MIGRAINE SURGERY
WHAT IS MIGRAINE?
The cause of migraine disease is still not fully understood today. It is thought to be a neurovascular disorder.[1] The main theory is thought to be related to increased excitability of the cerebral cortex and abnormal control of pain neurons in the trigeminal nucleus in the brainstem.[2] For this reason, neurology is the main department that diagnoses patients with migraine, administers drug therapy, and studies the pathophysiology of the disease. However, in some patients who had migraine attacks, it was realized that the reason was due to compression or irritation in the facial sensory nerves, which are branches of the trigeminal nerve in the periphery. Thereupon, plastic surgeons entered this field by surgically releasing the nerves that are thought to be under pressure, and successful results have been reported in many clinical studies.
MIGRAINE IN TURKEY
The incidence of migraine in Turkey was reported as 2.38% in a study conducted by Istanbul Medical Faculty Neurology Department in 2015.[3] In other words, millions of people in Turkey have been diagnosed with migraine and the fact that some of these patients can be cured by surgical treatment has been scientifically proven in the last 10 years.
BOTOX APPLICATION IN MIGRAINE TREATMENT
In connection with this issue, in 2010, the US Department of Health (FDA) approved the use of Botox in the treatment of migraine disease:
MIGRAINE SURGERY - PURPOSE
In the last 15 years, it has been noticed that migraine attacks decrease after Botox application in people who have migraine and have been applied Botox for cosmetic purposes to the forehead area. Thereupon, it was thought that the cause of migraine in some of the migraine patients might be the compression of some nerves under the face and scalp. Professor Bahman Guyuron, Head of the Department of Plastic Surgery at Case Western Reserve University School of Medicine in Cleveland, USA, was the first person to notice this situation. Based on the patients whose number of migraine attacks decreased after botulinum toxin application, he concluded that the compression of the nerves in the face and scalp within the muscles may cause migraine attacks. Statistical data obtained from nerve release surgeries performed in hundreds of patients with migraine diagnosis and findings of nerve compression in the head region within 15 years show that surgical recovery of the nerve from the pressure of the surrounding tissues gives positive results. The logic of this surgery is the same as the logic of nerve compression surgery in the wrist (median nerve in the carpal tunnel). The frequency, duration, and severity of migraine attacks of patients were statistically significantly reduced after surgery (see references). The determination of Dr. Guyuron, who has written over 40 articles on this subject, has been accepted by many plastic surgeons, and it is now an accepted view that surgery has a place in the treatment of migraine in selected patients.
The following link is available for the Harvard Medical School Department of Plastic Surgery Migraine surgery program.OPERATION
It is possible to operate under local anesthesia in the majority of patients diagnosed with migraine due to nerve compression. Before the operation, the trigger point, which is shown by the patient as the area where the attack started, should be determined. It is an approach to apply Botox to the possible area to be sure of the trigger point, and to indicate an operation if the attack frequency, severity and duration of the person decreases. It may sometimes be appropriate to use endoscopy to reach the trigger point of the nerve that is thought to be compressed. If the nerves in the forehead are thought to be compressed, the nerves can be accessed by making an incision in the upper eyelid. Partial removal of the connective tissue of the muscles around the nerve, expansion of the bone tunnel around the nerves when necessary, and if irritation in the nerve due to the pulsation of the vessel adjacent to the nerve is considered, ligating the artery constitutes the basic stages of the surgery. The most important issue in these procedures is the correct indication of the operation. In other words, compression of the nerves in the head region can only be considered as one of the possible causes of migraine. The underlying cause is not the same in every migraine case. If a migraine patient clinically has a finding of nerve compression in any of the sensory nerves on the face or scalp, only in this case the patient may benefit from the surgery.
REFERENCES
- Bartleson JD, Cutrer FM (May 2010). "Migraine update. Diagnosis and treatment". Minn Med 93 (5): 36–41. PMID 20572569.
- Dodick DW, Gargus JJ (August 2008). "Why migraines strike". Sci. Am. 299 (2): 56–63. Bibcode 2008SciAm.299b..56D.
- Baykan B, Ertas M, Karlı N, Uluduz D, Uygunoglu U, Ekizoglu E, Kocasoy Orhan E, Saip S, Zarifoglu M, Siva A. Migraine incidence in 5 years: a population-based prospective longitudinal study in Turkey. J Headache Pain. 2015;16:103.
- A retrospective review of the outcomes of migraine surgery in the adolescent population. Guyuron B, Lineberry K, Nahabet EH. Plast Reconstr Surg. 2015 Jun;135(6):1700-5.
