Surgical Approaches to Migraine Headache

In the United States, 13% of Americans (37 million people) have migraine headaches with women affected three times more than men. The costs are staggering: we spend approximately $1 billion in medical costs and lose roughly $16 billion in productivity every year. Despite improvement in medications, pharmacologic treatments are often incompletely effective. It is commonplace for migraine patients to be prescribed and take prophylactic, abortive, and analgesic medications but experience residual disability when they do not work.

An October 2014 supplement to Plastic and Reconstructive Surgery addresses migraine headache and, specifically, the current state of the art in the surgical treatment of migraine headaches. Most approaches are based on the theory that migraines occur when the trigeminal and cervical spinal nerves’ extracranial sensory branches are irritated, entrapped, or compressed. Botulinum toxin injection and surgical decompression target these trigger points to reduce or eliminate migraines in patients for whom prescription medications fail. Botulinum toxin injection tends to provide temporary migraine prevention.

Evidence supporting safe and effective permanent surgical decompression of peripheral trigger points is growing. The authors report that after reviewing all available studies, they calculate the average success rate of surgery (meaning migraine headache elimination or at least 50% reduction in symptoms) at nearly 90%. Although only one study has followed patients for 5 years or more, most studies report sustained relief for at least 1 year.

This article reviews several types of studies (e.g., clinical, anatomical, and cost effectiveness) and provides links to online videos showing actual technique. The authors report that initial high surgical costs are rapidly offset by reduced need for medication and improved productivity. The most common adverse events associated with surgery for migraine include transient numbness or paresthesias at the surgical site, incisional alopecia, controlled intraoperative bleeding, and transient uneven brow movement.

Currently studies are underway to refine a surgical approach for migraine headaches, determine the best way to triage patients, identify additional trigger points, and expand knowledge of migraine’s anatomy.