Current Evidence in Migraine Surgery: A Systematic Review

Are Genetics the Predicting Factor for the Success of Migraine Surgery? A Report on Identical Twins

Migraine affects more than 1 billion people globally, with distinct genetic variations influencing susceptibility. Thereby, genetic variations play a key role in the probability of developing migraine. However, personalized genetic analysis-based treatment options in migraine treatments are limited. Notably, surgical deactivation of extracranial trigger has shown efficacy in the treatment of migraine patients with identifiable trigger points in specific anatomical locations in the head and neck region. We present the first case of monozygotic twin sisters, both experiencing occipital and temporal-triggered migraine headaches with identical history and characteristics and without response to conservative migraine treatments. After surgical intervention, targeting the greater and lesser occipital nerves as well as auriculotemporal nerves, both twin sisters exhibited an over 99% reduction in symptoms without postoperative complications. This case suggests a potential correlation between genetic background, irrespective of environmental factors, and the effectiveness of surgical deactivation of trigger points in migraine management.

Neurovascular Compression-Induced Intracranial Allodynia May Be the True Nature of Migraine Headache: an Interpretative Review

PURPOSE OF REVIEW

Surgical deactivation of migraine trigger sites by extracranial neurovascular decompression has produced encouraging results and challenged previous understanding of primary headaches. However, there is a lack of in-depth discussions on the pathophysiological basis of migraine surgery. This narrative review provides interpretation of relevant literature from the perspective of compressive neuropathic etiology, pathogenesis, and pathophysiology of migraine.

RECENT FINDINGS

Vasodilation, which can be asymptomatic in healthy subjects, may produce compression of cranial nerves in migraineurs at both extracranial and intracranial entrapment-prone sites. This may be predetermined by inherited and acquired anatomical factors and may include double crush-type lesions. Neurovascular compression can lead to sensitization of the trigeminal pathways and resultant cephalic hypersensitivity. While descending (central) trigeminal activation is possible, symptomatic intracranial sensitization can probably only occur in subjects who develop neurovascular entrapment of cranial nerves, which can explain why migraine does not invariably afflict everyone. Nerve compression-induced focal neuroinflammation and sensitization of any cranial nerve may neurogenically spread to other cranial nerves, which can explain the clinical complexity of migraine. Trigger dose-dependent alternating intensity of sensitization and its synchrony with cyclic central neural activities, including asymmetric nasal vasomotor oscillations, may explain the laterality and phasic nature of migraine pain. Intracranial allodynia, i.e., pain sensation upon non-painful stimulation, may better explain migraine pain than merely nociceptive mechanisms, because migraine cannot be associated with considerable intracranial structural changes and consequent painful stimuli. Understanding migraine as an intracranial allodynia could stimulate research aimed at elucidating the possible neuropathic compressive etiology of migraine and other primary headaches.