There are times in medicine, especially in surgery, when you feel incredibly blessed and lucky to be doing what you are doing. I’ll share a brief story with you, and I hope you’ll see what I mean.
If you don’t know, I love the migraine part of my practice. You can read more about it by clicking here. The other day, Karri, who is new to our office staff but has been working with us for years in the operating room, walked into my office as I was doing paperwork.
“Can you do those migraine injections for me”, she asked, referring to a few Botox injection trials I had done earlier in the week for other patients.
Despite knowing her fairly well, I had no idea that she had migraines, much less the kind she described to me – 20 days a month of a headache rated 8 on a scale of 10, which she has had for 10 years. Despite the usual medications, nothing seemed to take the headache away. She had been told, in no uncertain terms, that she would be on migraine medication for the rest of her life and that her headaches were something that she’d have to learn to live with. It wasn’t until she began working with us everyday and seeing my migraine patients come in and out (headache free), that she began to question whether there was another option for her.
Sadly, when I asked her to tell me where her head hurt, she pointed to two areas that weren’t spots where Botox would be effective. However, just as I was getting ready to tell her I really couldn’t help out, I remembered some papers that I’d recently read about other “surgical” causes of migraines.
I asked a few questions about her headaches – did they get worse when she bent over, did they get worse when/if she coughed? All pointed to headaches whose pain is related to the dilation of scalp arteries in people who are prone to get migraines.
“Does your headache get better when you press on these spots”, I asked. I gently pressed on a spot on the back of her head, about halfway between her spine and the back of her ear, and then on a spot right in front and above her ear canal.
“Actually, it does.”
Her headache vanished, and came back when I let go.
Afterwards, I suggested injections of anesthetic and steroid over the spots we identified as a trial to see whether a small surgery to remove a segment of the offending arteries would be beneficial.
The first spot was injected, and the headache improved substantially.
Right in front of her ear, I injected the second spot. Karri didn’t say anything for a second. Instead, I saw a tear run down her face and she began crying.
Her headache completely disappeared!
After a few minutes, with tears staining her cheeks, she got up from her chair and called her husband to let him know that for the first time in 10 years of medications that helped little, if any, her headaches were gone. Completely gone. It was a touching moment, and Joannah, our PA, was fighting back tears, as well (she commented on it on my Facebook Page). It was one of those moments that make me proud to be doing what I’m doing.
Karri’s headache pain seems to stem from the vessels on one side of her scalp. The theory (now over 50 years old, but largely ignored by academic medicine) is that dilation of these vessels, along with inflammation, swelling of the vessel walls, and a lowered pain threshold, are responsible for the pain of some migraines. Typical migraine medication – Imitrex, Maxalt, Zomig, Migrinal, and the like – can help this pain by narrowing these arteries. However, as was the case with Karri, these medications didn’t help much, and tend to lose their efficacy over time. A small surgery – essentially clipping the vessels to stop their blood flow through a small (<1 inch) incision – can drastically reduce or eliminate these headaches altogether.
Karri is planning on having the surgery soon, as the injections have been successful in completely elminating her headaches, and surgery offers her the chance to be completely headache free and off medications for the rest of her life. I’ll keep you posted on her progress.
A special “thank you” should be extended to Dr. Eliot and Mr. Daniel Shevel of The Headache Clinic in Johannesburg, South Africa. They have dedicated their careers to treating migraine headaches, and are tireless advocates of the extracranial vascular theory of migraines, which was how Karri was able to get relief for the first time in over a decade. As with other surgical treatments for migraines (the nerve decompressions I’ve written about before), it is not appropriate for all migraineurs. However, without Dr. Shevel’s research and guidance, Karri and countless other migraineurs would still be stuck in world without a hope of treatment.