Migraine Headaches: What Works, What Doesn’t, and When Surgery Helps

Dr. Kuruvilla (00:11):
My name is Dr. Shannon Kuruvilla. I'm a plastic surgeon in Houston, Texas, and today we are talking about the surgical treatment for migraine headaches. So the different types of headaches range from tension headaches to cluster headaches. People can have sinus headaches, temporal headaches, occipital headaches, and then there's migraine headaches. And each of these have pretty specific diagnostic criteria based in the international classification of headache disorders. You would know what type of headache you're having based off of whether it's bilateral, unilateral, associated symptoms, timing in the day, whether it comes on all at once or starts in one spot and radiates. Those are a few of the different diagnostic criteria that a neurologist would use to categorize your headache type. So if you have migraine headache disorder and that migraine starts in the exact same spot every single time, and it's one point that you can point at with one finger. There's some trigger points that are more common than others, and these have known pathways that they travel within the soft tissues or the bones of your head.

(01:14):
A lot of these are either fascia or ligaments or muscles, and those can be released surgically to help reduce triggering of that nerve that then leads to your migraine headache. So migraines, while there's tons of really great research done on them, the total pathology is completely understood. There are some inflammatory molecules getting released that are causing inflammation of nerves and blood vessels. Patients do typically have to have some level of pain sensitization, meaning that they're just more prone to spreading of this inflammation or of these signals kind of hyper excitability within their brain. So that's kind of the central description of it within the brain. What I deal with is more the extra cranial triggering of that. So the thought is that these nerves are becoming inflamed, extra cranially, so outside your cranium, outside your skull, and that inflammation of that nerve can be communicated as a nerve is traced all the way back into your brain or spinal cord.

(02:10):
There's two broad categories of migraine headaches and a lot of people are familiar with this, either migraine without aura or migraine with aura,. And if you have the aura or if you don't have the aura determines how many of these headaches you have to have for to be qualified as a migraine. So a migraine without aura, it usually diagnosed if you've had five of these attacks, the headache lasts from four to 72 hours and it has at least two of certain criteria. So it's unilateral, it's pulsating, it's severe, you have kind of a known trigger, trigger such as food, sleep, exercise, and then it can also be associated with nausea or vomiting. If you have a migraine with an aura, which is kind of like a sensory experience you have before or during the migraine, you don't need of those attacks, you only need two. There's pretty strict clinical criteria to diagnose that and we really leave it to the neurologist to offer that diagnosis just because we don't want to be ruling out or ignoring any other more concerning causes for these headaches that patients might have.

(03:13):
Chronic migraines are actually 15 headache days a month, so you're having 15 headaches within a 30 day period and eight of those have what's called migrainous features. So some of those characteristics we talked about like the pulsating, the unilateral, the severe, and that has to happen for three months in a row to then be diagnosed as somebody with chronic migraines. Headaches are second leading cause of years living with disability according to the global burden of disease, and it's the first for females. We talk about how patients that have migraines, they tend to peak in your working years, so like in your twenties and your thirties and forties, and patients can expect to lose around 4.5 work days per month. So just the loss in productivity alone is pretty huge. Just on top of that is just this sense of lack of control of your life and not being able to predict this or always be worried about making any sort of plans.

(04:06):
I think that a lot of patients have their migraines well controlled that allows them to be a functioning member of society, reduce those days lost at work, fulfill their family duties, engage in meaningful relationships within society. There is a genetic component to migraines. Migraines tend to run in families. I know that there is this thought that there's a genetic predisposition to having reduced myelin around your nerves or which is like a coating around your nerves that can help almost serve as a pillow or a covering of your nerves to help protect against trauma. So some patient, there's a genetic cause that might reduce that and therefore make your nerves more sensitive to compression. So specifically talking about those trigger points. But yes, it can run in families. As we get into some of the hormonal causes of migraines, there's the thought that women have migraines I think three times more frequently than men.

(04:57):
One of those can be the menstrual migraines and the thought is this estrogen withdrawal hypothesis. So as your estrogen drops, your migraines can be triggered. Then you would think patients that are entering perimenopause and menopause as their estrogen is dropping, migraines might increase. So yes, you can outgrow them. I think adolescents who have migraines can outgrow them. It's pretty hard to predict who will. So sometimes patients that have either a deviated septum or something called a concha bullosa or other or a bone spur within their septum can cause compression nerves within the patient's nose that then can trigger a migraine. So that's one. You can also have vestibular migraines. I know changes in pressure and the weather can trigger migraines. That's kind of related to your sinuses. So the thought is that during a migraine, your central nervous system is kind of in this state of hyperexcitability, so it just reacts very easily to sensory stimuli such as sound or light, smell.

