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Why Are Neurologists Against Migraine Surgery?

Understanding Migraine

People who have not experienced a migraine headache tend to assume that a migraine is just a really bad headache. However, it’s much more than that. Migraine is a neurological condition that causes many other symptoms apart from an intense, debilitating headache. Some of the other symptoms that accompany a migraine are:(1, 2, 3)

  • Pain on usually one side of the head, but can also affect both sides.
  • Nausea
  • Vomiting
  • Sensitivity to sound and light
  • Sensitivity to smell and touch
  • Throbbing or pulsating pain
  • Pins and needles sensation
  • Difficulty speaking
  • Vision loss
  • Visual phenomenon, including seeing bright spots, flashes of light, or various shapes in your field of vision.
  • Numbness or weakness in the face or one side of the body.

Migraine tends to run in families, and it can affect people of all ages. It has been found that females are more likely to be diagnosed with migraine than men. The diagnosis of migraine is made based on clinical history, symptoms and by ruling out other causes of the headache. People usually describe migraine pain as being pulsating, throbbing, debilitating, or pounding.(4, 5) It commonly affects the forehead area, usually just on one side of the head. It usually feels like a severe, dull, and steady pain. In some people, the pain may begin as mild but, left untreated, it can quickly progress to moderate to severe pain.

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Migraine attacks usually last for around four hours. If not treated, or if they don’t respond to treatment, they can even last for as long as 72 hours to a week. Some individuals experience migraine with aura, in which the pain may overlap an aura or might not even occur.(6)

Migraine has a huge impact on the quality of life for those who are affected, and it has become a very common condition today. In fact, according to estimates by the UK’s National Health Service, migraine is believed to affect one in five women, and one in every 15 men.(7)

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When migraine stops responding to treatments like dietary changes and prescription medicines, many doctors tend to recommend surgery. While some research is available that suggests that migraine surgery might be effective for some people, the majority of neurologists and headache experts do not endorse such types of experimental treatments. Many insurance companies also do not pay for such procedures, citing a lack of evidence that they are successful.(8)

What is Migraine Surgery?

The exact cause of migraine headaches still remains unclear, and researchers are still trying to discover the exact causes behind the different types of migraine headaches. Some doctors say that migraine begins when the blood vessels or nerves get compressed or irritated. These compression points are referred to as trigger points, and depending on the type of migraine attack, there may be one trigger point or several.(9, 10)

One of the common types of migraine surgery focuses on relieving this pressure by removing certain smaller sections of bone or tissue that press on the nerves or sometimes even cut the nerves themselves. Other types of migraine surgery focus on reducing the size of the structures in the sinus area that are believed to be making your migraine headache worse.(11, 12, 13)

Why Are Neurologists Against Migraine Surgery?

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Many neurologists who specialize in treating headache disorders are of the opinion that there is minimal evidence to support the success of surgical intervention for migraine. These surgical treatments are not extensively studied. While there are some studies that suggest that there might be certain types of people who may benefit from migraine surgery, but since it is difficult to have a thorough trial design in such types of surgical studies, the results are not as reliable as surgeons and doctors would prefer them to be.

Keeping this in mind, the American Headache Society urges patients and doctors not to go ahead with the surgical deactivation of migraine trigger points in the brain outside of clinical trials. The organization firmly declares that there is a lack of reliable research and information about the possible side effects of such a surgery, and there are almost no studies that show the long-term impact of migraine surgeries.(14)

The American Headache Society has also shared that studies that have shown some benefit from migraine surgery have been observational, or they only involved a small number of participants within a controlled trial. And in order to accurately assess the potential effectiveness and side effects of migraine surgery, there have to be large randomized controlled trials that include long-term follow-ups. The major concern with migraine surgeries at this point is the absolute lack of research on the long-term side effects of such a surgery.(15)

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Types of Migraine Surgery

Even though headache specialists and neurologists do not recommend surgery for migraine, some surgeons are still performing these surgical procedures. Here are some of the major types of migraine surgery and some information on why this type of surgery may or may not work for you.

