SURGERY

A solution for long-term relief.

The best treatment for your migraine pain is whatever gives you relief. Your care provider, whether one of the doctors here at Migraine Relief Center or another medical professional, will begin by suggesting the simplest and least invasive option that’s appropriate for your migraines. If medication or other treatments are effective, you can go back to your daily life with your pain well controlled. However, if the easier options don’t provide the relief you need, your best hope may be to consider migraine surgery.

For patients who don’t respond well to other treatments, surgery can be the migraine treatment that restores their quality of life. Surgery can provide long-term relief. The goal of migraine surgery is headache and migraine reduction. The patient may still get headaches, but to a much lesser degree.

Here are the facts you’ll need to make a decision about whether migraine surgery is right for you.

patient guide to surgery

Why surgery for migraine?

Migraines have long been associated with the compression and irritation of key nerves in your face and head. These triggers are chronic, and may have genetic causes—just the way your personal anatomy is put together—or can be the result of changes that take place over time. Surgically relieving the pressure on those nerves can reduce the frequency, severity and duration of your headaches, or even eliminate them altogether.

How was this type of surgery developed?

Physicians noticed a connection between anatomy and headaches back in 1919. By the 1980s, patients were reporting relief from headaches after sinus surgery reduced contact between nerves and nasal turbinates or septum. ENT specialists performing the surgeries began to theorize that pressure created by such contact was the trigger for headache pain.

In the early 2000s, plastic surgeon Bahman Guyuron, M.D., observed that patients who suffered chronic migraine (at least 15 headaches per month for at least three months) frequently reported fewer headaches—or none at all—after undergoing certain cosmetic procedures such as brow lifts. He conducted research, and developed the theory that migraine pain is caused by inflamed trigeminal nerve branches in the head and neck. These nerves become irritated when surrounding tissues, such as muscles and fascia, apply excessive pressure. Dr. Guyuron realized that if a patient’s specific trigger sites could be pinpointed, surgical intervention could stop the irritation, repairing the inflammation and eliminating the migraine trigger.

Today there have been multiple articles published studying migraine surgery. Even though insurances refuse to acknowledge and accept that migraine surgery is an option for patients, literature is slowly showing that it is an acceptable option when others have failed

Where are these trigger points?

There are four sites generally considered to be likely trigger points. Each has a specific surgical procedure to correct the pressure and irritation.

Frontal headaches (starting above the eyebrows) are caused by irritation of the supratrochlear and suborbital nerves in the glabellar area. The surgeon endoscopically resects the corrugator and depressor supercilii muscles through a tiny incision.

Rhinogenic or nasal headaches (behind the eyes), treated with a septoplasty (see Types of Migraine Surgery below).

Occipital headaches (originating in the back of the neck) are caused when the greater occipital nerve is impinged by the semispinalis capitis muscle. During surgery the muscle is resected and the nerve shielded from further irritation.

How does it work?

Migraine surgery reduces the irritation and compression, either by correcting the tissue surrounding the nerves or by blocking the pain signals.

Types of Migraine Surgery

There are different surgical treatments for migraine: nerve release and pain blocking.

The tissue surrounding a nerve—the muscle, fat, or other structures—can impinge or compress the nerve and trigger migraine pain. Since a number of different nerves can be triggers, there are several different types of corrective surgeries. The surgery that will work for you depends on the location of your personal triggers and pain.

  • Supraorbital nerve compression (We have made an acronym to shorten the name of the procedure: M.I.S.O.N., or Minimally Invasive Supra-Orbital Nerve). The supraorbital nerve is a network of tiny nerve endings in the forehead. It’s a common site where nerve compression can trigger migraines. Surgery is done endoscopically through tiny incisions in the scalp and around the eyebrows – normally within the hairline. The goal is to alleviate pressure on this specific nerve, allowing the patient to be pain free. Sometimes it could be pressure from the corrugator muscle, or the little tiny hole (foremen) the nerve pierces through. It could be scar tissue. Patients usually describe severe pain in the back of their eye. The often rub the area around their eye brow for relief. People describe it as “ice picks” jabbing their eye, and light sensitivity is very common (photosensitivity).
  • Occipital Neuralgia, are the common pains associated with the back of the head and neck. Tight neck muscles and their outer tissuemigraine surgery layer known as fascia are usually the cause. The procedure we perform, we have adapted the acronym, M.I.G.O.N.E., or Minimally Invasive Greater Occipital Nerve Entrapment. The greater occipital nerve provides sensation for much of the back and top of the head (and can cause pain as far forward as the eyes). It’s also a common site for migraine triggers. The surgeon removes enough of the tissue surrounding this large nerve to free it and allow it to function normally. This procedure takes about 2-3 hours to perform.
  • Occipital Neuralgia surgery. Occipital neuralgia is not the same as migraine, but is often accompanied by migraine pain. It is much less common than migraine, and is frequently caused by trauma such as an auto accident. ON pain is often severe, and does not usually respond to medication. The same nerve decompression surgery that can benefit migraine patients can help ON patients, too. The C2 nerve root, ganglion and postganglionic nerve may be treated, and surgery is minimally invasive.

Both M.I.S.O.N. and M.I.G.O.N.E. surgeries are minimally invasive, performed using HD cameras, and are generally performed as outpatient procedures.

