorish physician.<ref>{{Cite journal
| journal=Al-Tasrif
| author = Al-Zahrawi, Abu al-Qasim
| year = c. 1000}}</ref> Historically, it has been reported that Ambroise Paré (1510–1590 AD), father of modern medicine, ligated his own temporal vessels for relief of his migraines. Since then the efficacy of arterial ablation for migraine treatment by ligation, cryotherapy, or cauterization of the relevant vessels has been confirmed repeatedly.<ref>{{Cite journal
|journal=Zhonghua Bing Li Xue Za Zhi(Chinese)
|author=Shi FY
|title=[Morphological studies of extracranial arteries in patients with migraine]
|volume=18
|pages=271–3
|year=1989
|pmid=2636957
|issue=4}}</ref><ref>{{Cite journal
|journal=Fortschr Med (German)
|author=Hankemeier U
|title=[Therapy of pulsating temporal headache. Resection of the
superficial temporal artery.]
|volume=103
|pages=822–4
|year=1985
|pmid=4054803
|issue=35}}</ref><ref>{{Cite journal
|journal=Annales de la Real, X Sesion Cientifica (Spanish)
|author=Sacristán HD, Ramírez AB
|title=Tratamiento Quirurgico de las Jaquecas.
|date=@9 April
|year=1980}}</ref><ref>{{Cite journal
|doi=10.1016/S0301-0503(76)80029-X
|journal=J Maxillofac Surg
|author=Rapidis AD
|title=The therapeutic result of excision of the superficial temporal artery in atypical migraine.
|volume=4
|pages=182–8
|year=1976
|pmid=1066419
|issue=3}}</ref><ref>{{Cite journal
|journal=Proc Aust Assoc Neurol
|author=Holland JT
|title=Three cases of vascular headache treated by surgery
|volume=13
|pages=51–4
|year=1976
|pmid=1029006}}</ref><ref>{{Cite journal
|journal=Rev Chir Oncol Radiol O R L Oftalmol Stomatol Otorinolaringol. (Romanian)
|author=Florescu V, Florescu R
|title=[Value of resection of the superficial temporal vasculo-nervous bundle in some cases of vascular headache.]
|volume=20
|pages=113–7
|year=1975
|pmid=127294
|issue=2}}</ref><ref>{{Cite journal
|journal=Ann Otolaryngol Chir Cervicofac. (French)
|author=Bouche J, Freche C, Chaix G, Dervaux JL.
|title=[Surgery by cryotherapy of the superficial temporal artery in temporo-parietal neuralgia]
|volume=91
|pages=56–9
|year=1974
|pmid=4603862
|issue=1}}</ref><ref>{{Cite journal
|doi=10.1111/j.1526-4610.1973.hed1204143.x
|journal=Headache
|author=Cook N.
|title=Cryosurgery of migraine.
|volume=12
|pages=143–50
|year=1973
|pmid=4682552
|issue=4}}</ref><ref>{{Cite journal
|journal=Res Clin Stud Headache
|author=Cook N.
|title=Cryosurgery of headache
|volume=5
|pages=86–101
|year=1978
|pmid=674810}}</ref><ref>{{Cite journal
|doi=10.1111/j.1526-4610.1968.hed0803112.x
|journal=Headache
|author=Murillo CA
|title=Resection of the temporal neurovascular bundle for control of migraine headache.
|volume=8
|issue=3
|pages=112–117
|year=1968
|pmid=5730120}}</ref><ref>{{Cite journal
|journal=JAMA
|author=Nadler SB.
|title=Paroxysmal temporal headache
|pages=334–335
|year=1945}}</ref>