  1. Peripheral Neurolysis

    Peripheral neurolysis is a term used to refer to several types of migraine surgeries that target the nerves involved in triggering a migraine attack. One such type is known as nerve liberation or nerve decompression. In nerve decompression, a surgeon removes a small part of bone or area of tissue surrounding a nerve located in the head, face, or neck. The goal of this surgery is to relieve the pressure on that nerve to reduce migraine attacks.(16, 17)

    Once the nerve has been decompressed or liberated, the surgeon plumps up the area with fat in order to prevent other structures from pressing on the same place again in the future. Another type of nerve surgery for migraine involves cutting the nerve entirely and burying the ends of the nerves in nearby muscles.

    Many of these surgical procedures can be performed endoscopically, which means that the surgeon operates with tiny instruments that are inserted inside through a thin tube. Endoscopic surgeries are far less invasive than surgeries that involve making larger and open incisions.

    A research review carried out in 2020 across 39 articles found that such type of surgery was a valid treatment option for migraine. The study concluded that several patients experienced less frequent and less severe migraine attacks following the surgery.(18)

    However, despite the study’s results, many headache specialists and neurologists feel that it is still too early to conclude that migraine surgery is a safe treatment option. This is in part because of the challenge involved in carrying out high-quality surgical studies to prove that these surgical methods are effective and safe, especially in the long term. There is a significant lack of randomized, controlled studies to support whether these procedures are safe.

  2. Septoplasty

    Septoplasty is a type of surgery that helps correct a deviated septum. A deviated septum occurs when the wall that separates your nostrils, known as the septum, begins to lean towards one side, thus blocking the airflow. When the airflow gets blocked, it can cause intense headaches.(19)

    A septoplasty surgery repairs and reshapes the septum and opens up your airway, thus relieving pressure and pain. These surgeries are usually performed by doctors who specialize in ear, nose, and throat (ENT) conditions.

    It is important to keep in mind that even when a septoplasty opens up the airway successfully, there is no guarantee that it will relieve migraine headaches. During a ten-year follow-up study, researchers concluded that it was likely that the headaches might not get reduced even after surgical procedures. They further added that it was certain that, in time, more headaches would follow.(20)

  3. Neuromodulation

    The procedure of neuromodulation makes use of electromagnetic pulses to stimulate the nerves that are believed to cause migraine headaches. The US Food and Drug Administration (FDA) has approved the use of many external neuromodulating devices for treating migraine headaches.(21) These neuromodulating devices send electromagnetic pulses through the skin.

    In some cases, it is also possible to surgically implant a neuromodulator underneath the skin, but there is a lot of debate about whether such implanted devices are safe to use and work as effectively as external neuromodulating devices. Even though some of these implanted devices have been researched during clinical trials, there is currently more evidence available that supports the use of external neuromodulating devices.(22)

    The Food and Drug Administration has approved several non-invasive electrical stimulation neuromodulating devices for the treatment of migraine. Since the transcutaneous devices don’t carry the same risks as surgery, it is possible to use such devices at any point during the process as well as part of a multipronged approach for the treatment of migraine. There are also no chances of side effects and interactions that are typically associated with medications.

    Electrical stimulation devices are also sometimes used in combination with medications for the treatment of migraine. However, this option is not for everyone, as many patients don’t like the sensation the device creates. While the risks of surgery with implanted devices are usually low, when it comes to planting neuromodulators, there is a possibility of the electrodes moving away from the target areas, and the wires may also break. This may cause some patients to have to undergo multiple procedures.

  4. Turbinectomy

    Turbinectomy is a surgical procedure that removes some of the soft tissue and bone inside the nose. These structures are referred to as turbinates, and they moisten and warm the air that you breathe in. When these structures grow too large, they make it more difficult to breathe. They may also be the cause of headaches.

