Leeches, fungus, exorcism. Headache specialists have seen it all when it comes to migraine treatments. The most invasive therapies, such as boring a hole into one’s head, have gone by the wayside, making way for more traditional therapies such as medications. But a recent invasive procedure is making waves among migraineurs and has headache specialists concerned.
In 2009, Bahman Guyuron, MD, chair of the plastic surgery department at University Hospitals Case Medical Center in Cleveland, Ohio, set out to determine whether plastic surgery could provide relief for migraineurs. The results of his study were published in the Aug. 2009 journal Plastic and Reconstructive Surgery and received extensive media coverage from outlets such as The New York Times, ABC News and The Wall Street Journal. The idea that a cosmetic procedure could relieve pain intrigued readers and seemed easy enough.
Still, headache specialists say any invasive surgery comes with risks; without more data, it would be safer for migraineurs to try traditional therapies first.
The Plastic Surgery Study That Drew America’s Attention
Dr. Guyuron’s study was not the first to explore the use of a cosmetic procedure for migraine relief. Researchers have been looking into onabotulinumtoxinA injections (Botox®) as a migraine treatment for several years. An extensively modified protocol of the kind used in cosmetics was approved by the FDA for treatment of chronic migraine in 2010. Patients who undergo the treatment generally receive injections every 12 weeks around the head and neck to dull the symptoms of the migraine, according to the FDA’s 2010 press release.
To qualify for Dr. Guyuron’s plastic surgery study, patients had to first respond well to Botox for migraine relief; he found 76 patients who met the requirements. Dr. Guyuron theorized that those who responded well to Botox would find more permanent relief through surgery. It should be noted that, when used for migraine treatment, neither procedure is used to change the patient’s looks; instead, the techniques are applied to migraine trigger points in an attempt to relieve pain.
In the case of Dr. Guyuron’s outpatient procedure, a surgeon incises through the skin into the areas of fibrous tissue through which nerves run. Specifically, the surgeon looks for either scarring of nerves or nerves trapped in muscle in three trigger sites (the forehead, temples or back of the head). If the nerves or muscles seem to be to blame for the migraine pain, the surgeon surgically deactivates the trigger site in question by removing any excess muscle and injecting fat to cushion the nerves and fill any pockets left from the removal of the muscle. The whole thing takes less than an hour.
The 76 patients in Dr. Guyuron’s study were divided into three groups (based on the trigger sites). In each group, two-thirds of the patients underwent surgery to deactivate muscles. The other one-third of patients in each group underwent “sham surgery” in which the surgeon made incisions to expose the muscles but did not deactivate them. The results were positive: 15 of the 26 in the sham surgery group and 41 of the 49 people in the actual surgery group reported at least a 50 percent reduction in migraines for one year after the surgery. Of the 41 in the actual surgery group who reported a reduction, 28 said their migraines had been completely eliminated.
Downfalls of Dr. Guyuron’s Study
Positive results aside, headache specialists have reservations about recommending plastic surgery based on Dr. Guyuron’s study alone. For one thing, the way the study was devised might lead to a false assumption, says Mark Green, MD, director of the Center for Headache and Pain Medicine at the Mount Sinai School of Medicine in New York City, and an NHF Board member. It is unclear whether Botox affects migraine by paralyzing muscles or inhibiting nerves that transmit pain signals to the brain. If researchers don’t believe that Botox works by paralyzing muscles, “then why are we operating and cutting muscles through plastic surgery?” Dr. Green wonders, adding that the assumption that Botox and plastic surgery could have similar effects needs further investigation.
Even though the plastic surgery did have a positive impact on patients in Dr. Guyuron’s study, data that show the effects of the surgery over time do not yet exist. Without long-term data, “you end up with a lot of anecdotal information, and that’s where problems can occur,” says Roger Cady, MD, associate executive chairman of the National Headache Foundation (NHF) and founder and director of the Headache Care Center and Primary Care Network, Inc., in Springfield, Mo. Dr. Cady would like to see more clinical trials related to plastic surgery for migraine treatment so that physicians can make scientifically based decisions involving a larger pool of information.