==== When is arterial surgery indicated? ====

This treatment modality is of particular value in: 1) patients who have not responded to conventional drug therapy, 2) patients who are unable to use drug therapy because they experience unacceptable side effects, or 3) patients who would prefer not to be on permanent medication. Included in this category are those with Chronic Daily Headache (headache on more than 15 days per month) and patients with what is known as "refractory headache" - headache that has not benefited from any other form of treatment. A recent study has shown that patients with chronic migraine experienced a significant reduction in pain levels and significant improvement in their quality of life following the surgery.<ref>{{Cite journal
|journal=Therapy
|author=Shevel E.
|title=Vascular Surgery for Chronic Migraine.
|volume=4
|issue=4
|pages=451–456
|year=2007
|doi=10.2217/14750708.4.4.451}}</ref> The most common vessels involved in the pain of migraine are the terminal branches of the external carotid artery, and in particular, the [[superficial temporal artery]] and its frontal branch, and the [[occipital artery]]. These vessels are subcutaneous and the small incisions required to access them mean that the surgery is minimally invasive and can be done in a day facility. As these vessels have no connection with the arterial supply to the brain, MIAS is exceedingly safe with no unpleasant side effects. The cosmetic effect is excellent as most of the incisions are within the hairline.

==== How do we diagnose who will benefit from arterial surgery? ====

There are a number of methods used to diagnose whether arterial surgery will be of benefit.

1) There are certain scalp arteries that most commonly cause the pain of migraine. These are compressed with the fingertip during an attack. If blocking the artery by pressure relieves the pain temporarily, and the pain returns when the finger pressure is removed, then arterial surgery is indicated.<ref>{{Cite journal
|journal=Future Medicine
|author=Shevel E
|title=Vascular Surgery for Chronic Migraine
|volume=4
|issue=4
|pages=451–456
|year=2007
|doi=10.2217/14750708.4.4.451}}</ref>

2) Some migraine sufferers get relief from tying a tight band round the head just above the eyes and ears. This closes off the arteries that are causing the pain. If a tight band provides relief, then the surgery is indicated.<ref>{{Cite journal
|doi=10.1111/j.1526-4610.1993.hed3301040.x
|journal=Headache
|author=Vijayan N
|title=Head band for migraine headache relief
|volume=33
|issue=1
|pages=40–42
|year=1993
|pmid=8436498}}</ref>

3) Certain medications provide relief from migraine pain by constricting or narrowing the scalp arteries. If these medications give relief, then the arterial surgery is indicated.<ref>{{Cite journal
|doi= 10.1111/j.1526-4610.2011.01844.x
|journal= Headache
|author= Shevel E
|title= The Extracranial Vascular Theory of Migraine – A Great Story Confirmed by the Facts
|volume=51
|issue= 3
|pages=409–417
|year=2011
|pmid= 21352215}}</ref> These medications include the:

a) Triptans, namely sumatriptan (Imitrex, Imigran, Cinie, Illument, Migriptan), zolmitriptan (Zomig), eletriptan (Relpax), rizatriptan (Maxalt), frovatriptan (Frova, Migard, Frovamig), naratriptan (Amerge, Naramig), avitriptan (BMS-180,048), and almotriptan (Axert, Almogran).

b) Ergots. Any medications that contain ergotamine or dihydroergotamine.

=== Trigger site release ===
It has been theorized that [[trigger site]]s (TSs) exist where [[sensory nerve]]s are being [[Stimulation|stimulated]] by a surrounding [[muscle]] or specific contact points.
Due to this nerve [[irritation]], a cascade of events is initiated, leading to the inflammation of the [[Meninges|meningeal layers]] surrounding the [[brain]], and to migraine headaches.

Thus far, four trigger areas have been identified as surgical candidates. Three of these are in locations where the nerve passes through a muscle&mdash;where the [[greater occipital nerve]] pierces through the [[semispinalis capitis muscle]], the [[zygomaticotemporal nerve]] through the [[temporalis muscle]], and the [[supraorbital nerve|supraorbital]]/[[supratrochlear nerve|supratrochlear]] nerves through the [[glabella]]r muscle group (the [[corrugator supercilii]], [[depressor supercilii]], and [[procerus muscle]]s).<ref name="Mosser 2004">{{cite pmid|14758238}}</ref><ref name="Guyuron 2005">{{cite pmid|15622223}}</ref><ref name="Poggi 2008">{{cite doi|10.1097/PRS.0b013e31817742da}}</ref> The fourth trigger point, however, has been identified in the nose of patients who have significant [[nasal septum deviation]] with enlargement of the [[turbinate]]s.<ref name="Guyuron 2005"/> 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.

