Plastic Surgery for Migraine Prevention? The Pros and Cons.

I was responding to a patient’s e-mail inquiry about this procedure tonight and I thought I would carry that thought here to our web page.

Background:

To make a long story short, and I may have a couple of the facts incorrect but I don’t think so, the idea of doing plastic surgery to treat migraines first came from Dr. Bahman Guyuron, a plastic surgeon in Cleveland, OH.  I think he got the idea around the year 2000 when there was evidence of Botox helping migraine.

In the beginning it was assumed that Botox was helping migraine sufferers because, like in the way it helps wrinkles, was relaxing muscles in the face and head.  Dr. Guyuron carried this further, looking for a permanent way to “relax” or remove the tight muscles from around nerves by cutting them.  He became intrigued with this when his own patients were reporting success from this procedure.  Eventually he did publish a paper (summarized at the end of this  article) of his successes.

I wanted to discuss the Pros and Cons of this idea.

Cons:

First of all, tight muscles around the head have nothing to do with migraine as far as we know. We think we know the the major mechanism of migraine formation and it is brain problem . . . not a face or head muscle problem. So, this surgery doesn’t make any sense from a pathophysiology standpoint.

The other con to this concept is the fact that about every few years someone, usually someone who has no background in headache medicine or has never been to a headache research meeting, claims that they have found the cure.

I can remember in the early 1980s that dentists were claiming that TMJ problems were the cause. We even had an oral surgeon associated with our headache clinic who did a lot of TMJ replacements (and bought himself some nice homes from the profits of his surgeries) but later we saw that these procedures did not help and even ended up with many complications.

Then I remember a physician who went around the country claiming that she had proof that all headaches were caused by pressure on and deformities in the skull from the birthing experience and needed surgery on the skull to fix it. It wasn’t hard to prove that was bogus, especially when you consider all the people with migraine who was born via cesarean section.

About ten years ago cardiovascular surgeons began claiming that they found the cure to migraine by closing the hole in the heart that thirty percent of us have (the company that made the closure device was also drooling over the possible new, migraine market).  However, the headache scientific world (having been burnt before) insisted that placebo-controlled studies had to be done before they would endorse the procedure.

Then, several world-wide studies of the closure was done. The studies were placebo-controlled, meaning half the patients really got the closure and half didn’t get the closure but neither knew who did and who didn’t.  Both groups were equally better, proving that it was a psychological effect and had nothing to do with the actual closure.  That was good to know because the procedure was not safe and indeed at least one of the study patients died during the procedure of closing the hole.  Until this day you will hear patients and some medical providers saying that closing a PFO cures migraines.  These stories steal the front page of newspapers and national TV news shows.  But it was just a passing fad.

The dentists are at it again with claims that they have a jaw aliment device that cures migraine. However, there have been no placebo-controlled studies for that device and while it dose have FDA approval for helping bite aliment, it certainly doesn’t have FDA approval for treating headaches and is not endorsed by the scientific headache societies.

So, with this background, The American and International Headache Societies are very leery  about the plastic surgery being a legitimate treatment for migraine and have come out with a statement that they do not support it. They don’t want people spending money and being put under potential dangerous procedures if there is no proof that it works beyond just a psychological benefit.  They are asking the plastic surgeons to do a well-designed study with a placebo group. He did publish one placebo-controlled study in 2009 and here is the American Headache Society’s response to it.

I admit that it is very hard to do a placebo group in such a study. Half the group would be headache sufferers who have their muscles cut and half the group would have to have their skin cut and then sewed up to look like their muscles were cut, but not cut. No one would know (except the study controller) who actually got the real procedure. The patients would then they would measure their headaches to see who if they got better and if the treated group got better more than those who weren’t treated.  The major criticism of Dr. Guyuron’s study was that it was small and that many of the patients didn’t have many headaches to start with, which can skew results.

It is interesting that his study was not published in any major headache journal. This could mean that the study was of poor quality . . . or that the headache societies have a bias against this approach.

Migraine headaches are very prone to the placebo effect.  When we do medication studies, half the group gets a fake pill (usually corn starch) and the other half get the active drug. In the end, the corn starch (or sugar, or flour) pill people have a 50% improvement in their headaches and our medications have about a 60-65% improvement. So it is very easy to have people say that something worked, really believing it, when it has not.

One last item of “Con” is the fact that I personally know a migraine sufferer who had the procedure from Dr. Guyuron. She suffers horribly from chronic migraine. The procedure cost her a lot of money (as it is not covered by insurance because it is not FDA approved) and she had absolutely no benefit.

PROs:

First of all, just because someone wasn’t trained in headache disorders doesn’t mean that they can discover a major breakthrough in treatment if they are lucky . . . and smart.  I will say that in the study, summarized below, Dr. Guyuron did a decent job and the only short-coming was that he didn’t have a placebo group. It is worth reading and considering. Then of course his study in 2009 did have a placebo group, which he did in response to the criticism. I’ve only been able to read the abstract and not the entire article because it was published in a plastic surgery journal, for which I don’t have a subscription.

Dr. Guyuron and those following his technique, certainly have a lot of patients who give testimonies of success which you  can see on their websites.  I’ve also had someone contract me through this web site telling me of her daughter’s story.  Her daughter suffered horribly from migraines and had failed some treatments. But then she had the surgery from Dr. Guyuron and says she is much better.

From a human side I wanted to add another thought. When I see a patient who has suffered greatly from migraine and has failed most of the therapies, which are standard and have scientific proof, I can see why they want to try something outside the box.  I understand why they would want the procedure.

I personally suffer from Sjogren’s Syndrome and have a huge problem with dry eyes.  I have been treated with about every FDA approved treatment and I still suffer badly.  I am considering a technique that would about be on par with the plastic surgery for migraine, not being FDA approved but significant evidence and qualified people doing it. If I were to do it, I would probably go to Mayo Clinic for the treatment since I know a lot of people there.  My own ophthalmologist doesn’t support me going. However, I suffer so much that I feel I have to try and do something to help.  My only problem would mean that I would be gone from the office for a week and that is enough down time to bankrupt us.

So, my point is that I know where headache sufferers are coming from who do want this surgery.  I can’t endorse it unless it is FDA approved, but I certainly wouldn’t discourage someone from going.

Here is a summary of the original study by Dr. Guyuron.

Source: Plast Reconstr Surg  |  Posted 2 years ago

 Five Year Outcome of Surgical Treatment of Migraine Headaches; Guyuron B, Kriegler JS, Davis J, Amini SB; Plastic and Reconstructive Surgery (Oct 2010)

BACKGROUND:: This study was designed to assess the long-term efficacy of surgical deactivation of migraine headache (MH) 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 MH. Patients were asked to complete the SF-36, MSQ, and MIDAS questionnaires prior to treatment and at the postoperative follow-up at 12 and 60 months. The treatment group received botulinum toxin to confirm the trigger sites, while controls received saline injections. Patients in the treatment group underwent surgical deactivation of trigger site(s). The results were analyzed at 1 year, which has previously been published, and 5 years postoperatively, which is the subject of this report. RESULTS:: Eighty-nine/100 patients in the treatment group underwent surgery and 79 have been 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 of 69 (88%) patients have experienced a positive response to the surgery after 5 years. Twenty (29%) reported complete elimination of MH, 41 (59%) noticed a significant decrease and 8 (11%) experienced no significant change. When compared to the baseline values, all measured variables at 60 months improved significantly (p<0.0001). CONCLUSIONS:: 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 MH in a lasting manner.