(05:56):
So things that would otherwise be non bothersome can be quite painful or aggravating to a migraine because you're in this kind of state of hyper excitability. The natural progression of migraine kind of describes this prodrome where patients can almost sense out of migraines coming on. It's some sort of sensory change doesn't necessarily have to be an aura, maybe pins and needles or a sense of anxiety. I think that that is when patients usually reach for their abortive medications, they can tell that it's coming on in some sort of sensory change. In my subset of patients, they'll note a very specific spot on their temple forehead back of their scalp where they're experiencing a very sharp pain that then will start to radiate and spread and become almost unilateral of the entire head on one side. So if you have been diagnosed with chronic migraines, the best advice I could give you is to keep a migraine journal.

(06:53):
I'm sure a lot of these patients already have because I'm sure they're trying to get to the root of why they're suffering 15 days a month from headaches, but really pinpointing where that migraine is starting and where it's spreading. And drawings and sketches and studies have actually been very helpful and determining patients that would respond well to surgery. There's kind of this classic sketch for each nerve involved and it's how you draw the progression of your migraine matches those sketches. It's more likely that you would respond well to surgery. There are nonsurgical options for patients with migraines. Starting at the most basic, there's medications. Prescription medications that are typical for chronic migraine sufferers are either preventive or abortive. So preventive medications are your medicines that are like your antidepressants such as amitriptyline or venlafaxine or fexotor, some anticonvulsants. The most common one you might hear of is Topamax.

(07:49):
And then other medications such as nurtec, those are all preventive. And then your abortive medications, the most common ones are your triptan. So your sumatriptan is probably the one that people hear about the most. And then the ergot. So ergotamine is a really common one as well, and the triptans will actually help constrict the blood vessels that help reduce inflammation and the ergots will actually block some serotonin receptors, and those are all to stop a migraine. So that's what someone you would reach for if they fill a migraine coming on. I think the most common one I hear about is related to the triptan medications, so those can actually cause a chest tightness as well as some fatigue. Myalgias and flushing are pretty common. Patients who have had a stroke or a prior heart attack aren't allowed to take your triptans. And then I think people are very aware of Botox and that's its role in treating migraines.

(08:38):
So the FDA does have approval for Botox and the treatment of chronic migraines and they have a pretty specific injection protocol. When you go and get Botox injected according to kind of the FDA protocol, you have all of these muscles injected whether or not your migraine is starting at all of those places. So in my patient that I'm working up for migraine surgery, I like to be a little bit more specific with my Botox injection and only inject where I think their trigger site is. So if their migraine is starting in the back of their skull or their neck, then I would focus on those muscles along the trapezius and less on the frontal muscles. For clarity of nerve involvement, I would be a little bit more specific with my injections. There are devices that some patients can wear that help with migraines. These are called remote electrical neuromodulation devices.

(09:23):
They essentially stimulate certain nerves or use some sort of electrical stimulation to help treat migraines. I think that's probably more patient specific. I do think that in many patients these nonsurgical options can be very beneficial and help patients live almost a normal life, almost migraine free. So there are certain foods when ingested they can trigger migraines. So common ones are artificial sweeteners, nitrate containing foods, alcohol is one of the biggest triggers of migraines. On the flip side of that, some foods can help stop migraines. So caffeine that can lead to a dependence, but caffeine can help with migraines, electrolytes, some people have talked about turmeric and things of that nature can also help prevent migraines or treat them. Certain exercises can be a trigger for migraines and patients, I think the most common is patients whose trigger point is kind of occipital and their trapezius muscle can constrict it.

(10:18):
So any sort of exercise that would contract that muscle, but I think a balance of sleep and a balance of exercise like with anything can help with migraines. Alcohol avoidance I think is always preached to migraine patients as well. And there's other alternative therapies and I think it's important to validate the patient experience. If they feel like these things help their headaches, then believe them. So like acupuncture, yoga, meditation, therapy, if they're particularly anxious or stressed, lifestyle modifications definitely can improve the frequency and intensity of migraines. So ice or heat can help migraines if they're triggered by it's a certain vessel that is compressing the nerve, putting ice to constrict that vessel can stop it from compressing that nerve kind of if you think about this artery up here a lot of times will compress a nerve there and cause migraines, ice might help with that.

(11:08):
Heat similar to the massage can help maybe relax a muscle that's serving as a compression point of a peripheral nerve. Some of the most effective or most well-known medications for migraine relief are your Aleve, your Tylenol and ibuprofen or the Excedrin Migraine cocktail. The secret ingredient in Excedrin migraine is the caffeine and that can help be a powerful abortive medicine for migraines. I learned about migraine surgery during my residency. It is part of our core curriculum in the plastic surgery residencies in all of our plastic surgery textbooks. But the most I learned was from one of my mentors at University of Virginia, Dr. Jonathan Black who built a migraine surgery practice while I was in residency. What about those patients that I remember the most was actually his description of them when I first started working with him. And he said that when you first meet these patients, you open the door to their clinic room and the lights are off and they are just very tense.

(12:07):
There's this atmosphere of just anxiety and apprehension and they talk very slowly and you can tell they're very much in pain. And then when you see them in their postoperative visits and seeing somebody, just the light inside of them has come back. It's a true huge difference that you notice in these patients. I remember him describing that to me and then I would witness it and it was so tangible, the difference that it had made and seeing patients smile and just be happy and feel like they could actually live their life pain-free or with a significant reduction in their pain burden. So once we have really developed clarity in which nerve is involved causing your migraine, depending on that site, we make a small incision either hidden in the crease of your eyelid for frontal migraines or hidden somewhere in the hairline for temporal and occipital migraines.

