Migraine

Over the last 20 years many clinical studies have shown that nerve decompression surgery by removing constricting structures, vessels and muscles around nerves can provide a significant reduction of migraine symptoms.

MIGRAINE

Migraine is the most common neurologic disease and occurs more often than diabetes, asthma and epilepsy together. About 12 percent of the world population suffers from migraine, women 3 times more often than men. Migraine is more than just a severe headache; it is a complex disease with a spectrum of symptoms. There is a pulsating headache on one side of the head that can worsen during normal daily activities. In addition, there may be nausea, vomiting and hypersensitivity to light, noise and smell. A combination of these symptoms can last 4 to 72 hours. To make the diagnosis of migraine there have to be at least 5 migraine headaches a month for 3 months in a row. When there are 15 headache episodes a month 3 months in a row the diagnoses of chronic migraine can be made. At least 8 headaches will need to fulfill the criteria of migraine. Chronic migraine occurs in 2% of the world population.

DETAILS OF THE TREATMENT

CAUSE

The cause of migraine is still not clear. There seems to be a lower stimulus threshold for stimuli. Under certain circumstances the stimulus threshold can temporarily change such as tiredness, menstruation, relaxation after stress, sleep disturbances, dehydration, alcohol, certain foods and odors or weather changes. This hypersensitivity is likely to be hereditary to a great extent. Due to this hypersensitivity certain regions of the brain are over-stimulated causing a temporary disruption that influences nerves, vessels of the meninges. This leads to a headache and disruption of the cerebral cortex.

A migraine attack generally goes through four phases: the prodromal phase, the aura phase, the headache phase and the resolution phase.

The prodromal phase presents with atypical symptoms i.e., yawning, lethargy, elation, anorexia, food craving and mood changes. Due to these signals you can anticipate a migraine headache. The prodromal phase can last from 2 hours to 2 days.

About 30% of migraineurs experience an aura. These are short lasting neurologic disturbances such as visual symptoms, tingling in the hands, speech disturbances, and muscle weaknesses. An aura develops gradually and lasts 5 minutes to one hour.

During the headache phase there is a throbbing headache on one side of the head. This can be accompanied by nausea/vomiting and hypersensitivity to light, noise and odor. Preferably the patient would like to lie in bed in a dark and silent room. The headache phase lasts 4 hours to 3 days.

During the resolution phase the headache starts to subside. Often the patient falls asleep and wakes up with a light headache. There will still be fatigue and anorexia that may last hours to several days.

In many instances drug treatment can suppress the symptoms of migraine relatively well. There are two type of drug treatments. Firstly, there are drugs that can suppress a migraine attack that need to be taken as soon as the first symptoms of a migraine presents. These are amongst others, acetaminophen, NSAIDS, ergotamine, caffeine and the highly effective Triptans. Excessive use of all these drugs can however lead to medication overuse headaches. Secondly, there are drugs that reduce the frequency, duration and intensity of migraine attacks. The three most important groups of medication are antidepressive, antihypertensive and antiepileptic drugs. The side effects, however, can limit their usefulness. Furthermore, there are new drugs being developed that focus specifically on the mediators that play a role on developing neurogenic inflammation during the headache phase of migraine. These drugs seem very promising.

Botox temporarily paralyzes muscles and are being used to reduce wrinkles in the face. It appears that migraine patients who undergo a cosmetic Botox treatment experience a reduction of their migraine symptoms in the months thereafter. In the 2011 prospective double blind placebo controlled PREEMPT study the efficacy of Botox as a prophylactic treatment was demonstrated. In various locations of the forehead, temporal region and occiput a standard dose of Botox is injected. Botox takes effect on migraine symptoms after 2 – 3 weeks and can last 3 months.

In 2000 plastic surgeon dr. Bahman Guyeron accidentally discovered that patients suffering from migraine who had undergone a cosmetic forehead lift experienced a reduction of their migraine. This has led to the assumption that peripheral cranial nerves are triggers for the development of migraine attacks. The irritation of these nerves through muscle contraction, adjacent blood vesicles and compressing fascial structures cause release of mediators by neurons. These mediators play a central role in the development of migraine by inducing neurogenic inflammation.

There are four migraine trigger zones:

1. The nerves of the forehead, the supratrochlear and supraorbital nerves can become irritated through contraction of the frown muscles and can trigger a migraine attack. The muscles through which these nerves run can be removed through an upper eyelid correction or an endoscopic forehead lift.

  1. In the temporal region the zygomatico-facial and auriculo-temporal nerves can trigger a migraine headache. Decompression of the zygomatico-facial nerve can be performed through an upper eyelid incision, endoscopically or through a direct one cm incision. An auriculo-temporal nerve decompression is done through a one cm preauricular incision, whereby the adjacent compressing artery is tied off.
  2. The occipital region has several nerves that may need to be addressed. The most important greater occipital nerves can be compressed at different levels. Decompression at all these levels can be performed through a 5 cm vertical incision in the middle of the back of the head. The lesser occipital nerve can be found behind the ear and can be decompressed through a 1 cm incision.
  3. When the septum of the nose is deviated and touches the mucosa of the sidewall of the nasal cavity migraine can be triggered in a susceptible patient. Nose drops may reduce this typical migraine and when suspected, a CT scan is required for confirmation. A septoplasty to correct the deviated septum can alleviate a migraine of rhinogenic origin.

Migraine surgery is mainly indicated for patients suffering from chronic migraine with whom drug treatment is insufficiently effective or having unacceptable side effect. It is important that the diagnoses migraine has been made by a neurologist. Firstly, the all the trigger sites need to be determined. How, what and where the patient experiences the migraine will already indicate the possible trigger sites. When the patient experiences a headache at the time of the consultation nerve blocks can be given at the suspected trigger sites. When the headache subsides, these nerves are a candidate for decompression. When there is no headache present at the time of consultation Botox can be injected. In general, migraine patients that react positively to Botox treatments are considered good candidates for migraine surgery. Therefor Botox plays an important role in selecting patients for migraine surgery and in determining the trigger sites.

Over the last 20 years many clinical studies have shown that nerve decompression surgery by removing constricting structures, vessels and muscles around nerves can provide a significant reduction of migraine symptoms. Migraine surgery involves mainly plastic surgical procedures and techniques with low complication rates. In 80 – 90% of patients there will be a 50% or more reduction in frequency, intensity and duration of migraine attacks and in 30% the migraine is completely eliminated.