Migraine 'Trigger Site' Surgery May Provide Relief, But Many Are Skeptical (mobile format)

http://www.medscape.com/viewarticle/737101


Migraine 'Trigger Site' Surgery May Provide Relief, But Many Are Skeptical



February 9, 2011 — In appropriate patients with migraine headache, surgical manipulation to deactivate migraine trigger sites can produce a lasting reduction in the frequency, duration, and intensity of migraine pain, according to a study in the February issue of Plastic and Reconstructive Surgery.

Senior author Bahman Guyuron, MD, chair of the Department of Plastic Surgery, Case Western Reserve University and University Hospitals Case Medical Center in Cleveland, pioneered surgical techniques to deactivate trigger sites for migraine headache after noticing that some patients with migraine had fewer headaches after cosmetic forehead-lift procedures.


Dr. Bahman Guyuron
"A large number of migraine headaches are triggered from the peripheral branches of the trigeminal nerve, which are irritated by the surrounding muscles, vessels or because of being compressed by some anatomical structures," he told Medscape Medical News.

"These mechanical stimuli (peripheral mechanism) begin a cascade of events that if they continue will result in central sensitization and thus the related symptoms. We deactivate these trigger sites by eliminating the physical elements that irritate the nerves, such as surrounding muscles, fascia bands, and vessels," Dr. Guyuron explained.

High "Positive" Response Rate at 5 Years

In their paper, Dr. Guyuron and colleagues report 5-year outcomes for a group of patients with neurologist-confirmed migraine who underwent surgical deactivation of 1 to 4 common trigger sites. Dr. Guyuron presented preliminary results of the study at Plastic Surgery 2009: American Society of Plastic Surgeons Annual Meeting.

One hundred patients in the treatment group received botulinum toxin A injections to confirm trigger sites, and 25 patients in the control group received saline injections. Among 100 patients randomly assigned to surgery, 91 had successful detection and confirmation of the trigger sites and underwent surgery, including the following:

Removal of the glabellar muscle group for the frontal trigger site;
Avulsion of the zygomaticotemporal branch of the trigeminal nerve for the temporal trigger site;
Septoplasty and turbinectomy for the intranasal trigger site; and
Removal of a small portion of the semispinalis capitis muscle and shielding of the greater occipital nerve for the occipital trigger site.
Eighty-nine of the 91 surgery patients were followed for 1 year, and 79 were followed for 5 years. During follow-up, 10 of these patients underwent deactivation of other trigger sites to provide "additional relief," the researchers report.

These 10 patients were not included in the final analysis to "avoid extra confounding factors affecting the results," the authors note. The final outcome with or without inclusion of these 10 patients was not statistically significantly different.

Patients completed the Medical Outcomes Study 36-Item Short-Form Health Survey, the Migraine Specific Quality of Life, and the Migraine Disability Assessment questionnaires before treatment and 1 and 5 years after treatment.

According to the criteria of at least 50% reduction in baseline frequency, intensity, or duration of migraine 5 years after surgery, 61 of 69 surgery patients (88%) had benefits from surgery and have maintained overall improvement, the researchers report.

Twenty patients (29%) reported complete elimination of migraine headache, and 41 (59%) reported a significant decrease in migraine headache. Eight patients (12%) have seen no significant changes. The overall frequency of migraine attacks decreased from about 11 to about 4 per month, and their average duration decreased from 1.4 to 0.42 days.

At 5 years, the researchers say all measured variables have significantly improved (P < .0001).

Adverse events include occasional itching and hair thinning at the surgery site; hypersensitivity, hyposensitivity, or numbness along the supraorbital or supratrochlear nerves; mild occipital stiffness or weakness; and injury to the temporal branch of the facial nerve, which recovered completely.

"Appropriate candidates for the surgery," Dr. Guyuron told Medscape Medical News, "are patients who have at least 2 migraine headaches a month that are severe or do not respond to the conventional treatment or those who cannot take triptans or other effective medications, especially those with chronic migraine headaches."

Skepticism Abounds


Dr. Alexander Mauskop
Reached for independent comment, Alexander Mauskop, MD, director and founder of the New York Headache Center in New York City and board-certified neurologist, said migraine surgery is "controversial and, obviously, headache specialists don't think it's appropriate for plastic surgeons to be treating headache patients."

"With that aside, Dr. Guyuron has been working with a neurologist, which makes it better, but the issue with surgery is that it is permanent and there are potential side effects, including risk of infection," Dr. Mauskop said.

…obviously, headache specialists don't think it's appropriate for plastic surgeons to be treating headache patients.
He also made the point that migraine is a "self-limited disease and it often just goes away; that's the nature of the disease, even chronic severe headaches disappear with time for a variety of reasons. If you take a group of headache patients and follow them for 5 years, many of them will not have any headaches without any intervention. So for a variety of reasons, I don't think this should be a standard treatment for migraine."

Placebo Effect?

Stephen Silberstein, MD, director of the Headache Center at Jefferson Medical College in Philadelphia, Pennsylvania, remains unconvinced of any real benefit of migraine surgery. "Surgery is a great placebo," he told Medscape Medical News.

Surgery is a great placebo.
In their paper, Dr. Guyuron and colleagues acknowledge the high placebo response rate in patients with migraine, but they say placebo responsiveness is "short-lived, and an 88% placebo effect lasting 5 years has never been documented."

Dr. Guyuron and colleagues agree that many unanswered questions remain, including the precise anatomic reasons for the apparent benefits. "We have a number of studies in process, both clinical and basic science, that we are looking forward to sharing with our neurology, plastic surgery, and neurosurgery colleagues," he said.

Dr. Guyuron and colleagues and Dr. Silberstein have disclosed no relevant financial relationships. Dr. Mauskop reports that he has conducted research and served as a consultant and a speaker for Allergan, maker of Botox.

Plast Reconstr Surg. 2011;127:603-608. Abstract