Surgical Treatment of Migraine Headaches:

The Evolution of Migraine Surgery: Two Decades of Continual Research. My Current Thoughts

SUMMARY

A mere serendipitous finding has culminated in a life-changing development for patients and a colossally fulfilling field for many surgeons. The surgical treatment of migraine headaches has been embraced by many plastic surgeons after numerous investigations ensuring that the risks are minimal and the rewards inestimable. Seldom has a plastic surgery procedure been the subject of such scrutiny. Through retrospective, prospective pilot, prospective randomized, prospective randomized with sham surgery, and 5-year follow-up studies, the safety, efficacy, and longevity of the given operation have been confirmed. Although the first decade of this journey was focused on investigating effectiveness and risk profile, the second decade was largely devoted to improving results, reducing invasiveness, and shortening recovery. Multiple publications in peer-reviewed journals over the past 20 years, several independent studies from reputable surgeons at recognized centers, and over 40 studies from the author's center have established the surgical treatment of headaches as a standard practice.

Hair Transplantation in Migraine Headache Patients

Background:

Migraine headache is a primary neurologic disease affecting millions of people worldwide. As a consequence, quality of life is diminished, productivity suffers (through loss of work force), and treatment costs are substantial. The occurrence rate in the general population is quite high, with women accounting for 3 of every 4 cases.

Methods:

Between January 2011 and May 2012, a total of 221 patients received hair transplants. Another 590 patients underwent hair transplantation between June 2012 and December 2016. Initially (first interval), patients were not questioned on migraine headaches in preoperative visits, but questioning was regularly done thereafter. Overall, 150 patients given transplants in the first period were surveyed by phone regarding preoperative migraine headaches. Aside from the 1 incidental discovery, no other instances of migraine emerged. Headache origins were occipital-frontal in 2 patients, occipital-temporal in 2 patients, and occipital-temporal-frontal in the 2 others. Donor/receiver areas in hair transplantation and migraine trigger zones shared locations. Headache frequencies ranged from 4 to 8 days per month (average, 6 days), and pain scores were 5–8 (10 being highest). Duration of pain was 3–5 hours (average, 4 hours). All six patients had used various medications, such as triptans, ergot, and nonsteroidal anti-inflammatory drugs, before hair transplantation. The 1 female patient was a 32-year-old seeking treatment for alopecia, with a 6-year history of migraine headaches. The male patients presenting with androgenetic alopecia (grade 4–5 by Norwood classification) had 6- to 20-year migrainous histories.

Results:

After hair transplantation, each migraine sufferer was checked once in the first month and then once every 3 months. Those who could not appear in person after the first year were evaluated by phone every 3 months. Migraine headaches had ceased in all 6 patients, none of whom used medical treatments for migraines thereafter. The postoperative improvement each patient experienced was dramatic (P < 0.001). Overall, the mean intensity of headaches declined from 6.6 ± 1.47 to 0, on an analog scale of 1–10 (P < 0.001); and mean headache frequency was reduced from 5.83 ± 1.03/month to 0/month (P < 0.001). Likewise, the migraine pain index fell from a mean of 149.33 ± 19.21/month to mean of 0/month (P < 0.001).

Conclusions:

This report details 6 patients who experienced abatement of migraine headache symptoms following hair transplantation. The positive effects of hair transplantation on migraine headache and potential mechanisms of action are also discussed.

Five-year outcome of surgical treatment of migraine headaches

BACKGROUND

This study was designed to assess the long-term efficacy of surgical deactivation of migraine headache trigger sites.

METHODS

One hundred twenty-five volunteers were randomly assigned to the treatment (n = 100) or control group (n = 25) after examination by the team neurologist to ensure a diagnosis of migraine headache. Patients were asked to complete the Medical Outcomes Study 36-Item Short Form Health Survey, Migraine-Specific Quality of Life, and Migraine Disability Assessment questionnaires before treatment and at 12- and 60-month postoperative follow-up. The treatment group received botulinum toxin to confirm the trigger sites; controls received saline injections. Treated patients underwent surgical deactivation of trigger site(s). Results were analyzed at 1 year (previously published) and 5 years postoperatively (the subject of this report).

RESULTS

Eighty-nine of 100 patients in the treatment group underwent surgery, and 79 were followed for 5 years. Ten patients underwent deactivation of additional (different) trigger sites during the follow-up period and were not included in the data analysis. The final outcome with or without inclusion of these 10 patients was not statistically different. Sixty-one (88 percent) of 69 patients have experienced a positive response to the surgery after 5 years. Twenty (29 percent) reported complete elimination of migraine headache, 41 (59 percent) noticed a significant decrease, and eight (12 percent) experienced no significant change. When compared with the baseline values, all measured variables at 60 months improved significantly (p < 0.0001).

CONCLUSION

Based on the 5-year follow-up data, there is strong evidence that surgical manipulation of one or more migraine trigger sites can successfully eliminate or reduce the frequency, duration, and intensity of migraine headache in a lasting manner.

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.