This type of migraine surgery is not offered as a first line of treatment, but after extensive evaluation and failure of traditional medical treatments.<ref name="Guyuron 2005"/><ref name="Guyuron 2002">{{cite pmid|12045534}}</ref><ref name="Totonchi">{{cite pmid|15622263}}</ref> 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.{{Citation needed|date=September 2009}} Currently this treatment has institutional approval for adults, and trials for the [[pediatric]] population are ongoing.{{Citation needed|date=September 2009}}

==== Details of the procedure ====
Patients have to be screened preoperatively with a full [[neurological examination]], and subsequent [[Botox]] injection and/or [[Rhinoscope|nasal endoscopy]]. A positive response to Botox has been a positive predictor of a successful outcome. Single or multiple TSs may be treated. Migraine headaches can start in one area depending on their corresponding trigger site and spread to the rest of the head. It is important to identify the initial trigger sites rather than address all the areas of pain, after the inflammation involves the entire [[Trigeminal nerve|trigeminal tree]]. Four different types of migraine have been defined based on their trigger point location, and are addressed individually. Sometimes the alleviation of one trigger site results in the unmasking a second site.

''[[Forehead]] migraine headaches'': In the [[glabella]]r area the [[Supraorbital nerve|supra-orbital]] and [[Supratrochlear nerve|supra-trochlear]] nerves are [[wikt:Skeleton#Verb|skeletonized]] by [[Segmental resection|resect]]ing the [[Corrugator supercilii muscle|corrugator]] and [[depressor supercilii muscle]] using an [[endoscopic]] approach similar that of used for cosmetic [[forehead lift]].

''[[Temple (anatomy)|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. This results in a slight sensory defect over temporal skin area, but cross-[[innervation]] from other sensory nerves helps to limit the damage.

''[[wikt:Rhino-|Rhinogenic]] migraine headaches'': The nasal trigger points where enlarged turbinates are in contact with the [[nasal septum]] are addressed with a [[septoplasty]] and a [[Turbinate#Turbinate dysfunction|turbinectomy]].

''[[Occipital]] migraine headaches'': The [[Posterior triangle of the neck|posterior neck]] area where the [[greater occipital nerve]] passes through the [[semispinalis capitis muscle]] is addressed with an [[open surgery|open surgical approach]] with resection of a small segment of the semispinalis muscle and shielding the nerves with a [[Subcutaneous fat|subcutaneous adipose]] flap.<ref name="Guyuron 2005"/>

=== Patent foramen ovale closure ===
Several clinical trials are currently under way in an effort to determine the existence of a causal linkage between migraines and the presence of a [[patent foramen ovale]] (PFO), a hole between the upper chambers (the [[Atrium (heart)|atria]]) of the heart. There is significant evidence that a link exists between migraine with aura and the presence of a PFO.<ref name="Schwedt 2009">{{cite doi|10.1016/j.ncl.2008.11.006}}</ref>

It is estimated that 20-25% of the general population in the [[United States]] has a PFO.<ref name="Washington Times">{{cite news|title=Easing Migraines.; Drugs, surgery help some; heart defect role studied| last=Waters| first=Jen| date=31 Jul 2007| work=[[Washington Times]]| publisher= |pages=B01| location=[[Washington, D.C.]]|accessdate=2007-11-09}}</ref><ref name="Post 2007">{{cite pmid|17143907}}</ref> Medical research studies have shown that migraineurs are twice as likely as the general population to have a PFO,<ref name="Schwedt 2009"/><ref name="Washington Times"/> that over 50% of sufferers of migraine with aura have a PFO,<ref name="Schwedt 2009"/> that patients with a PFO are 5.1 times more likely to suffer from migraines and 3.2 times more likely to have migraines with aura than the general population,<ref name="Schwedt 2009"/> and that patients with migraine with aura are much more likely to have a large opening than the general PFO population.<ref name="Schwedt 2009"/><ref name="Post 2007"/><ref name="Wilmshurst 2004">{{cite doi|10.1136/hrt.2003.025700}}</ref>

