Dr. Robbins weighs in on the subject of migraine headache surgery, by reviewing the article “A Critical Evaluation of Migraine Trigger Site Deactivation Surgery,” by P. Mathew, published in Headache, 2013.

The excellent article by Mathew, “A Critical Evaluation of Migraine Trigger Site Deactivation Surgery,” casts doubt on the data supporting migraine surgery. Migraine surgery is being promoted by plastic surgeons. A common statement on certain surgery sites states that “of the 60 to 80% of patients who respond to Botox, 90% will benefit from migraine surgery.” The word “cure” appears all too often.

The following are observations about migraine surgery:

1. Migraine is a complex syndrome involving genetics, brain chemistry, neuro-inflammation, behavioral aspects, etc., and it is unlikely that a simple surgery would fix all of these factors.

2. Response to Botox (which most of the surgeons use as a guideline) should not necessarily predict a successful surgery; the mechanism of action of Botox for migraines probably involves, among other factors, an anti-inflammatory response, not simply via muscle relaxation.

3. The surgery is supposed to be primarily for refractory migraine patients but is being done for those with new onset daily persistent headache (NDPH), post- traumatic headache, occipital neuralgia, and other varied headache syndromes.

4. Migraine and NDPH patients who have not had trials of medications are being operated upon, some of whom have had headaches for less than 1 year, and the patients have not necessarily been under the care of a neurologist or headache specialist.

5. Surgery about the head is not new: migraine patients who have undergone various cosmetic procedures (which are similar to the surgery begin promoted) have not reported (in my experience) an improvement in headaches.

6. The disappointment after failed surgery cannot be underestimated. A young man in my practice had NDPH and was 50% improved over 6 months. We could not dissuade him from undergoing the surgery (he was enthralled by the website claims), and after the surgery failed, the patient committed suicide. He was severely depressed, but the disappointment may have been a contributing factor.

7. Adverse events from the surgery should not be minimized; these are sensitized patients, often with allodynia, and cutting structures about the headache may lead to increased headaches or new neuralgia pains.

8. My “anecdotal scorecard” for the surgery results in about a 10% success rate, not the 90% often stated on the surgery websites.

We need multi center trials to evaluate migraine surgery. Without adequate studies, the surgery remains an unproven and experimental procedure.

Note: this letter originally appeared in Headache, Vol. 54, Feb. 2014

Lawrence Robbins, MD

Robbins Headache Clinic – Neurology