by Lindy Keane Carter
The sensory nerves that lie under the face and scalp are tiny but mighty. When compressed by musculofascial tissue, they can cause migraine headaches that degrade quality of life for millions of people and cost billions of dollars to treat. The estimated total annual costs (direct and indirect) of treating migraine headache in the U.S. is $13 to $17 billion.1 Plastic surgeons at MUSC are now offering relief from this debilitating pain with a surgical technique that releases the compression of those nerves. Kevin O. Delaney, M.D., Assistant Professor of Plastic and Reconstructive Surgery, and Jason P. Ulm, M.D., Assistant Professor of Plastic and Reconstructive Surgery, have completed nine surgeries together and are reporting excellent results in alleviating migraine headache pain.
“Overall, the patients are ecstatic,” Dr. Delaney says. “Nearly all of them have had complete elimination of pain or a reduction in frequency or intensity.”
These outcomes are similar to those reported by the plastic surgeon who pioneered this nerve decompression technique–Dr. Bahman Guyuron, M.D., Chief of Plastic and Reconstructive Surgery at University Hospitals in Cleveland, OH. After five years, 61 (88%) of 69 patients benefited from the surgery (defined as at least a 50% reduction in baseline migraine frequency, intensity, or duration).2 Twenty (29%) reported elimination of the migraines and 41 (59%) experienced a significant decrease. Of MUSC’s nine patients, four have experienced complete elimination of pain and four have experienced a reduction. One patient with multiple headache disorders had slight improvement.
The technique arose as the result of an unexpected benefit of cosmetic surgery. Several years ago, Dr. Guyuron began investigating the role that nerves play in migraine headaches when he noticed that some of his patients who received forehead lifts subsequently reported relief from their migraines. His research later showed that the release of the forehead’s supraorbital and supratrochlear nerves from the corrugator supercilii muscle, commonly resected during the forehead lift surgery, was the reason for this improvement. Subsequent research identified other nerve compression sites, or “trigger points,” from which migraines arise: the zygomaticotemporal nerve; the greater occipital nerve; and the retro-orbital zone, often associated with a deviated septum and the resultant intranasal contact points.
Dr. Delaney completed a fellowship in Plastic and Reconstructive Surgery at the Ohio State University Medical Center, as well as a Hand and Microsurgery fellowship at Jackson Memorial Hospital in Miami, FL. He has attended several nerve decompression surgeries performed by Dr. Guyuron in Cleveland. Dr. Delaney now partners with Dr. Ulm, who completed a fellowship in Craniofacial Surgery at Massachusetts General Hospital/Harvard Medical School, for each of these procedures. Together in the OR, they offer patients a skill set unique in the Southeast, according to Dr. Ulm. “I think that Dr. Delaney’s specialty training in microsurgery and peripheral nerve surgery coupled with my craniofacial surgery training at one of the major migraine surgical treatment programs in the country makes us uniquely qualified to offer this kind of specialty treatment,” he notes.
MUSC’s comprehensive approach to the treatment of migraine headaches is also unique in the Southeast. In December 2013, MUSC created the Advanced Migraine Surgery Program (AMSP), reported to be one of only five multidisciplinary migraine surgery programs in the nation. Migraines are caused by many culprits, so the first step in treatment of a new AMSP patient is a systematic ruling-out of other causes. To this end, the AMSP offers guidance from neurologists, pain specialists, physical therapists, nutritionists, psychologists, psychiatrists, massage therapists, and acupuncturists. The program’s patient care coordinators help patients navigate the program every step of the way. Other AMSP team members also play key roles in directing the patients to the appropriate specialists.
Migraines confound patients and providers alike. Approximately one-third of migraine sufferers are not helped by standard therapies.3 The medications that are helpful can be costly and often have negative side effects, including weight gain, fatigue, dizziness, and nausea. Though injections of botulinum toxin A (Botox®; Allergan, Irvine, CA) can alleviate pain, the effect is temporary and some patients tire of having to receive the injections every three to four months.