==== Anatomy ====
{{main|Atrial septal defect|Foramen ovale}}
The [[foramen ovale]] (literally ''oval hole'') is present in all [[fetus]]es. Because a fetus' blood is [[Oxygenation (medical)|oxygenated]] through the mother's [[placenta]] and not through [[breathing]], the [[pulmonary system]] is unneeded. To make the [[fetal circulatory system]] more effective, the hole exists so that blood can travel from the [[right atrium]] to the [[left atrium]] without entering the [[pulmonary circulation]]. When the baby is born and begins breathing, the resistance in the lungs decreases dramatically, and blood begins to travel into the pulmonary system. This results in increased [[pressure]] in the left atrium, which then forces the flap down and effectively seals the hole. Once fully [[wikt:fused|fused]], the resulting structure is called the [[fossa ovalis]] (literally ''oval ditch''). If the hole is not fully sealed, it is said to be [[wikt:patent#Etymology 2|patent]] (literally ''open'').

==== Pathophysiological theories ====
In certain scenarios, such as when a person sneezes, the pressure in the left atrium decreases and the flap over the still-present foramen ovale opens temporarily. When this happens, blood is able to bypass the lungs and therefore the [[Lung#Non respiratory functions|filtration process]] in the pulmonary system. There are at least 4 theories as to how this defect leads to migraines.<ref name="Post 2007"/>

===== Toxic circulation =====
Early speculation regarding this link centered on the idea that, because blood bypasses the detoxificaiton process in the lungs and reenters the circulatory system uncleaned, this "toxic blood" may contain various substances that then trigger migraines.<ref name="Post 2007"/><ref name="Diener 2007">{{cite pmid|17504652}}</ref> There is speculation that one of these substances is 5-HT, more commonly known as [[serotonin]]. Normally, 5-HT is filtered in the pulmonary circulation. However, if blood is bypassing that filtration process, 5-HT can re-enter [[systemic circulation]] and travel to and enter the brain. Numerous studies have related 5-HT to migraine pathogenesis, and the current pharmacological treatment of choice is a [[triptan]] drug, which binds to [[serotonin receptor]]s in the brain and leads to the migraine being cured. This evidence lends support to the theory that 5-HT is one of the substances that triggers a migraine in a patient with a PFO.<ref name="Post 2007"/><ref name="Wilmshurst 2006">{{cite doi|10.1111/j.1526-4610.2006.00374.x}}</ref>

===== Micro-emboli =====
There is speculation that micro[[emboli]] that develop in the venous system pass through the PFO and are able to reach the [[central nervous system]].<ref name="Schwedt 2009"/><ref name="Post 2007"/> The [[paradoxical embolism]] then reaches the [[Cerebral cortex|cortex]], triggering [[cortical spreading depression]], a phenomenon that leads to migraines. There is also evidence that the number of gas bubbles in a paradoxical gas embolism is correlated with the severity of the headache.<ref name="Wilmhurst 2003">{{cite pmid|11171291}}</ref>

===== Genetic linkage =====
One study has found a [[genetic linkage]] between migraines and PFOs.<ref name="Wilmshurst 2004"/> It was found that PFOs have an [[autosomal dominant]] pattern of [[inheritance]], and that migraine with aura appears to be coinherited in some families.

===== Atrial natriuretic peptides =====
It has been shown that the changes in interarterial pressure that occur with a PFO cause an increase in [[atrial natriuretic peptide]] (ANP), and that the ANP concentration in migraineurs with aura is lower than the concentration in control subjects. A study has shown that when the cortical spreading depression phenomenon was induced in mice, ANP was [[Gene expression|expressed]] in the brain.<ref name="Yankovsky 2003">{{cite doi|10.1046/j.1526-4610.2003.03096.x}}</ref> As well, ANP levels are elevated in patients with a PFO.<ref name="Yankovsky 2003"/> All together, this suggests a possible correlation between ANP concentration and migraine with aura.<ref name="Yankovsky 2003"/>

==== Procedures ====
It has been shown that migraine frequency and severity is reduced if the hole is patched surgically.<ref name="Chwerzmann 2004">{{cite pmid|15111681}}</ref> [[Mark Reisman]], cardiologist at [[Seattle]]'s [[Swedish Medical Center]] explained an advantage to non-pharmacological migraine relief. He said, "In contrast to drugs, PFO closure appears highly effective against migraines and usually has no side effects".<ref name="Reisman">{{cite jstor|4016110}}</ref> Because PFO closure continues to prove successful, new devices are being produced to make the surgery easier to perform and less invasive.

