Could getting rid of the wrinkles on your forehead also eliminate your migraine headaches? It might sound too good to be true, but a recent study found that 80% of patients who underwent a cosmetic-type surgery on one of three “trigger” areas experienced a significant reduction in headache frequency and intensity—even after one year.
The surgery was pioneered by plastic surgeon Bahman Guyuron, MD, chair of the Department of Plastic and Reconstructive Surgery at University Hospitals Case
Medical Center in Cleveland and former president of the American Association of Plastic Surgeons. A little more than a decade ago, he became intrigued when patients who had brow lifts—cosmetic procedures designed to smooth furrowed brows—reported that their headaches disappeared along with their wrinkles. Since then, he’s refined his procedures and conducted a number of studies to prove that the controversial technique is effective at controlling migraine pain.
In this new study, reported in 2009 in the journal Plastic Reconstructive Surgery, 69 of 79 patients who received the surgery (88%) experienced a positive response—29% reported complete elimination of their migraine headaches and 59% showed a significant decrease (at least a 50% reduction in headache frequency, intensity or duration). Only 11% experienced no real change.
So how does it work? Dr. Guyuron attributes most migraine pain to irritation of the terminal branches of the trigeminal nerve, which is responsible for sensation in the face. The tiny nerves at the end of the branches can get irritated by surrounding structures like muscles, connective tissue, bones or blood vessels, according to Dr. Guyuron. When stimulated, these nerves carry pain signals to the face and head.
The surgery, which can range from removing a tiny nerve branch to removing the frowning muscles in the forehead, “deactivates” trigger areas that are susceptible to this irritation.
“The trigeminal nerve is like a tree with multiple branches,” Dr. Guyuron says. “In order for the tree to catch on fire, you need a match. Our surgery is like pouring water on the branch so it can’t catch on fire.”
To determine which trigger sites are involved, patients receive Botox® injections in the forehead, temples and back of the head. If they get relief from the injections, they are considered viable candidates for the surgery.
Although complications are typically minimal, like all surgeries, this one does carry risks, ranging from infection to blood clots. For this reason, many headache specialists remain skeptical. In addition, surgery in general is known to have a placebo effect—often migraineurs find their headaches disappear for a time following surgery.
The latest five-year study was devised, in part, to counter this criticism. “The placebo effect does not last for five years, and it is not almost 90% effective,” Dr. Guyuron says. “Even if you take the placebo effect into consideration, the surgery has a substantial effect. Patients are symptom-free or significantly improved.”
Richard B. Lipton, MD, director of the Montefiore Headache Center in the Bronx, N.Y., and professor and vice chair of neurology at the Albert Einstein School of Medicine in New York City, says the surgery has proven its value for select patients, but additional studies involving independent headache experts would increase confidence in the results.
“The approach is directed to the identification and treatment of factors outside of the brain that can make migraine worse, sometimes called peripheral factors,” he explains. “While it seems radical to some, mainstream migraine treatment has long included identifying other peripheral factors—for example, disease of the cervical spine, disease in the nose (concha bullosa) and temporomandibular joint disorder (TMJ). These peripheral factors vary from person to person.”
Though Dr. Guyuron’s treatment responses are impressive, Dr. Lipton cautions that this surgical approach is not for everyone. “Successful treatment depends upon targeting the factor, or factors, that matter in a particular individual,” Dr. Lipton says. “For many patients, there is no peripheral factor, and this approach is, therefore, not relevant. It should be considered only for severe migraine sufferers who have not responded to less invasive and more conventional approaches.”
Dr. Guyuron agrees. “These have to be serious, disabling headaches,” he says. He recommends the surgery for only a specific set of migraineurs—those with at least two or more migraine days per month who have either not responded to medications or for whom medications are not recommended or tolerated. Before he will operate, he also insists patients have a diagnosis of migraine from a neurologist and don’t have medication overuse (rebound) headaches.
Even with the latest study, not all headache specialists are convinced. “This surgical procedure is still highly controversial in spite of the success rate in the reported study,” says Arthur Elkind, MD, director of the Elkind Headache Center in Mount Vernon, N.Y., and president of the NHF board of directors. “It is difficult to have a scientifically controlled group when the treated individuals are subjected to an invasive procedure. A large double-blind study with a sham procedure is still needed, and the patients will need to be evaluated by another physician who is not aware of the treatment given.”