  • Septoplasty, or surgical correction of a deviated septum. The nasal septum is the cartilage and bone structure that divides the nostrils, and it’s not uncommon for it to be deviated, or bent. That puts pressure on the nerves that pass through it, and can trigger headaches. Septoplasty straightens the cartilage and relieve the pressure.
  • Neurostimulators, tiny electrodes that “override” pain signals. The electrodes are surgically placed under the skin, surrounding the trigger nerve. They’re connected by wire to a battery, also under the skin. The electrodes gently stimulate the nerve, keeping it occupied and preventing the harsher pain signals from getting through to the brain. Initially, your surgeon will do a temporary installation, easily removable, to make sure the treatment will help you. If it prevents your headaches, you’ll get a permanent implant. MRC surgeons work with pain management physicians to place the electrodes, to achieve the best possible results.
  • Nerve block. Unlike the other migraine surgeries, a nerve block isn’t necessarily permanent. It’s simply an injection of local anesthetic and a steroid, directly into the nerve. The anesthetic blocks the pain signals for a period of time, and the steroid works to “calm down” the irritated nerve, sometimes eliminating the need for further treatment. Because the injection into the nerve is painful, nerve blocks are performed under anesthesia.
  • Occipital Neuralgia. As with nerve decompression surgery, the same surgery that benefits migraine sufferers can help with the pain of occipital neuralgia. Neuro-stimulators are embedded at the base of the head and block pain messages to the brain.

What are the “typical” results of migraine surgery?

In a study published in Plastic and Reconstructive Surgery, 88% of the patients surveyed five years after their migraine surgery reported at least 50% reduction in the frequency, severity and duration of their headaches. The University of Wisconsin–Madison reports studies showing success rates greater than 70%, with about a third of those patients reporting their headaches eliminated completely. UT Southwestern claims an amazing 60% of patients who are pain free after surgery, and almost 90% report at least a 50% improvement.

Insurance

Your migraine surgical procedure may be covered by your insurance. Just as BOTOX® treatments for migraine are now often covered, insurance providers have begun to recognize that surgical intervention is much less costly over the long run. Check with your insurance provider.

What kind of results does MRC usually see?

There are no guarantees for any medical treatment, and every individual case is different, but the surgical treatment MRC offers is especially tailored to reduce the number and severity of your migraines. We can’t promise specific results, but 90% of our patients say their migraines are less frequent and don’t last as long, while 50% say they’re migraine-free within months of their surgery.

Is surgery right for you?

There are a number of factors to consider in deciding if migraine surgery is your best option.

Your history

Our surgeons will need as much information about all your medical conditions as possible. We’ll need

  • Medical records from other physicians who have treated you for headaches. If you cannot obtain copies of your records, you can provide a summary of the care you received, including dates, procedures, tests, and medications.
  • Any MRI, MRA and CT scan results, both scans and radiology reports.
  • Our Migraine Questionnaire, which will cover your symptoms, family history, triggers, and any other information you feel will be helpful.
  • Any other pertinent medical records from your neurologist or primary care physician.

Consultation

Our surgeons will talk to you about your migraines, and your medical history. We’ll examine you to determine if nerve compression is causing your headaches, or if there are other indications that you will respond well to surgical treatment.

Test results

There are treatments that give a temporary version of the relief that surgery would provide, such as BOTOX® or nerve blocks. If you haven’t had such treatment in the past, our surgeons will administer them, to evaluate how much help surgery might be in your case.

Migraine Diary

After your diagnostic treatment, you’ll need to keep a written record of your symptoms for several weeks. Reviewing this pain diary can reveal how beneficial surgery might be for you.

Why should I trust Migraine Relief Center?

Successful migraine surgery requires an expert plastic or peripheral nerve surgeon to correctly identify and locate your trigger sites. MRC’s Khorsandi brothers are board-certified and hold many top honors in their respective fields. Their specialized training and years of experience make them experts in evaluating a patient’s trigger sites and determining how much relief surgery can provide.

Our pre-surgical selection process includes diagnostic and therapeutic testing to provide you with the best possible results. You’ll have a physical exam, give a thorough medical history, and be asked to keep a Migraine Diary. If you’re considered a candidate for surgery, you’ll most likely receive botulinum toxin (BOTOX®), nerve blocks, or steroid substitutes to evaluate your response to soothing the nerves at your trigger point. That’s an important step in predicting your surgical outcome. Please note, BOTOX® is not always prognostic of how the surgery will do, but nerve blocks are. Patients that have had failure with BOTOX® are still considered good candidates for surgery, as long as there is some response to the nerve block procedure.

Through every step, we make sure your potential benefits outweigh the risks of surgery, and that you know what to expect.

Results

As with any medical procedure, no one can guarantee results. However, our exacting pre-surgical protocol is designed to make sure your treatment gives you the best possible outcome. You should experience fewer and less severe headaches within three months, and half our surgical patients report being pain-free.

Risk

Every surgery involves risk. You may experience side effects, and complications are possible. However, MRC’s surgical procedures are minimally-invasive, and our patients’ tend to recovery easily and quickly. If you have any concerns, please be sure to discuss them with your physician.

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