Surgical treatment of migraine headaches

This prospective study was conducted to investigate the role of removal of corrugator supercilii muscles, transection of the zygomaticotemporal branch of the trigeminal nerve, and temple soft-tissue repositioning in the treatment of migraine headaches. Using the criteria set forth by the International Headache Society, the research team's neurologist evaluated patients with moderate to severe migraine headaches, to confirm the diagnosis. Subsequently, the patients completed a comprehensive migraine headaches questionnaire and the team's plastic surgeon injected 25 units of botulinum toxin type A (Botox) into each corrugator supercilii muscle. The patients were asked to maintain an accurate diary of their migraine headaches and to complete a monthly questionnaire documenting pertinent information related to their headaches. Patients in whom the injection of Botox resulted in complete elimination of the migraine headaches then underwent resection of the corrugator supercilii muscles. Those who experienced only significant improvement underwent transection of the zygomaticotemporal branch of the trigeminal nerve with repositioning of the temple soft tissues, in addition to removal of the corrugator supercilii muscles. Once again, patients kept a detailed postoperative record of their headaches. Of the 29 patients included in the study, 24 were women and five were men, with an average age of 44.9 years (range, 24 to 63 years). Twenty-four of 29 patients (82.8 percent, p < 0.001) reported a positive response to the injection of Botox, 16 (55.2 percent, p < 0.001) observed complete elimination, eight (27.6 percent, p < 0.04) experienced significant improvement (at least 50 percent reduction in intensity or severity), and five (17.2 percent, not significant) did not notice a change in their migraine headaches. Twenty-two of the 24 patients who had a favorable response to the injection of Botox underwent surgery, and 21 (95.5 percent, p < 0.001) observed a postoperative improvement. Ten patients (45.5 percent, p < 0.01) reported elimination of migraine headaches and 11 patients (50.0 percent, p < 0.004) noted a considerable improvement. For the entire surgical group, the average intensity of the migraine headaches reduced from 8.9 to 4.1 on an analogue scale of 1 to 10, and the frequency of migraine headaches changed from an average of 5.2 per month to an average of 0.8 per month. For the group who only experienced an improvement, the intensity fell from 9.0 to 7.5 and the frequency was reduced from 5.6 to 1.0 per month. Only one patient (4.5 percent, not significant) did not notice any change. The follow-up ranged from 222 to 494 days, the average being 347 days. In conclusion, this study confirms the value of surgical treatment of migraine headaches, inasmuch as 21 of 22 patients benefited significantly from the surgery. It is also evident that injection of Botox is an extremely reliable predictor of surgical outcome.     

Comprehensive surgical treatment of migraine headaches

The purpose of this study was to investigate the efficacy of surgical deactivation of migraine headache trigger sites. Of 125 patients diagnosed with migraine headaches, 100 were randomly assigned to the treatment group and 25 served as controls, with 4:1 allocation. Patients in the treatment group were injected with botulinum toxin A for identification of trigger sites. Eighty-nine patients who noted improvement in their migraine headaches for 4 weeks underwent surgery. Eighty-two of the 89 patients (92 percent) in the treatment group who completed the study demonstrated at least 50 percent reduction in migraine headache frequency, duration, or intensity compared with the baseline data; 31 (35 percent) reported elimination and 51 (57 percent) experienced improvement over a mean follow-up period of 396 days. In comparison, three of 19 control patients (15.8 percent) recorded reduction in migraine headaches during the 1-year follow-up (p < 0.001), and no patients observed elimination. All variables for the treatment group improved significantly when compared with the baseline data and the control group, including the Migraine-Specific Questionnaire, the Migraine Disability Assessment score, and the Short Form-36 Health Survey. The mean annualized cost of migraine care for the treatment group (925 dollars) was reduced significantly compared with the baseline expense (7612 dollars) and the control group (5530 dollars) (p < 0.001). The mean monthly number of days lost from work for the treatment group (1.2) was reduced significantly compared with the baseline data (4.41) and the control group (4.4) (p = 0.003). The common adverse effects related to injection of botulinum toxin A included discomfort at the injection site in 27 patients after 227 injections (12 percent), temple hollowing in 19 of 82 patients (23 percent), neck weakness in 15 of 55 patients (27 percent), and eyelid ptosis in nine patients (10 percent). The common complications of surgical treatment were temporary dryness of the nose in 12 of 62 patients who underwent septum and turbinate surgery (19.4 percent), rhinorrhea in 11 (17.7 percent), intense scalp itching in seven of 80 patients who underwent forehead surgery (8.8 percent), and minor hair loss in five (6.3 percent). Surgical deactivation of migraine trigger sites can eliminate or significantly reduce migraine symptoms. Additional studies are necessary to clarify the mechanism of action and to determine the long-term results.     

