March 6, 2020

Q&A: Migraines and nerve decompression surgery

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Nerve decompression surgery for migraines might be an option for your ongoing discomfort.

Migraine headaches cause plenty of misery. Migraine sufferers describe sharp pain and/or other debilitating symptoms. A migraine easily prevents someone from working or doing nearly any activity. Usually, someone having a migraine needs to lie down in a dark, quiet room and wait for it to pass, which in some cases can take hours or days.

Recently, some plastic surgeons have begun offering surgery that can prevent migraines, or possibly reduce their frequency. At Vanderbilt Plastic Surgery,  Salam Kassis, M.D., answers common questions about nerve decompression surgery for migraines, occipital nerve decompression (it’s the same surgery for treatment of occipital neuralgia and occipital migraines), or peripheral nerve/trigger site surgery. It’s proven helpful for treating some — not all — types of migraines.

Question: What is a migraine?

Answer: Migraine is a debilitating recurring headache that is sometimes preceded by an aura (a disturbance in your senses, usually something affecting vision). During a migraine, the person is very sensitive to light and sound, and they’re likely to suffer nausea and vomiting. Migraines affect 16% of women and 6% of men. Patients frequently worry about when are they going to experience their next migraine. Every time they are planning an event with family or friends, they’ll have anxiety: “Am I going to have a migraine, and will it ruin vacation?” Or an important work interview or test. So migraine can really affect the quality of life.

Q: What distinguishes a migraine from an ordinary headache?

A: The International Headache Society has these guidelines for diagnosing chronic migraine if you’ve had at least five attacks with these criteria:

  1. A headache lasting 4 to 72 hours;
  2. A headache with at least two of these characteristics: It’s on only one side of the head; the pain feels pulsing; the pain is moderate to severe; and/or the headache is aggravated by or causes you to avoid routine activities, such as walking.
  3. The headache comes with nausea or vomiting; sensitivity to light; and/or sensitivity to noise.
  4. The headache isn’t explained by another illness or condition.

Q: What causes migraines?

A: Migraine can be caused by different factors. We can divide them by either being caused by something inside the brain, or by something outside the brain. An example of a cause outside the brain is compression of a nerve that is coming from the brain; that nerve will get inflamed. This is what would cause the migraine, and for this subset of patients, the surgery would work.

Q: How did doctors discover that surgery could relieve some migraines?

A: It’s pretty interesting that plastic surgeons accidentally found this surgery. Patients would come in to have their cosmetic procedure to lift the eyebrows; they would come in later and say, “I’m doing great — I used to have migraines and they went away!” Those patients were not coming in to have surgery for migraines per se. They were coming to have a cosmetic procedure, but that cosmetic procedure removes the muscle the nerve is passing through or lying against, and the muscle was compressing the nerve, triggering the migraine. In this cosmetic procedure, that nerve decompresses and the migraine goes away.

Bahman Guyuron, M.D., a plastic surgeon in Ohio, did a study in 2000. He looked back at all his patients in which he did a resection (surgery) of these frown muscles, and found out that 80% of the patients who had migraines before this surgery had improvement or elimination of their migraine afterward. After that, since 2000, there have been so many studies and clinical trials that have proven that migraine surgery is very effective on a select group of patients.

Q: Which people are the best candidates for nerve decompression surgery for migraines?

A: Patients who are good candidates are typically those who can identify a specific spot on their face or neck where their migraine starts. They say, “Before I have my migraine, I will have pain above my eye.” And they point to the spot on their forehead where the migraine starts and say, “Before my migraine starts, I have a headache there, and sometimes I rub that area or I put an ice pack or a warm pack on it and that sometimes can abort my migraine.” There are seven different trigger spots that we can operate on.

Q: So the surgery doesn’t only address migraines that start in the forehead?