Recent studies, however, have emphasised caution in relating PFO closure surgeries to migraines, stating that the favourable studies have been poorly-designed [[retrospective studies]] and that insufficient evidence exists to justify the dangerous procedure.<ref name="Schürks 2009">{{cite pmid|19048002}}</ref><ref name="Sarens 2009">{{cite pmid|19172218}}</ref> As well, at least one patient with infrequent migraines who underwent the surgery ended up with daily migraines for at least 6 months,<ref name="Yankovsky 2003"/> and others have reported short-term increases in migraine frequency and intensity following the surgery.<ref name="Bhindi 2008">{{cite doi|10.1002/ccd.21394}}</ref><ref name="Wilmshurst 2005">{{cite doi|10.1136/hrt.2004.047746}}</ref><ref name="Sharifi 2005">{{cite doi|10.1111/j.1540-8183.2005.04068.x}}</ref>

=====Coherex FlatStent Closure System=====
From Coherex Medical Inc. of Salt Lake City, a device called the Coherex FlatStent PFO Closure System is being tested as a new product for PFO closure. This device is first being studied by a European clinical study in Frankfurt, Germany. If this study proves to be a success, the device will begin to undergo FDA approval.<ref name="Collins">{{cite news|title=Utah company's new stent may help repair heart defects|last=Collins|first=Lois M.|date=October 3, 2007|work=Deseret News |pages=E1|accessdate=2007-11-09 |location=[[Salt Lake City, Utah]], [[USA]]}}</ref> The Coherex Closure System is an alternative to the typical method of repairing a PFO by placing a disk on each side of the defect and clamping them together to form a solid wall. The typical method doesn't always work particularly well with PFOs because the lengths, widths and dimensions of the defect are always different. The Coherex device is small and looks delicate, although it's not. One of its unique features is that it's deployed inside the tunnel of the PFO, so it closes the defect from within Because of its construction, it adapts to a PFO's individual shape in terms of length and width, thus avoiding the typical problem with PFO closure. Besides pulling the opening closed, it has a sponge polymer that encourages tissue to grow into it and integrate it into the heart's structure.{{Citation needed|date=September 2009}}

=====CardioSEAL=====
Another closure system is in use right now called CardioSEAL.<ref name="Cleveland">{{cite web|url=http://www.clevelandclinic.org/heartcenter/pub/guide/disease/congenital/pfo.htm|title=Patent Foramen Ovale|date=August 2009|work=Cleveland Clinic|publisher=Cleveland Clinic}}</ref> This device looks like a small umbrella made out of Dacron fabric and folded into a special catheter. This catheter is inserted into a vein in the leg like the Coherex device. In order to close the PFO valve, each umbrella opens up and the device is pushed out of the catheter. The device is absorbed into the heart as the heart tissues grow over the implant in time.<ref name="CardioSEAL">{{cite web |url=http://www.nmtmedical.com/technology.aspx?id=90 |title=CardioSEAL Technology/Approach |work=NMT Medical, Inc.}}</ref>

=====AMPLATZER PFO Occluder=====
Another device for PFO Closure is called the AMPLATZER PFO Occluder device.<ref name="Cleveland"/>

It consists of two wire mesh discs filled with polyester fabric. It is folded into a special delivery catheter, similar to the catheter used during a catheterization. The catheter is inserted into a vein in the leg, advanced into the heart and through the defect.

When the catheter is in proper position, the device is slowly pushed out of the catheter until the discs of the device sit on each side of the defect (like a sandwich). The two discs are linked together by a short connecting waist. The discs and the waist are filed with polyester fabric to increase the device’s closing ability.