The struggle to successfully treat migraines is a significant issue in medicine, as more than 30 million Americans (18% of women and 6% of men) suffer from these headaches.4 Surgery is often a patient’s last resort, and it should be, Dr. Delaney notes. It is paramount that less invasive therapies are tried first. “Even though we’re surgeons, surgery is actually the last step we recommend for those unfortunate patients who have attempted other treatments but still suffer from migraine headaches.” As part of the pre-surgical evaluation, a candidate typically will receive an injection of Botox® into the migraine trigger sites. After six to eight weeks, the patient is re-evaluated to determine the benefit of the Botox®. If the treatment has been successful, he or she is considered to be a good candidate for the surgery.
Patients may have one or multiple trigger points. All of the surgery is done through microscopic lenses, also known as loupe magnification. Surgeons target four main migraine trigger points:
1. The frontal region (above the eyebrows). After making an incision in the upper eyelid crease, which is the same incision used for an upper eyelid lift, the surgeon retracts the skin to resect the glabellar muscle groups and a portion of the corrugator supercilii to decompress the supraorbital and supratrochlear nerves.
2. The temple region. Again, the upper eyelid crease incision is used. The surgeon removes a portion of the zygomaticotemporal branch of the trigeminal nerve.
3. The occipital area (the back of the lower scalp). The surgeon makes a small incision above the hairline (so that the scar will be concealed in the hair) and retracts the skin to remove a small segment of the semispinalis capitis muscle (decompressing the greater occipital nerve) and then creates a subcutaneous cushion flap to shield and protect the nerve.
4. Retro-orbital/intranasal area (behind the eyes). Headaches emanating from this trigger site are often due to intranasal problems such as a deviated septum or enlarged turbinates. After the physician completes a physical examination, he or she often orders computed tomography of the facial bones and sinuses to confirm the anatomical problem. The surgeon then may perform a septoplasty and/or turbinectomy.
Efficacy: Some patients report relief as early as the day after surgery, but for most, relief does not arrive for a few weeks. The effects are shown to last for at least five years. The 2009 study conducted by Dr. Guyuron evaluating the efficacy of surgical deactivation of migraine trigger sites found that after five years elimination or reduction in frequency, duration, and intensity of migraine headaches was still achieved.2
Adverse effects: Adverse events reported in the five-year study include occasional itching at the incision site (common after all surgeries), hypersensitivity or hyposensitivity along the course of the supraorbital or supratrochlear nerves, and numbness in the same areas. Other patients reported some mild occipital stiffness or weakness. One patient reported injury to the temporal branch of the facial nerve, which later resolved completely. The study did not address loss of forehead muscle control, but because the corrugator supercilii muscle is the scowl muscle, the lack of movement here is of minimal functional or aesthetic consequence, notes Dr. Ulm.
New medical techniques are often met with spirited discussion about efficacy and this one is no exception, but Dr. Delaney points out that substantial research data compiled over many years support the efficacy of this surgery. “A variety of different specialists from multiple medical institutions have shown that the surgical treatment of migraine headaches can result in significant improvement and even complete relief. We, as physicians, surgeons, and researchers are continuing to study and realize the exact mechanisms responsible for migraine headaches in an effort to find the ever-elusive magic bullet,” he says.
Drs. Delaney and Ulm have received inquiries from migraine sufferers throughout the Southeast and are evaluating patients and scheduling migraine surgeries to meet the growing demand. “The reduction in headache pain that we’re seeing is rewarding because migraines are so debilitating to the patients, their families, and their way of living. We’re enabling those people to get back to their lives and engage,” says Dr. Ulm.
For more information or to make a referral, call MEDULINE at 1-800-922-5250 or 843-792-2200.
1 Goldberg LD. The cost of migraine and its treatment. Am J Manag Care 2005;11:S62-S67.
2 Guyuron B. Five-year outcome of surgical treatment of migraine headaches.
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3 Dodick DW. Triptan nonresponder studies: Implications for clinical practice. Headache 2005:45:156-162.
4 Lipton RB. Prevalence and burden of migraine in the United States: Data from the American Migraine Study II. Headache 2001;41:646-657..