- A Prospective Randomized Outcomes Comparison of Two Temple Migraine Trigger Site Deactivation Techniques.Guyuron B, Harvey D, Reed D. Plast Reconstr Surg. 2015 Jul;136(1):159-65.
- Use of a Doppler signal to confirm migraine headache trigger sites. Guyuron B, Riazi H, Long T, Wirtz E. Plast Reconstr Surg. 2015 Apr;135(4):1109-12.
- Intraoperative corticosteroid injections in migraine surgery: efficacy in preventing refractory symptoms. Lineberry K, Lee M, Monson A, Guyuron B. Plast Reconstr Surg. 2015 Feb;135(2):393e-6e.
- The effect of preoperative migraine headache frequency on surgical outcomes. Molavi S, Zwiebel S, Gittleman H, Alleyne B, Guyuron B. Plast Reconstr Surg. 2014 Dec;134(6):1306-11.
- Electron microscopic and proteomic comparison of terminal branches of the trigeminal nerve in patients with and without migraine headaches. Guyuron B, Yohannes E, Miller R, Chim H, Reed D, Chance MR. Plast Reconstr Surg. 2014 Nov;134(5):796e-805e.
- A review of current evidence in the surgical treatment of migraine headaches. Janis JE, Barker JC, Javadi C, Ducic I, Hagan R, Guyuron B. Plast Reconstr Surg. 2014 Oct;134(4 Suppl 2):131S-41S.
- Nonendoscopic deactivation of nerve triggers in migraine headache patients: surgical technique and outcomes. Gfrerer L, Maman DY, Tessler O, Austen WG Jr. Plast Reconstr Surg. 2014 Oct;134(4):771-8.
- A discussion of "critical evaluation of migraine trigger site decompression surgery". Guyuron B. Headache. 2014 Jun;54(6):1065-72. doi: 10.1111/head.12370. No abstract available.
- In-depth review of symptoms, triggers, and treatment of temporal migraine headaches (Site II). Kurlander DE, Punjabi A, Liu MT, Sattar A, Guyuron B. Plast Reconstr Surg. 2014 Apr;133(4):897-903.
- Impact of preoperative narcotic use on outcomes in migraine surgery. Adenuga P, Brown M, Reed D, Guyuron B. Plast Reconstr Surg. 2014 Jul;134(1):113-9.
- An anatomical study of the lesser occipital nerve and its potential compression points: implications for surgical treatment of migraine headaches. Lee M, Brown M, Chepla K, Okada H, Gatherwright J, Totonchi A, Alleyne B, Zwiebel S, Kurlander D, Guyuron B. Plast Reconstr Surg. 2013 Dec;132(6):1551-6.
- Intraoperative anatomical variations during greater occipital nerve decompression. Junewicz A, Katira K, Guyuron B. J Plast Reconstr Aesthet Surg. 2013;66(10):1340-5.
- The role of the third occipital nerve in surgical treatment of occipital migraine headaches. Lee M, Lineberry K, Reed D, Guyuron B. J Plast Reconstr Aesthet Surg. 2013 Oct;66(10):1335-9.
- Positive botulinum toxin type a response is a prognosticator for migraine surgery success. Lee M, Monson MA, Liu MT, Reed D, Guyuron B. Plast Reconstr Surg. 2013 Apr;131(4):751-7.
- The role of occipital artery resection in the surgical treatment of occipital migraine headaches. Chmielewski L, Liu MT, Guyuron B. Plast Reconstr Surg. 2013 Mar;131(3):351e-6e.
- Reply: Outcome comparison of endoscopic and transpalpebral decompression for treatment of frontal migraine headaches. Guyuron B. Plast Reconstr Surg. 2013 Feb;131(2):277e-278e.
- Discussion: The anatomical morphology of the supraorbital Notch: clinical relevance to the surgical treatment of migraine headaches. Guyuron B. Plast Reconstr Surg. 2012 Dec;130(6):1234.
- The auriculotemporal nerve in etiology of migraine headaches: compression points and anatomical variations. Chim H, Okada HC, Brown MS, Alleyne B, Liu MT, Zwiebel S, Guyuron B. Plast Reconstr Surg. 2012 Aug;130(2):336-41. doi: 10.1097/PRS.0b013e3182589dd5.
- Outcome comparison of endoscopic and transpalpebral decompression for treatment of frontal migraine headaches. Liu MT, Chim H, Guyuron B. Plast Reconstr Surg. 2012 May;129(5):1113-9.
Treatment Features
ANESTHESIAMostly local anesthesia, sometimes general anesthesia
DURATION OF SURGERY2 - 3 hours
HEALING TIME10 days
FINAL RESULT6 months - 1 year
TIME OF USEForever
ACHEno
NOTEFor migraine cases due to nerve compression