Over time, heart tissue grows over the implant, and it becomes part of the heart. The tissue grows over the device over time.<ref name="AGA">{{cite web |url=http://international.amplatzer.com/international_products/pfo_device/tabid/522/default.aspx |title=AMPLATZER® PFO Occluder for Patent Foramen Ovale Closure |year=2008 |work=AGA Medical Corporation | location=[[Plymouth, Minnesota]], [[USA]]}}</ref>

=====Premium trial=====
University of Washington Medical Center tests the effectiveness of PFO closure in eliminating migraines in a clinical trial called the Premium Trial.<ref name="Black">{{cite news |title=Researchers Look to Herat for Migraine |last=Black|first=Cherie|date=October 22, 2007 |work=[[Seattle Post-Intelligencer]] |pages=A1 |accessdate=2007-11-09 |location=[[Seattle, Washington]], [[USA]]}}</ref> All patients must meet certain criteria to qualify for the study including a diary that recounts the severity and frequency of migraines and undergoing tests to eliminate other medical reasons for migraines. A random selection process is then used to determine which patients have their PFO repaired and which ones do not. After a year, the patients will find out if they had the actual procedure and physicians will be able to determine if the process really worked.

The surgery is not performed by cutting open the chest and working on the heart. Instead, a catheter is pushed up to the hole in the heart after it is inserted in a vein in the leg. In order to keep the study blind, all patients are blindfolded and wear headphones while being mildly sedated. All patients receive a catheter in the leg, but not all catheters are pushed up to the heart.

=====ESCAPE migraine trial=====
One clinical trial being undertaken began in October 2007 called the ESCAPE Migraine trial to test the relation to PFO closure to migraine relief. Feldman, along with Dr. Susan Rubin, are co-principal investigators of the trial. “The clinical trial expects to enroll 500 patients in the U.S. who have not found relief from migraines with preventive medicine, have experienced unwanted side effects from drug therapy or have been advised by a doctor against medications due to another condition”.<ref name="Tribune">{{cite news |title=Clinical Trial in the Works; Probing a heart-migraine tie |last=Yalonsky Stat |first=Terry|date=October 28, 2007|work=[[Chicago Tribune]] |pages=8 |accessdate=2007-11-28}}</ref> This trial will use the closure system called the Premere<!--spelling correct--> PFO Closure System that uses the catheter system in the leg to go to the heart. This closure system was designed by St. Jude Medical but is only available for this clinical trial because it has not been approved by the Food and Drug Administration. The study is closed to new participants and has completed final data collection for its primary outcome. Results are expected to be released in fall of 2013.<ref>{{cite web|url=http://clinicaltrials.gov/ct2/show/NCT00267371?intr=%22PFO+Closure%22&rank=3|publisher=clinicaltrials.gov}}</ref>

The procedure involves two-thirds of the patients who had their PFO closed, while the other third had a tube placed in their heart to measure the size of their PFO. The risk of migraine is related to the size of the PFO. Patients will not know until the end of the trial if they were assigned to receive PFO closure. Once the trial is complete, trial participants will meet with a cardiologist for a heart evaluation and a neurologist to evaluate and monitor their migraines after intervention. They were asked to maintain an electronic journal of their migraines for one year. The apparent relation between an opening of the PFO valve and migraines may receive further validation through this study.

=== Spinal cord stimulation ===

[[Spinal cord stimulator]]s are medical stimulators implanted 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 per month.<ref name="Matharu 2004">{{cite pmid|14607792}}</ref>

== Non-surgical procedures ==
[[Botulinum toxin|Botulinum neurotoxin A]] (BoNT-A, popularly known as Botox) injections have been reported by various headache specialists as a potential treatment for migraines.<ref name="Schulte-Mattler 1999">{{cite pmid|10336407}}</ref><ref name="Samton 2006">{{cite pmid|16533136}}</ref><ref name="Blumenfeld 2003">{{cite pmid|12940810}}</ref><ref name="Cady 2007">{{cite pmid|18047501}}</ref><ref name="Schürks 2008">{{cite pmid|18325296}}</ref><ref name="Naumann 2008">{{cite pmid|18458231}}</ref><ref name="Ondo 2004">{{cite pmid|14687015}}</ref><ref name="Dodick 2005">{{cite pmid|15836567}}</ref>