Dr. Cady says four of his patients have undergone plastic surgery for migraine treatment and several more are in the evaluation stage for possible plastic surgery. While he did not encourage the treatment, he says he also did not stand in their way. “These are patients with extensive histories of medication failures and long-standing, disabling chronic migraine,” he says. “We’re as curious and hopeful as anyone to see how they do.” Dr. Cady says he doesn’t have any patients who are beyond the six-month mark, post-surgery. He and their surgeon are following their progress closely.
Reservations, Risks of Plastic Surgery for Migraine Relief
All medical treatments for chronic migraine involve a degree of risk—but the risk associated with surgery is more permanent, Dr. Cady says. Plastic surgery for migraine relief involves a multi-week recovery period as well as the potential for rare side effects such as hair loss, itching and asymmetric eyebrow movement.
“The concern is that people will try this procedure before they’ve gone through appropriate diagnosis, evaluation and more traditional treatments,” he says.
Experts say the best approach to migraine treatment is to work with a headache specialist who has a deeper knowledge of the pathophysiology of migraines and who has access to information on what treatments are FDA approved and have consensus in the field. Permanent procedures would likely be met with a physician’s skepticism if simpler, temporary relief can be obtained through medication.
In their own statements, the NHF and the American Headache Society have also noted reservations about the surgery. “I think both of those organizations presently see this procedure as a last resort,” Dr. Cady says.
Discarded Migraine Treatments
By Seymour Diamond, MD, Executive Chairman and Founder of the National Headache Foundation (NHF)
Migraine has been a recognized disorder for 2.5 millennia. Yet it was not until 1938, when John Graham and Harold Wolff discovered that the use of ergot (a fungus that grows on rye) could successfully treat acute migraine attacks, that a recognized effective therapy was identified. Since that discovery, we have seen a proliferation of effective prophylactic and acute agents. In 1987, in his text, Headache, my late friend J.N. Blau noted that “only charlatans claim a cure for migraine, and the majority of patients appreciate [that] a cure is unattainable with our present knowledge.”
From the earliest times, focal treatment to the head or neck during a migraine attack was advised. John Fordyce (who published De Hemicrania in 1758) noted that during an acute headache, he plunged his head into cold water. Thomas Willis (1621-1675) recommended applying a plaster consisting of leeches to the head. In a treatise published posthumously in 1684 titled Willis’ Practice of Physick, Being the Whole Works of that Renowned and Famous Physician, blood-letting was suggested as an acute headache treatment.
During the 17th century, the application of a tight bandage around the head became common practice. Shakespeare noted this treatment in two plays:
- In King John, Act IV, Scene 1, Prince Arthur remarks to Huber, his executioner:
When your head did but ache, I knit my handercher about your brows
- In Othello, act III, scene 2, in a dialogue between Othello and Desdemona:
Desdemona: Why do you speak so faintly? Are you not well?
Othello: I have a pain upon my forehead here.
Desdemona: ‘Faith, that’s with watching; ‘twill away again: Let me but bind it hard, within this hour.’ It will be well.
Going back further in history, Abulcasis (936-1013) advised that if hot applications to the head failed, the tender blood vessels in the temple should be severed and the wound dressed with garlic. Trephining, which involved making a burr hole in the skull, was still employed frequently until the 20th century. I continued to see recommendations for its use, and publicity about its curative value, until the 1970s.
In many cases, both prophylactic and acute treatments have not been subject to rigid scrutiny. Whatever studies were done, they were not replicated and merely afforded the opportunity for expensive and minimally effective help. As an example, I would cite repairs of the patent foramen ovale (a congenital hole between the chambers of the heart) and its alleged relationship to migraine. This condition may be persistent throughout life. Some studies, reportedly demonstrating these interventions to be effective, have been associated with a grandiose public relations campaign. With such a long history of discarded therapies, migraineurs should be wary of any pronouncement of a treatment that claims to be a cure-all for their headaches.
To learn about the history of migraine treatments, read Headache Through the Ages by Seymour Diamond, MD, and Mary A. Franklin, available on Amazon.com.