A: Correct. The forehead is just one of them. These are the seven trigger locations that surgery can improve:

  1. Frontal headaches: The pain starts above the eyebrows, typically in the afternoon. Patients commonly have a droopy eyelid on the affected side when the pain is happening. Putting pressure on these sites may stop the migraine when it has just started. Application of cold or warm compresses on these sites often reduces or stops the pain. The pain is usually imploding in nature. Stress can trigger this type of migraine.
  2. Temporal trigger: The pain starts at or near the temple, on the side of the face. Patients usually wake up in the morning with pain after clenching or grinding their teeth during the night. Rubbing or pressing the temple at the painful point can stop or reduce the pain when this migraine starts. A cold or warm compress to this point may also reduce or stop the pain. Patients usually describe an imploding pain. Stress can trigger these migraines.
  3. Occipital trigger: The pain starts at the back of the head, where neck muscles meet the skull, slightly to one side. There is no specific starting time for the pain. Some people with this type of migraine may have a history of whiplash. The neck muscles are usually tight. Heavy exercise can trigger this kind of migraine. The compression of this site can stop the pain in the early stage, but at the later stage, the spot is tender. Application of cold or heat at this site may result in some improvement in the pain. Stress can trigger occipital migraines.
  4. Rhinogenic trigger: The pain starts behind the eye. The patient commonly wakes up with the pain in the morning or at night. Changes in weather usually trigger this type of migraine. The patient may have a runny nose on the same side where the pain happens. This type of migraine can be related to nasal allergy symptoms. Menstrual cycles can also trigger this type of migraine. Patients usually describe an exploding pain. People with this type of migraine have CT scans that show a deviated septum or other variations in the anatomy of the inside of their nose or sinuses.
  5. Auriculotemporal trigger: The pain is near the jaw joint.
  6. Lesser occipital trigger: This pain is in the neck, closer to the ear than in migraines with an occipital trigger.
  7. Nummular trigger: Pain in an area of the scalp not related to any of the sites listed above.

Q: Does someone need to be referred for surgery by a neurologist?

A: You don’t have to be referred to a neurologist. We prefer that they are under the care of a neurologist and that they have tried medications, but the patients can also come directly to us.

Q: What is the success rate now? You mentioned 80% when it first started, but what does this look like now?

A: In the last decade, we have had a 50% chance of cure, 40% chance of improvement, and in 10% of patients the surgery will not work. In other words, for about 90% of patients who are good candidates for this surgery, they will see improvement or elimination of their migraines.

Q: What is the recovery like?

A: The surgery takes one to two hours, depending on how many sites of compressed nerves we are eliminating. It is an outpatient surgery. Patients come and have the surgery, they go home. Depending on where their compressed nerve lies, they may have bruising around the eye for a few days. The recovery time is one to two weeks.

Q: Can children have this surgery?

A: Depending on the age of the child and symptoms, it can be done in very selected cases.

Q: Can this surgery relieve migraines relating to problems with the temporomandibular (jaw) joint?

A: TMJ disorders can cause migraines, but TMJ specialists provide the best guidance.

Q: Are there types of migraines that cannot be helped with this nerve decompression surgery?

A: Yes. Unfortunately, this surgery does not treat migraines that start in the central nervous system; or hormone-driven migraines, vestibular migraines or those triggered by sinus problems. In the case of sinus-related migraines, if the sinus symptoms are treated, that may help reduce migraines. But for sinus problems, you should work with an ear-nose-throat doctor.

Migraines can be debilitating. Learn more from Vanderbilt's Dr. Kassis about same-day outpatient surgery that can help. For questions call (615) 936-2700.

Posted by Vanderbilt Health on Thursday, July 18, 2019

If you are dealing with chronic migraines and have questions about surgery that may offer relief, call Vanderbilt Plastic Surgery at 615-322-2350.

Salam A. Kassis, M.D.

Salam A. Kassis, M.D., is an assistant professor in the Department of Plastic Surgery at Vanderbilt University Medical Center. His research focuses on nerve surgery and migraine surgery.