Headache Medicine 2020, 11(1):1-2 ISSN 2178-7468, e-ISSN 2763-6178

ASAA

DOI: 10.48208/HeadacheMed.2020.1

Headache Medicine

Editorial

Migraine surgery

Élcio Juliato Piovesan

Neurologist responsible for the Committee on Invasive Procedures of the Brazilian Headache Society.

The Brazilian Headache Society hereby states its position regarding migraine surgery, a

procedure created by American plastic surgeon Bahman Guyuron and that has been re-

ported over the past months in the Brazilian media. The premise of Guyuron’s technique is

that there are four trigger sites for headaches in patients with Chronic Migraines, namely:

frontal, temporal, occipital and rhinogenic sites

. Guyuron suggests that there is a muscle

component and a vascular component in these regions. The vascular component (vasodilation)

compresses the nerve and causes pain (in the vein-artery-nerve complex), while the muscle

component is contracted especially in the sites where nerves go through muscles, also known

as X foramens, and promotes pain.

There are numerous scientic studies on the subject, many with decient methodology and

other with more appealing methodology. Professor Rami Burstein (world renowned referen-

ce in the eld of physiopathology of headaches), in an article evaluating a series of seven

patients, showed that some individuals had improvements in post-traumatic headaches and

persistent daily headaches since the beginning, while others were non-responsive (chronic

migraine). The Professor himself questions if the procedure works or not, suggesting that it

should be applied to experimental studies.

A task force from the American Headache Society stated their concern on the subject as

such: “Don’t recommend surgical deactivation of migraine trigger points outside of a clinical

trial. The value of this form of “migraine surgery” is still a research question. Observational

studies and a small controlled trial suggest possible benet. However, large multicenter, ran-

domized controlled trials with long-term follow-up are needed to provide accurate estimates

of the effectiveness and harms of surgery. Long term side effects are unknown but potentially

a concern.”

3-7

The members believed that this term would make it easier for doctors and patients to recognize

the procedures at hand. The idea of a surgical “solution” is inherently attractive to patients.

Interest in surgical approaches to headaches has been motivated by the accidental improve-

ment in headaches observed among patients that have undergone several “forehead rejuve-

nation” surgical procedures. These procedures are based on the premise that the contraction

of facial and other muscles collides with branches of the trigeminal nerve.

The procedures are frequently referred to collectively as “headache deactivation surgery”,

though multiple locations and surgical procedures are involved. These include corrugator

supercilii resection with fat grafting, “temporal liberation” procedures, involving dissection

of the glabelar region, transection of the zygomaticotemporal branch of the trigeminal ner-

ve and resection of the semispinalis capitis muscle with fat grafting to reduce pressure on

the occipital nerve. Finally, some surgeons also conduct nasal septoplasty or try to address

possible intranasal trigger sites.

Élcio Juliato Piovesan

piovesan1@hotmail.com

Received: February 12, 2020.

Accepted: March 16, 2020.

Edited by

Mario Fernando Prieto Peres

ASAA

Piovesan EJ

Migraine surgery

However, there is limited evidence to support that such sur-

geries are effective or safe. Several randomized studies have

been conducted, but there are methodological deciencies.

Moreover, most studies in the literature were conducted by

the same group of surgeons proposing the procedure and

published in a single subspecialty journal.

4-7

Despite the lack of good quality evidence to balance the pros

and cons of surgical treatments for headaches, these proce-

dures are becoming more common. Recent research from the

Plastic Surgery Society found that 18% of interviewees had

conducted a headache surgery. Sixty percent of those that

did not conduct the surgery said they were “interested if the

patient was referred to them by a neurologist.”

The American Headache Society emitted a statement urging

“patients, healthcare professionals and migraine treatment

specialists themselves, to exercise caution in recommending or

seeking such therapy”. The statement continued declaring that

“In our view, surgery for migraine is a last-resort option and

is probably not appropriate for most sufferers. To date, there

are no convincing or denitive data that show its long-term

value. Besides replacing the use of more appropriate treat-

ments, surgical intervention also may produce side effects

that are not reversible and carry the risks associated with any

surgery. It also can be extremely expensive and may not be

covered by insurance.”

Given that the value of a headache

migraine is still uncertain, the AHS and Choose Wisely Task

Force believe that patients should only undergo this treatment

in the context of procedures within clinical trials that seek to

develop good quality evidence on the harms and benets

of treatment.

References

1. Guyuron B. Is migraine surgery ready for prime time? Thesurgi-

cal team’s view. Headache 2015; 55:1464-1473.

2. Blake P, Nir R-R, Perry CJ, Burstein R. Tracking patients with

chronic occipital headache after occipital nerve decompression

surgery: A case series. Cephalalgia. 2019; 39: 556-563.

3. Gaul C, Holle D, Sandor PS, et al. The value of “migraine sur-

gery.” Overview of the pathophysiological concept and current

evidence. Nervenarzt. 2010;81:463-470.

4. Guyuron B, Reed D, Kriegler JS, Davis J, Pashmini N, Amini S.

A placebo-controlled surgical trial of the treatment of migraine

headaches. Plast Reconstr Surg. 2009;124:461-468.

5. Kung TA, Pannucci CJ, Chamberlain JL, Cederna PS. Migraine

surgery practice patterns and attitudes. Plast Reconstr Surg.

2012;129:623-628.

6. American Headache Society urges caution in using any surgical

intervention in migraine Treatment. Position Statement of the

American Headache Society. http://www.americanheada-

chesociety.org/american_headache_society_urges caution in

using any surgical intervention in migraine treatment/ Accessed

January 11, 2013.

7. Guyuron B, Kriegler JS, Davis J, Amini SB. Comprehensive

surgical treatment of migraine headaches. Plast Reconstr Surg.

2005; 115:1-9.