    Some evidence indicates that a turbinectomy can help people who have severe headaches. In a recently conducted large Taiwanese study, it was found that turbinectomy caused a 14.2 reduction in the number of patients who were admitted to the hospital because of severe migraine. The participants of the study had a long history of sinus problems.(23)

    There is usually some form of overlap between the ear, nose, throat, and migraine. And sometimes, people who undergo surgeries like tubinectomies and septoplasties to relieve what is believed to be a sinus condition, they discover that it was migraine that was the underlying cause the entire time.

    A 2021 research review found that tension headaches and migraines were responsible for causing much of the pain that is associated with sinus headaches.(24)

    Turbinectomies may help decrease the frequency or severity of migraine headaches, but researchers say there is a need for carrying out more high-quality studies to confirm these outcomes. And for many people, headaches tend to return after the surgery.(25)

Are There Any Risks Associated With Migraine Surgery?

Any surgery or medical procedure has some percent of risk associated with it. The risks of migraine surgeries are still not fully known, but they are likely to be less. As with any surgery, there is always a risk of bleeding, infection, or scarring. It is also possible to experience some amount of itching in that area.

In the case of peripheral neurolysis, a non-cancerous or neuroma tumor can form at the site of the surgery. Burying the nerve endings in the muscle may be able to reduce this risk. When it comes to implanted neuromodulation, it is possible that toe leads or wires could loosen and shift from the targeted nerve. Wires can also get damaged over a period of time. Such instances would mean that you have to undergo another procedure.

In the case of turbinectomy and septoplasty, there is a likelihood that your sense of smell could get affected. Migraine surgeries can also change the shape of your nose and may also cause damage to the septum in the process. You may even develop some symptoms of sinus due to the surgery, including nasal dryness and pain.

Conclusion

While migraine surgery may be a potential treatment for migraine headaches, there is still very limited research available on it. Due to this, most headache specialists and neurologists do not recommend it. The lack of high-quality and reliable studies makes it challenging to determine if migraine surgeries will work or not and which people should undergo such a surgery. Furthermore, there is a lack of data available on the long-term effects of such surgeries.

References:

