Surgical Options for Headaches

Unruptured saccular intracranial aneurysm (SIA) is associated with an increased prevalence of migraine. Clipping the aneurysm may improve the remission rate of migraine and other recurrent headaches. These researchers interviewed 87 SIA patients with migraine or other recurrent headaches before and 1 year after aneurysm clipping. Remission rates of migraine and tension-type headache in these patients were compared to 92 patients from a headache center.

Lebedeva ER, et al. Remission of migraine after clipping of saccular intracranial aneurysms.Acta Neurol Scand. 2015 Feb;131(2):120-126. http://www.ncbi.nlm.nih.gov/pubmed/25288229 The year after clipping, the decrease of migraine in SIA patients was significantly higher (74.5%) than in controls (12.8%). The year preceding rupture, 33 patients with SIA had a history of tension-type headache. During the year after clipping, 44 SIA patients had tension-type headaches. Among control patients, 41 had tension-type headaches. After 1 year of treatment, 27 did, a reduction of 34%. No factors except clipping of the aneurysm could explain the remission of migraine.

The pathogenesis of migraine headache substantiates a neuronal hyperexcitability and inflammation involving compressed peripheral craniofacial nerves. These trigger points can be eliminated by surgery. Researchers describe a modified, innovative, minimally invasive endoscopic technique to perform selective myotomies for migraine and tension-type headaches.

The study enrolled 43 patients who experienced 15 or more frontal migraine headaches without aura, tension-type headaches, or new daily persistent headaches each month. Of the 15 patients followed for 2 years, 14 patients (93.3%) reported a positive response to the surgery. 5 patients (33.3%) observed complete elimination and 9 patients (60%) experienced significant improvement (at least 50% reduction in intensity or frequency). 1 patient (6.6%) did not notice a change in headaches.

Edoardo R et al. Frontal endoscopic myotomies for chronic headache. J Craniofac Surg. 2015 May;26(3):e201-e203. http://www.ncbi.nlm.nih.gov/pubmed/25887206 Researchers conclude that a modified endoscopic procedure leads to better results as compared to previous techniques.

Stimulation of peripheral nerves can treat chronic refractory pain, including headache disorders. This systematic review of 5 randomized controlled trials (RCT) and 7 case series examines the effectiveness and adverse effects of occipital nerve stimulation for chronic migraine.

Chen Y-F, et al. Occipital nerve stimulation for chronic migraine-a systematic review and meta-analysis. PLoS One. 2015;10(3):e0116786. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4368787/ Pooled results from 3 multicenter RCT show that occipital nerve stimulation leads to a mean reduction of 2.59 days of prolonged, moderate-to-severe headache per month at 3 months compared with a sham control. Results for other outcomes generally favor occipital nerve stimulation over sham controls, but quantitative analysis is hampered by poor study designs. Lead migration and infections are common and often require revision surgery. Long-term effectiveness can be maintained in some patients, but the evidence is limited.

Migraine prevalence in patients with saccular intracranial aneurysm decreases significantly after aneurysm clipping. A modified endoscopic procedure for myotomies of chronic headache eliminates the need for general anesthesia, reduces invasiveness, and decreases the number of postoperative scars. Occipital nerve stimulation shows modest effects in the treatment of chronic migraine, and further measures are needed to reduce the risk of adverse events and revision surgery.