In 2008, a subcommittee of the [[American Academy of Neurology]] (AAN) assessed the effectiveness of botulinum toxin in numerous disorders, with one report focusing on autonomic disorders and pain, including 'chronic daily headache'&mdash;they noted that this group's headaches were "mainly transformed migraines", and 'chronic tension-type headaches' were not included&mdash;and 'episodic migraines'.<ref name="Naumann 2008"/> For chronic daily headaches, four studies were analyzed where the reduction in headache frequency when injected with BoNT-A was compared to a [[placebo]]-injected [[control group]]. While two of these studies showed favourable results,<ref name="Ondo 2004"/><ref name="Dodick 2005"/> others observed no significant benefits.<ref name="Mathew 2005">{{cite pmid|15836565}}</ref><ref name="Silberstein 2005">{{cite doi|10.4065/​80.9.1126}}</ref> The AAN has thus reported that they can not yet draw any conclusions on the effectiveness of BoNT-A injections in chronic daily headaches.<ref name="Naumann 2008"/> It was noted that, in one study where subjects were stratified based on whether or not they were currently being treated with a [[prophylactic]] medication, patients who were not taking prophylactic medications concomittantly fared significantly better than those who were.<ref name="Naumann 2008"/><ref name="Dodick 2005"/>

In the same report, the AAN concluded that the injections were "probably ineffective" in treating episodic migraines. Other studies have reached the same conclusion.<ref name="Cady 2007"/><ref name="Schürks 2008"/>

Studies examining the effectiveness of BoTN-A injections that were not included in the AAN report have yielded positive results.<ref name="Schulte-Mattler 1999"/><ref name="Samton 2006"/><ref name="Blumenfeld 2003"/><ref name="Cady 2007"/><ref name="Schürks 2008"/> It has been noted, however, that repeated injections are required to keep the headaches under control&mdash;the BoTN-A may have a cumulative effect&mdash;and they do not address the headaches which are triggered from the septum and turbinates.<ref name="Samton 2006"/><ref name="Ondo 2004"/>

==References==
{{Reflist|2}}

== Additional References==
{{Refbegin|2}}
* {{cite book |editor1-first= Laura B |editor1-last= Clarke |editor1-link= |title= Migraine Disorders Research Trends |series= |volume= |date= September 19, 2007 |publisher= [[Nova Science Publishers]] |location= [[New York, New York]], [[USA]] |isbn= 9781600215537 | url=http://books.google.com/?id=j-TgnRFVVm8C}} <!-- Clarke -->
* {{cite pmid|16868520}} <!-- Fan -->
* {{cite pmid|15622223}} <!-- Guyuron, Kriegler -->
* {{cite pmid|12045534}} <!-- Guyuron, Tucker -->
* {{cite jstor|4016110}} <!-- Harder -->
* {{cite pmid|18339350}} <!-- Jensen -->
* {{cite pmid|14607792}} <!-- Matharu -->
*{{cite web |url=http://www.clevelandclinic.org/heartcenter/pub/guide/disease/congenital/pfo.htm |title=Patent Foramen Ovale |date=August 2009 |work=Cleveland Clinic |publisher=Cleveland Clinic}}
* {{cite pmid|16533136}} <!-- Samton -->
* {{cite pmid|15111681}} <!-- Schwerzmann -->
* {{cite doi|10.2217/14750708.4.4.451}} <!-- Shevel -->
* {{cite conference| first = Ali M | last = Sultaneh| authorlink = | year = 2001 | title = Migraine - New Surgical Treatment | conference = [[Congress of Neurological Surgeons]] Annual Meeting | format = Oral Poster presentation | location = [[San Diego, California]], [[USA]]
| url = http://abstracts.neurosurgeon.org/view.php?id=6714 | accessdate = | id = | doi = }}
* {{cite pmid|15622263}} <!-- Totonchi -->
{{Refend}}

{{DEFAULTSORT:Migraine Surgery}}
[[Category:Migraine]]
[[Category:Surgery]]

Revision as of 11:08, 16 August 2011

Migraine surgery is any surgical operation undertaken with the goal of reducing or preventing migraines.

Retrieved from "https://en.wikipedia.org/w/index.php?title=Migraine_surgery&oldid=445135716"