Almost 25% of women between 18 and 50 suffer from migraine headaches. As any of you who suffer from migraines knows, the cost – in terms of medications, ER visits, lost days at work, etc (not to mention time lost with your family and friends, which is irreplaceable) is immense.
A little science – the accepted theory as to why migraines occur goes like this (and there are people who have dedicated their lives to figure this out, and the theories are evolving constantly as we learn more):
A migraine trigger signals a depressive wave through the main part of the brain, which causes chemical irritants to be released. This, in turn, causes sensory fibers in the meninges – the covering of the brain – to fire, which is then felt as pain. If this process continues long enough, a part of the brain and brainstem known as the trigeminal nucleus caudalis becomes inflamed and starts a process called central sensitization (a “full blown” migraine). The main hallmark of central sensitization is pain or discomfort from things that are seemingly innocent, like brushing your hair, breathing thru the nose on cool days, or having the shower water splash your face. Stopping the headache at this point is difficult – typical medications will tend to “take the edge off”, but will not completely get rid of the migraine. The key is to stop the headache before it gets to this stage by blocking the inflammation and release of triggering chemicals. Imitrex and the other triptan medications works at this point of the cycle.
As the frequency of migraine headaches increase, there can be anatomic changes in the brain as a result of prolonged sensitization of the nerve pathways. It is thought that by removing the triggers (which is, essentially, fuel for the fire), the headaches will diminish in intensity, frequency, and duration or, hopefully, disappear altogether. It is at this point that surgery should be considered.
In plastic surgery, we are trained to work on and with nerves in the arms and legs. There are certain syndromes (like carpal tunnel syndrome) that we deal with frequently where we are able to restore function that is compromised as the result of nerve compression. It is theorized that surgery to treat migraine headaches works in a similar manner to that for carpal tunnel syndrome – releasing pressure on nerves from otherwise normal surrounding anatomy that inexplicably causes problems in some people but not in others.
There are a number of areas in the head and neck where sensory nerves can be compressed by surrounding structures (muscles or the muscle covering, known as fascia). In people with a genetic predisposition to getting migraine headaches, these compression points can act as a trigger that starts the cascade towards central sensitization and chronic migraine headaches. By surgically releasing these nerves from their compression points, the anatomic stimulus for the headache is removed, and the headaches either disappear or are greatly diminished. We are learning more about nerve compression points of the trigeminal nerve (the main sensory nerve of the head and neck, which gives sensation to your face and scalp through its numerous branches) every day.
To date, known compression points (which can be successfully treated with surgery) are:
- supraorbital and supratrochlear nerves
- zygomaticotemporal nerve
- auriculotemporal nerve
- greater occipital nerve
- lesser occipital nerve
- numerous small nerve branches of the nasal septum & turbinates
A disclaimer: Not everyone with migraine headaches will have these triggers, and surgery is definitely not the solution for everyone with migraine headaches. In quite a number of people, avoidance of known triggers and prescription medications is enough to limit or eliminate the headaches.
However, as we have seen in the numerous publications by Dr. B. Guyuron and colleagues at Case Western Reserve University, surgical decompression can lead to a drastic reduction or elimination of migraines in 80-90% of selected patients. I personally feel that it is a treatment that is backed by sound science and logical thinking, and should be considered as a valid treatment option as the severity of the headaches increases.
While I haven’t operated on the 900+ patients that he has, I have a number of migraine sufferers in my own practice whose lives are much better after surgery than before, and are some of the most grateful people I have the privilege to take care of.