Deborah Reed

A placebo-controlled surgical trial of the treatment of migraine headaches.

Background: Many of the nearly 30 million Americans suffering with migraine headaches are not helped by standard therapies, a proportion of which can harbor undesirable side effects. The present study demonstrates the efficacy of independent surgical deactivation of three common migraine headache trigger sites through a double-blind, sham surgery, controlled clinical trial. Methods: Seventy-five patients with moderate to severe migraine headache who met International Classification of Headache Disorders II criteria were studied. Trigger sites were identified (frontal, temporal, and occipital), and patients were randomly assigned to receive either actual or sham surgery in their predominant trigger site. 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 1-year follow-up. Results: Of the total group of 75 patients, 15 of 26 in the sham surgery group (57.7 percent) and 41 of 49 in the actual surgery group (83.7 percent) experienced at least 50 percent reduction in migraine headache (p < 0.05). Furthermore, 28 of 49 patients in the actual surgery group (57.1 percent) reported complete elimination of migraine headache, compared with only one of 26 patients in the sham surgery group (3.8 percent) (p < 0.001). Compared with the control group, the actual surgery group demonstrated statistically significant improvements in all validated migraine headache measurements at 1 year. These improvements were not dependent on the trigger site. The most common surgical complication was slight hollowing of the temple in the group with temporal migraine headache. Conclusion: This study confirms that surgical deactivation of peripheral migraine headache trigger sites is an effective alternative treatment for patients who suffer from frequent moderate to severe migraine headaches that are difficult to manage with standard protocols.

The role of the third occipital nerve in surgical treatment of occipital migraine headaches

BACKGROUND The third occipital nerve is often encountered during the occipital migraine surgery, however its contribution to migraine headaches is unclear. The objective of this study was to determine whether removing the third occipital nerve plays any role in the clinical outcomes of occipital migraine surgery. METHODS A retrospective comparative review was conducted on all occipital migraine headache (Site IV) patients from 1/2000 to 12/2010. Inclusion criteria were: 1) completion of migraine questionnaire, 2) migraine Site IV decompression, and 3) minimum 6 months of follow-up. Patients were divided into those who had the third occipital nerve removed and those who did not. Outcome variables included overall Migraine Headache Index reduction and Site IV pain elimination. RESULTS 229 patients met the study inclusion criteria. The third occipital nerve removed group (111 patients) and the third occipital nerve not removed group (118 patients) were comparable in terms of age, gender, number of surgical sites, and statistically well matched regarding preoperative headache characteristics. Comparing the third occipital nerve removed to the third occipital nerve not removed group, Migraine headache index reduction was 63% vs. 64%. Patients experiencing migraine headache elimination (third occipital nerve removed 26% vs. third occipital nerve not removed 29%; p=0.45) and surgery success with at least 50% reduction in migraine headache (third occipital nerve removed 80% vs. third occipital nerve not removed 81%; p=0.82) were also similar. There was also no difference between the two groups in symptomatic neuroma formation. Site IV specific pain elimination was similar between the two groups (third occipital nerve removed 58% vs. third occipital nerve not removed 64%; p=0.54). CONCLUSIONS Removal of the third occipital nerve did not alter migraine surgery success.

Positive botulinum toxin type a response is a prognosticator for migraine surgery success

Background: The objective of the study was to determine whether botulinum toxin type A injections can serve as a prognosticator for migraine surgery success. Methods: Patients who underwent migraine surgery from 2000 to 2010 by the senior author (B.G.) were reviewed. Patients were included if they had botulinum toxin type A injection before surgery; had completed postinjection, postsurgery Migraine Headache Questionnaires; and had at least 1-year follow-up. Outcome variables include patient demographics and Migraine Headache Index. Treatment success was defined as at least a 50 percent reduction in Migraine Headache Index. Results: One hundred eighty-eight patients were included; 144 reported successful migraine headache reduction after injection (success group) and 44 did not (failure group). The groups were well matched for age, migraine headache characteristics, and number of surgical sites (p > 0.05). The surgery success rate was significantly higher in the success group overall (90.3 percent versus 72.3, p = 0.003), and in patients who reported botulinum toxin type A success and subsequent same-site surgery (97.9 percent versus 71.4 percent, p < 0.0001). Botulinum toxin type A success was prognostic for surgery success at the frontal trigger site (trigger site I) (92.5 percent versus 69.2 percent, p = 0.012), the temporal trigger site (trigger site II) (95.5 percent versus 73.3 percent, p = 0.005), and the occipital trigger site (trigger site IV) (95.9 percent versus 62.5 percent, p = 0.0003). Six patients had exclusively septum or turbinate (site III) surgery, and all failed injections. Conclusions: Positive botulinum toxin type A response is a significant predictor of migraine surgery success. When injections fail, nonmuscular abnormalities should be considered. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

A Prospective Randomized Outcomes Comparison of Two Temple Migraine Trigger Site Deactivation Techniques.

