'Doctor: Why Can't You Just Cut Out My Headache?'
Abstract & Commentary
By Dara Jamieson, MD, Associate Professor of Clinical Neurology, Weill Cornell Medical College. Dr. Jamieson reports she is a retained consultant for Boehringer Ingelheim, Merck, and Ortho-McNeil, and is on the speaker's bureau for Boehringer Ingelheim and Merck.
Synopsis: Surgery may offer pain relief for selected patients with specific headache types, such as migraines with trigger sites and Chiari I malformation related headaches.
Sources: Guyuron B, Reed D, Kriegler JS, et al. A placebo-controlled surgical trial of the treatment of migraine headaches. Plast Reconstr Surg 2009;124:461-468.
Janis JE. Discussion. A placebo-controlled surgical trial of the treatment of migraine headaches. Plast Reconstr Surg 2009;124:469-740.
Tisell M, Wallskog J, Linde M. Long-term outcome after surgery for Chiari I malformation. Acta Neurol Scand 2009 Jun 11. [Epub ahead of print.]
Headaches, an almost universal experience that can range from a mild annoyance to a crippling misery, have causes and treatments which are poorly understood. For many of the 30 million Americans who are suffering from chronic, disabling migraine headaches, the medications used to prevent their headaches have limited efficacy and problematic side-effects. A surgical treatment for headaches, including migraines, would offer substantial benefit to patients with this common affliction.
Guyuron and colleagues evaluated surgical deactivation of frontal, temporal, and occipital trigger sites in 75 patients (from 317 patients screened) with moderate to severe migraine headaches by International Classification of Headache Disorders II criteria. Patient description and symptomatic response to botulinum toxin injection were used to identify the trigger site "where the migraine begins and settles and corresponds to the anatomical zone of potential irritation of the trigeminal nerve." Patients were randomly assigned to receive either actual or sham surgery in their predominant trigger site. For actual surgery, glabellar muscles were removed from frontal trigger patients; a segment of the zygomaticotemporal branch of the trigeminal nerve was resected from temporal trigger patients; and a segment of the semispinalis capitis muscle was removed from occipital trigger patients. Patients completed the Migraine Disability Assessment, Migraine-Specific Quality of Life, and Medical Outcomes Study 36-Item Short Form Health Survey health questionnaires before treatment and at one-year follow-up. Of the 75 patients, 15 of 26 in the sham surgery group (57.7%) and 41 of 49 in the actual surgery group (83.7%) experienced at least 50% reduction in migraine headaches (p < 0.05).
While 28 of 49 patients in the actual surgery group (57.1%) reported complete elimination of migraine headaches, only one of 26 patients in the sham surgery group (3.8%) (p < 0.001) became headache-free. Compared with the sham surgery group, the actual surgery group demonstrated statistically significant improvements in all validated migraine headache measurements at one year. The headache improvement was not dependent on the migraine trigger site. The most common surgical complication was a slight temporal hollowing in patients with temporal trigger sites.
Tisell and colleagues examined the long-term effects of suboccipito-cervical decompression in 24 consecutive patients (14 females and 10 males with a median age of 26 years) who underwent decompressive surgery for Chiari I malformation during 19982006. The median tonsilar herniation was 15.5 mm (range 435 mm) and half the patients had an associated syringomyelia. Most patients had posterior head or neck pain exacerbated by physical activity. Patients were evaluated by questionnaire with a median post-operative follow-up of 3.2 years (range 1.79.2 years). There was an improvement in headache in 75%, decreased associated neurological symptoms in 88% and less negative impact on daily life in 75% of the 24 operated patients. The results of this uncontrolled study indicated potential benefit for surgical intervention in patients with symptomatic Chiari I patients.
Commentary
While the study by Guyuron and colleagues offers the intriguing possibility that surgical deactivation of peripheral trigger sites may be an effective alternative treatment for patients who suffer from intractable migraine headaches, the paper and the accompanying commentary point out some perplexing results. There was a high incidence of symptomatic improvement in the sham surgery group, paralleling placebo results in multiple studies of headache treatment. Despite rigorous patient selection, benefit was not achieved by all patients treated with actual surgery.
Headaches have multiple causes so historical details provide crucial information about diagnosis. Less than a quarter of patients who were screened for trigger sites were found to be eligible for the study, indicating that the "real-world experience" benefit of surgical deactivation in migraine patients may be limited. A Chiari I malformation may be an incidental finding or a possible etiology of headaches, and the efficacy of suboccipito-cervical decompression is dependent on appropriate patient selection. The results of these surgical treatment trials are intriguing and may offer benefit to patients with specific types of intractable headaches. However, the need for general anesthesia with some of these surgeries must be considered when comparing medical and surgical treatments for headaches. More investigation of the pathophysiological basis of surgical treatments for selected headache patients is needed before these techniques can be routinely recommended.
Surgery may offer pain relief for selected patients with specific headache types, such as migraines with trigger sites and Chiari I malformation related headaches.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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