Neurogenic inflammation and migraine: implications for the therapeutics

Significant recent advances in molecular pharmacology have elucidated the molecular pathways involved in neurogenic inflammation (NI). The release of tachykinins and endothelin-3 (ET-3) from trigeminal neurons induces dural vascular permeability and vasodilatation via activation of tachykinin receptor 1 (Tacr1) and endothelin receptor type B (Ednrb) on endothelial cells. Endothelial cell receptor stimulation results in cellular contraction, leading to plasma protein extravasation (PPE), which is the most recognized physiological hallmark of NI, and nitric oxide-induced vasodilatation. By contrast, the release of calcitonin gene-related peptide (CGRP) from trigeminal neurons--also a key physiological component of NI--does not affect vascular permeability but does induce neurogenic vasodilatation (NV) via the direct, (i.e., endothelium-independent) relaxation of vascular smooth muscle. The molecular pharmacology of NI is discussed within the context of migraine research and assesses the putative role of the two key physiological components of NI (i.e., PPE and NV) in migraine pathophysiology. The data indicate that the PPE component of NI plays no significant role in migraine but that NV is likely to be involved in migraine pathophysiology.     

Biofeedback control of migraine headaches: A comparison of two approaches

In order to assess the relative effectiveness of finger warming and temporal blood volume pulse reduction biofeedback in the treatment of migraine, 22 female migraine patients were assigned to one of three experimental conditions: temporal artery constriction feedback, finger temperature feedback, or waiting list. Biofeedback training consisted of 12 sessions over a 6-week period. All patients completed 5 weeks of daily self-monitoring of headache activity (frequency, duration, and intensity) and medication before and after treatment. Treatment credibility was assessed at the end of Sessions 1, 6, and 12. Results showed that temporal constriction and finger temperature biofeedback were equally effective in controlling migraine headaches and produced greater benefits than the waiting list condition. Power analyses indicated that very large sample sizes would have been required to detect any significant differences between the two treatment groups. No significant relationships were found between levels of therapeutic gains and levels of thermal or blood volume pulse self-regulation skills. Likewise, treatment outcome was not found to be related to treatment credibility. Further analyses revealed that changes in headache activity and medication were associated with changes in vasomotor variability. Because blood volume pulse variability was not significantly affected by biofeedback training, questions about its role in the therapeutic mechanism are raised.This research was supported in part by grants from the Quebec Ministry of Education and the Quebec Ministery of Social Affairs to the first author, and an award from the Medical Research Council of Canada to the second author. The authors are indebted to Drs. Frank Andrasik, Howard Barbaree, Edward Blanchard, Martin Ford, and Patrick McGrath, as well as to two anonymous reviewers, for their helpful comments on an earlier draft of this paper.     

Surgical treatment of migraine headaches by corrugator muscle resection

The authors, a plastic surgeon (Dirnberger) and a neurologist (Becker), conducted this study after reading the article by of Bahman Guyuron et al. in the August 2000 issue of Plastic and Reconstructive Surgery (106: 429, 2000). Sixty patients were operated on between June of 2001 and June of 2002; postoperative follow-up ranged between 6 and 18 months. Patients' charts were reviewed to confirm the diagnosis of migraine headache according to the criteria of the International Headache Society. Sixty patients (13 men and 47 women) from Austria and four neighboring countries took part in the study. The patients were divided into three groups, based on the severity of their migraines: group A comprised patients with up to 4 days of migraine per month; group B included patients with 5 to 14 days of migraine per month; and group C was composed of patients with more than 15 days of headache per month ("permanent headache") or evidence of drug abuse and drug-related headaches. The effectiveness of the operation was evaluated using the following factors: percentage reduction of headache days; percentage reduction of drugs; percentage reduction of side effects, severity of headaches, and response to drugs; and patient grade of personal satisfaction, using a scale from 1 to 5 [1 = excellent (total elimination of migraine headache) to 5 = insufficient or no improvement]. From the entire group of 60 patients, 17 (28.3 percent) reported a total relief from migraine, 24 (40 percent) reported an essential improvement, and 19 (31.7 percent) reported minimal or no change. Patients with a rather mild form of migraine headache had a much better chance (almost 90 percent in group A and 75 percent in group B) to experience an improvement or total elimination of migraine than those patients (n = 27) from group C with severe migraine, "permanent headaches," and drug-induced headaches. Contrary to the reports by Guyuron, 11 patients who had a very favorable response immediately and in the first weeks after the operation experienced a gradual return of their headaches to preoperative intensity after about 4 postoperative weeks. After 3 months, the results in all patients could be declared permanent. All side effects, such as paraesthesia in the frontal region, disappeared in all patients within 3 to 9 months.     

Temperature biofeedback and relaxation training in the treatment of migraine headaches

In a previous controlled group outcome study, a comparison of temperature biofeedback with progressive relaxation indicated that relaxation training was more effective in reducing migraine headache activity at the end of treatment. However, follow-up data obtained at 1, 2, and 3 months after the completion of treatment showed no difference between the two groups on any dependent measure. In the current study, 18 of 26 subjects who completed treatment in the original investigation collected headache data and completed a headache questionnaire I year subsequent to the conclusion of treatment in order to evaluate the long-term effectiveness of the two treatments. The results indicated that gains achieved in the reduction of headaches during both treatments were maintained at a 1-year follow-up. With the exception of medication consumption (for which relaxation training led to better long-term results) the 1-year follow-up data reveal no differential efficacy for temperature biofeedback or progressive relaxation in treating migraine headaches.