  1. Baloh, R.W., 1997. Neurotology of migraine. Headache: The Journal of Head and Face Pain, 37(10), pp.615-621.
  2. Goadsby, P.J., Lipton, R.B. and Ferrari, M.D., 2002. Migraine—current understanding and treatment. New England journal of medicine, 346(4), pp.257-270.
  3. Lipton, R.B., Diamond, S., Reed, M., Diamond, M.L. and Stewart, W.F., 2001. Migraine diagnosis and treatment: results from the American Migraine Study II. Headache: The Journal of Head and Face Pain, 41(7), pp.638-645.
  4. Steiner, T.J., Stovner, L.J. and Birbeck, G.L., 2013. Migraine: the seventh disabler. cephalalgia, 33(5), pp.289-290.
  5. Pietrobon, D. and Moskowitz, M.A., 2013. Pathophysiology of migraine. Annual review of physiology, 75, pp.365-391.
  6. Rasmussen, B.K. and Olesen, J., 1992. Migraine with aura and migraine without aura: an epidemiological study. Cephalalgia, 12(4), pp.221-228.
  7. nhs.uk. 2022. Migraine. [online] Available at: <https://www.nhs.uk/conditions/migraine/> [Accessed 11 April 2022].
  8. American Society of Plastic Surgeons. 2022. Migraine Surgery. [online] Available at: <https://www.plasticsurgery.org/reconstructive-procedures/migraine-surgery> [Accessed 11 April 2022].
  9. Giamberardino, M.A., Tafuri, E., Savini, A., Fabrizio, A., Affaitati, G., Lerza, R., Di Ianni, L., Lapenna, D. and Mezzetti, A., 2007. Contribution of myofascial trigger points to migraine symptoms. The Journal of pain, 8(11), pp.869-878.
  10. Calandre, E.P., Hidalgo, J., García‐Leiva, J.M. and Rico‐Villademoros, F., 2006. Trigger point evaluation in migraine patients: an indication of peripheral sensitization linked to migraine predisposition?. European journal of neurology, 13(3), pp.244-249.
  11. Kung, T.A., Guyuron, B. and Cederna, P.S., 2011. Migraine surgery: a plastic surgery solution for refractory migraine headache. Plastic and Reconstructive Surgery, 127(1), pp.181-189.
  12. Hatef, D.A., Gutowski, K.A., Culbertson, G.R., Zielinski, M. and Manahan, M.A., 2020. A comprehensive review of surgical treatment of migraine surgery safety and efficacy. Plastic and reconstructive surgery, 146(2), pp.187e-195e.
  13. Gfrerer, L., Austen Jr, W.G. and Janis, J.E., 2019. Migraine surgery. Plastic and Reconstructive Surgery Global Open, 7(7).
  14. Americanheadachesociety.org. 2022. [online] Available at: <https://americanheadachesociety.org/wp-content/uploads/2018/06/Choosing-Wisely-Flyer.pdf> [Accessed 11 April 2022].
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  16. Alizadeh, K., Kreinces, J.B., Smiley, A. and Gachabayov, M., 2021. Clinical Outcome of Nerve Decompression Surgery for Migraine Improves with Nerve Wrap. Plastic and Reconstructive Surgery Global Open, 9(10).
  17. Fan, Z., Fan, Z. and Wang, H., 2006. New surgical approach for migraine. Otology & Neurotology, 27(5), pp.713-715.
  18. Hatef, D.A., Gutowski, K.A., Culbertson, G.R., Zielinski, M. and Manahan, M.A., 2020. A comprehensive review of surgical treatment of migraine surgery safety and efficacy. Plastic and reconstructive surgery, 146(2), pp.187e-195e.
  19. Kwon, S.H., Lee, E.J., Yeo, C.D., Kim, M.G., Kim, J.S., Noh, S.J., Kim, E.J., Kim, S.G., Lee, J.H., Yoo, J.S. and hoon Koh, J., 2020. Is septal deviation associated with headache?: A nationwide 10-year follow-up cohort study. Medicine, 99(20).
  20. Kwon, S.H., Lee, E.J., Yeo, C.D., Kim, M.G., Kim, J.S., Noh, S.J., Kim, E.J., Kim, S.G., Lee, J.H., Yoo, J.S. and hoon Koh, J., 2020. Is septal deviation associated with headache?: A nationwide 10-year follow-up cohort study. Medicine, 99(20).
  21. U.S. Food and Drug Administration. 2022. Treating Migraines: More Ways to Fight the Pain. [online] Available at: <https://www.fda.gov/consumers/consumer-updates/treating-migraines-more-ways-fight-pain> [Accessed 12 April 2022].
  22. Clinicaltrials.gov. 2022. Search of: Neuromodulation migraine – List Results – ClinicalTrials.gov. [online] Available at: <https://www.clinicaltrials.gov/ct2/results?cond=Neuromodulation+migraine&term=&cntry=&state=&city=&dist=> [Accessed 12 April 2022].
  23. Cheng, C.A., Chang, Y.H., Cheng, C.G., Lin, H.C., Chung, C.H. and Chien, W.C., 2020. Turbinate Submucosal Reduction Operation Reduced Migraine Admission among Patients with Chronic Hypertrophic Rhinitis. International Journal of Environmental Research and Public Health, 17(15), p.5455.
  24. Straburzyński, M., Gryglas-Dworak, A., Nowaczewska, M., Brożek-Mądry, E. and Martelletti, P., 2021. Etiology of ‘sinus headache’—moving the focus from rhinology to neurology. A systematic review. Brain sciences, 11(1), p.79.
  25. Wormald, J.C.R., Luck, J., Athwal, B., Muelhberger, T. and Mosahebi, A., 2019. Surgical intervention for chronic migraine headache: A systematic review. JPRAS open, 20, pp.1-18.

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