Migraine Surgery: A Solution for a Common Problem?

August 7, 2015
Veronica Hackenthal, MD

When medications no longer offer relief to your patients with migraines, surgical treatment may be the answer.

Migraines affect about 43% of women and 18% of men over the course of their lifetimes.1 In the US, medical costs due to migraine are estimated at $1 billion, with $16 billion lost in productivity per year.2 Medical management is often ineffective. Botox is FDA approved for treating migraines but usually offers only temporary relief.

Study 1: Decompression of Trigger Points3

• Surgical treatment is based on the premise that peripheral sensory branches of the trigeminal and cervical spinal nerves become compressed and irritated, causing migraine.

• Surgery focuses on decompression of four main trigger points: frontal, temporal, nasoseptal, and occipital.

• As of October 2014, 17 clinical studies, including 2 RCTs, supported the efficacy of surgical decompression for migraines, with the overall success rate approaching 90%.

• Most common adverse events: transient numbness at the surgical site, incisional hair loss, intraoperative bleeding, transient uneven brow movement.

Study 2: Migraine Trigger Site Deactivation4

• A migraine trigger site, where the migraine begins, is defined by anatomical areas innervated by branches of the trigeminal or occipital nerves.

• Compression of the nerve at these sites and irritation of surrounding structures can lead to inflammation and migraine.

• A recent study looked at 20 adult patients with bilateral temporal migraines.

♦ Patients received unilateral surgical decompression and unilateral neurectomy (on the opposite side) of the zygotemporal branch of the trigeminal nerve between January 2011 and August 2012.

♦ 19 patients completed the study at 12 months followup.

• After surgery:

♦ 34/38 (89%) operative sites showed >50% improvement in migraine frequency, days, severity, and duration.

♦ 21/38 (55%) operative sites showed complete resolution of symptoms.

♦ No statistically significant difference was found between decompression vs neurectomy for decreased migraine frequency, days, severity, and duration.

♦ No major complications occurred.

• Conclusion: “Both avulsion neurectomy and decompression of the zygotemporal branch of the trigeminal nerve are equally effective methods for the treatment of temporal migraine headache… Performing decompression as the first option leaves avulsion neurectomy as another option if decompression fails to provide the intended relief.  It is our recommendation that whenever feasible, decompression should be attempted first.”

Migraine Symptoms for Decompression vs. Neurectomy

 

Frequency per month

Days per month

Severity

Duration (hours)

Migraine Headache Index Score 1

Decompression Group

Decreased from 14.6 to 2.2

Decreased from 14.1 to 2.3

Decreased from 7.0 to 2.9

Decreased from 9.6 to 4.8

Decreased from 42 to 2.9

Neurectomy Group

Decreased from 14.2 to 1.9

Decreased from 6.8 to 2.6

Decreased from 6.8 to 2.6

Decreased from 10.1 to 5.3

Decreased from 41 to 2.5

1. Migraine Headache index score = migraine frequency x duration x intensity

Study 3: Migraine Surgery in Adolescents5

• Migraine among adolescents is common, often not adequately controlled, and has been linked to psychosocial problems like anxiety and depression.

• Topiramate is the only FDA approved drug for migraine prevention in adolescents, approved for ages 12-17.

• A recent retrospective review looked at the surgical outcomes for one surgeon, Bhaman Guruyon, who pioneered migraine surgery.

• The study included all adolescent patients ≤18 years with a family history of migraine into adulthood, and neurologist confirmed refractory migraine.

• Legal guardians completed a migraine headache questionnaire preoperatively and at each postoperative visit.

• Analysis included 14 patients and 15 operations (11 girls, 3 boys, average age 16 years, average followup 38.2 months).

• One year followup after surgery:

♦ Migraine frequency and migraine days per month both decreased from 25 to 5 (P < 0.0001).

♦ Migraine index decreased from 148.1 to 12.4 (p < 0.001).

♦ Duration (number of hours/24 hours) decreased from 0.71 to 0.25 (p = 0.002).

♦ Migraine severity decreased from 8.2 to 4.3 (p = 0.0004).

♦ Five patients reported complete resolution of all migraine symptoms.

♦ One patient showed no improvement in frequency of migraine, but severity and duration did improve.

♦ No surgical complications were noted.

• Conclusion:  “In the adolescent population with migraine headaches refractory to traditional medical management, migraine surgery may offer symptomatic improvement of migraine headache frequency, duration, and severity in patients with identifiable anatomical trigger sites.”

Take Home Points

• Migraine is a common problem, especially in women; medications and botox may not treat the underlying disorder.

• Surgical treatment is based on the premise that peripheral sensory branches of the trigeminal and cervical spinal nerves become compressed and irritated, causing migraine.

• Studies suggest that surgical decompression for migraine may have an overall success rate approaching 90%.

• Neurectomy and decompression of the zygotemporal branch of the trigeminal nerve may be equally effective for treating temporal migraines.

• Surgical decompression may be effective for treating certain adolescents with migraine.