From Botox to headaches: history and potential of migraine surgery
Some 40 million Americans, or about 12 percent, experience the head and neck pain of a migraine.
I am part of this group. They started about 3 and a half years ago. My migraines started with a slight throbbing sensation in the back of the head that most people would associate with the need to stretch or roll their neck. But I soon realized that the light pulse would soon turn into an intense, radiating pain that raced up my scalp and into my right eye. It would destroy me for hours, if not all day.
After months of working with a neurologist to test different drug treatments, we found a drug that reduced my daily episodes to once every two weeks. But that came with an unpleasant side effect, namely brain fog. I had noticeable improvement with my migraines, but the brain fog was unbearable. I forgot names and passwords; I couldn’t watch a movie in one sitting; I got lost while walking in my neighborhood. My doctor told me it was normal and the key was not to panic. But my husband encouraged me to look for a more lasting solution.
When I asked my neurologist about other treatments, she told me we had exhausted all options. There was nothing else to try. It was frustrating and depressing to hear. But a few weeks later, by chance, I attended a presentation by Catherine Courtindoctor, a Stanford Medicine plastic and reconstructive surgeon, who was talking about occipital nerve decompression surgery.
Little did I know this would be my first introduction to surgery which literally cured me of my migraines. I recently spoke with Curtin to learn more about surgery, what it does for migraine sufferers, and why it’s often overlooked as a treatment option.
What is occipital nerve decompression surgery?
Occipital nerve decompression surgery is a procedure that can help treat a certain type of head pain. It’s a relatively quick surgery where we make a small incision in the back of your head and then free the nerve from any surrounding tissue pinching it and making it unhappy – the cause of this pain.
What is the success rate of the operation? What are the risks ?
In my experience, about 60% of people get better, but still have headaches. For about 20% of people, it’s amazing and perfect. And for 20% of people, it doesn’t work at all.
Any surgery carries risks such as bleeding, infection, or scarring. These are very rare. The main risk is that the surgery may not reduce your pain enough.
Why is this surgery not better known to doctors and patients?
The physician who largely pioneered nerve decompression surgery techniques for treating migraines, Bahman Guyuron, MD, is a plastic surgeon from Ohio. He noticed that after performing facelifts or treating patients with Botox, some patients mentioned that their migraines had improved significantly. He began to study this phenomenon and identified compressed nerves as a source of intense headaches.
He really got into the research and did a randomized controlled surgical study: some people had full nerve decompression surgery, and some people didn’t. Both groups of patients improved (because there is a true placebo effect), but the patients who had the decompression fared much better and the results persisted.
Many neurologists were quite skeptical that surgery could help relieve migraines. They reasoned that migraines stemmed from a more central problem such as abnormal blood flow or nerve activity in the brain. Some people have dismissed Guyuron’s research because he focused on cosmetic surgery. A group of neurologists lobbied quite aggressively against this operation. To date, some insurance companies still do not cover occipital nerve decompression.
I am a nerve surgeon and I decompress painful pinched nerves all over my body. I’ve done carpal tunnel releases a million times. So the idea that an unfortunate pinched nerve can cause headaches, and that this pain can be relieved by decompression, makes a lot of sense. This narrative that the nerves in the head are somehow unique and pose no risk of nerve compression baffles me.
There are always tensions between surgical and non-surgical specialties. I understand that non-surgeons want to protect their patients from unnecessary or risky procedures. But these protective instincts should not prevent treatments that could help patients get better.
Can anyone with migraines benefit from this procedure?
No, surgery only affects a subset of people with migraines or headaches. The trick is to disentangle people whose pain is caused by nerve compression.
Is migraine surgery an option of last resort? Or do you think it could benefit more patients as a first or second line of treatment?
You always start with conservative treatment before trying anything invasive; it’s a salary scale. If you’re going to compare it to carpal tunnel (the condition for which nerve decompression surgery is most often used), you start with the brace, and if that doesn’t work, you consider the injection. If that doesn’t work, you turn to surgery. There is a percentage of people who find a permanent solution through non-invasive treatments, and that goes for nerve compression headaches as well.
More information on occipital nerve decompression surgery can be found here.
picture by Mehrpouya H