Background: The authors compared the reduction of migraine headache frequency, days, severity, and duration after surgical decompression versus avulsion of the zygomaticotemporal branch of the trigeminal nerve for treatment of temporal migraine headache. Methods: Twenty patients with bilateral temporal migraine headache were randomized to undergo avulsion of the zygomaticotemporal branch of the trigeminal nerve on one side and decompression via fasciotomy and removal of the zygomaticotemporal artery on the other side. Results were analyzed after a minimum of 12 months of follow-up. Results: Nineteen patients completed the study. The patients experienced greater than 50 percent improvement in frequency, migraine days, severity, and duration in 34 of the 38 operative sites (89 percent). Complete elimination of symptoms was noted in 21 of the 38 operative sites (55 percent). In the decompression group, migraine frequency was reduced from 14.6 to 2.2 per month, migraine days from 14.1 to 2.3, severity from 7.0 to 2.9, duration from 9.6 to 4.8 hours, and Migraine Headache Index score from 42 to 2.9. In the neurectomy group, frequency decreased from 14.2 to 1.9 per month, migraine days from 14.1 to 2.3, severity from 6.8 to 2.6, migraine duration from 10.1 to 5.3 hours, and the Migraine Headache Index score from 41 to 2.5. There was no statistical significance in reduced migraine headache frequency, days, severity, and duration between the two groups. Conclusions: Neurectomy and decompression of the zygomaticotemporal branch of the trigeminal nerve are both appropriate treatment for temporal migraine headache. If decompression fails to provide sufficient relief, neurectomy is another option. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Impact of preoperative narcotic use on outcomes in migraine surgery.

Background: This study focuses on the impact of preoperative narcotic medication use on outcomes of surgical treatment of migraine headaches. Methods: A retrospective comparative review was conducted with patients undergoing migraine surgery. Data gathered included demographic information, baseline migraine headache characteristics, migraine surgery sites, postoperative migraine headache characteristics 1 year or more following surgery, and preoperative migraine medication use. Patients were grouped based on preoperative narcotic medication use. The narcotic users were subdivided into low and high narcotic user groups. Preoperative migraine characteristics were comparable between groups and the outcomes of migraine surgery were compared between the groups. Results: Outcomes in 90 narcotic users were compared with those for 112 patients not using narcotic medications preoperatively. Narcotic users showed statistically significantly less reduction in frequency, severity, and duration of migraine headaches after surgery. Narcotic users had clinical improvement in 66.7 percent of patients and elimination in 18.9 percent versus 86.6 and 36.6 percent, respectively, in the nonnarcotic group. The group that consumed narcotics had significantly lower rates of improvement in all migraine indices. Conclusions: Previous studies have discouraged the routine use of narcotic medications in the management of migraine medications. The authors’ study demonstrates that narcotic medication use before migraine headache surgery may predispose patients to worse outcomes postoperatively. Because pain cannot be objectively documented, the question remains of whether this failure to improve the pain was indeed a suboptimal response to surgery or the need for narcotic substances. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Treatment of dopplerable nummular headache with minimally invasive arterectomy under local anesthesia

OBJECTIVE The objective of the current study is to elucidate the potential role of surgery in the treatment of nummular headache (NH). BACKGROUND NH is a disorder in which pain is localized to a specific area. Treatment has traditionally been medical, with the recent addition of nerve blocks and botox injection with equivocal results. DESIGN Forty-nine patients were identified using the International Classification of Headache Disorders, third edition, beta version. Patients were asked to identify the area of maximal pain. Patients who had an associated Doppler signal within the area of pain underwent surgical arterectomy using local anesthesia. Preoperative and postoperative headache frequency, severity, duration, and headache-free days were analyzed. RESULTS There were a total of 49 patients included in the study (42F:7M) with an average age of 45 years (21-65 years). The average follow-up period was 16 months with a range of 8-33 months. There was a significant reduction in the frequency (-10.7 days; p < 0.001), severity (-3.5; p < 0.001), and duration (-0.3 hours; p = 0.4) of the headache. There was a significant increase in the number of headache-free days per month (10 vs. 21; p < 0.001). Headache index decreased by 39.6%, from an average of 378.6 to 228.4 (p < 0.05). Twelve patients (24.5%) were free from NH and able to discontinue their medications. There were no complications identified during the follow-up period. CONCLUSION NH, although rare, can be associated with significant disability despite current treatment modalities. In select patients, surgical arterectomy is a safe, minimally invasive, and effective treatment for NH.