(13:02):
That incision is usually about one to two inches long. You dissect down to a known tissue that is compressing that nerve. So depending on where it is, there's certain muscles that you remove. There's fascial bands that you might remove. There's blood vessels that can be involved with those nerves and that gets released. So the nerve is released. In some cases the nerve is transected and buried in a nearby muscle. I typically estimate about two hours per trigger site. So some patients might be having more than one trigger site released, so that would be additive. Some patients do report immediate relief. It can be pretty common actually that patients will have a migraine as they're waking up from surgery that then goes away within the next day. Usually it's an immediate relief up to about four weeks. I don't consider a surgery as incomplete treatment until about the four or six month mark if we've seen no improvement.

(14:00):
So it can be pretty common that once you rid a patient of their primary trigger point, it can then unmask a secondary trigger point. So essentially the major component of their pain was from this primary trigger point and that pain was so severe that they didn't really notice this minor pain from a secondary trigger point. I like to perform the surgery under general anesthesia. I don't like to flood the field with too much local anesthetic that would be needed to make the patient comfortable. I think it can distort things. So personally I do like to perform it under general anesthesia and then I would inject some numbing medicine at the end just to help with that immediate postoperative pain. A migraine surgery patient in order to prepare for their surgery, I would still like you to continue paying particular attention to where your migraine starts, any changes in that. If you are on chronic narcotics and work closely with a pain medicine specialist and they feel like you could potentially wean those narcotics, I would like that.

(14:53):
Studies have shown that patients on chronic narcotics tend to have slightly lower success rates in migraine surgery. Continue taking your migraine medications. Don't stop them just because you're having surgery and then of course stop smoking six weeks before surgery. So the literature quotes 86.6% of patients report improvement in their migraines after trigger site deactivation surgery and 36.6% of patients report complete elimination, meaning their migraines are gone. So risks of this particular surgery, anytime you are manipulating nerves, you run the risk of a neuroma, which is kind of an enlargement of that nerve that can become painful or similarly, like neuropathic symptoms. That's pretty rare because if you transect the nerve, we bury in a muscle to prevent that and majority of cases you just release the nerve. In places like the forehead if I need to remove a muscle that's compressing the nerve, sometimes that can cause a contour irregularity.

(15:52):
We can do fat grafting to prevent that. Where the scars are made in your hair, we make them pretty short and pretty thin. So there is a slight risk of alopecia in that area where the scar is, but that is very low risk. And then the biggest one that I would counsel with my patients is just incomplete relief either because you have a secondary trigger point that we couldn't find because your primary trigger point was so powerful or you have another underlying cause for your migraines. You might be a good candidate for migraine surgery if you have severe migraines that are disruptive to your life, migraines that don't respond to medical management or you just don't tolerate those medications or Botox injections for whatever reason or the side effects are not tolerated. If you are losing numerous days at work or at school because of your migraine headaches and most importantly you have an identifiable trigger site that can surgically decompress.

(16:47):
Interestingly enough, studies have shown that adolescents can have a positive response to surgery. Those studies focus at about an age of 16 years. I will take it on a case by case basis, but I'm unlikely to operate on a patient younger than 15. When you call our clinic or text our clinic, we will ask you to keep a migraine diary and lots of patients kind of already know this, but part of that migraine diary, I want you to have a sketch of where your migraine is starting and where it radiates and we will provide that for you. We have little figures for you to draw on a skull where your migraine is starting and then with an arrow showing where on your cranium it's spreading. I want that. I want you to have a diagnosis of migraine headache by your neurologist. I will see you, we'll go into your migraine history and your medical history pretty detailed.

(17:37):
I might use a doppler ultrasound to see if I can identify any blood vessels in the area that could be compressing that nerve. If you come in with an active migraine, I might inject numbing medicine to where your trigger site is and we assess whether or not that migraine either goes away or is improved upon. That can help me more specifically identify your nerve that might be causing your migraine. And then I'll also likely inject Botox where I think your trigger site would be. You'll continue keeping your migraine journal and tell me whether or not you had complete elimination improvement and how much improvement was it, 10% improvement, 50% improvement, et cetera. I need to see my patient in person before moving forward with surgery at least once. I think discussion of your migraine history and your migraine diary can be done virtually, but that wouldn't obviate the need for me to see you in person.

(18:29):
So patients who should not have migraine surgery are any patients who their cause of headache might be due to some sort of other intracranial or spinal cord disease. Any patients with what's called red flags, so other neurologic deficits, night sweats, fevers, chills, anyone with known intracranial pathology on imaging. So if you have a known mass or a known hemorrhage, anybody with increased pressure, so basically other neurological diseases of your brain, you should not have migraine surgery for treatment of your migraines. Patients who are on chronic narcotics should just be wary that according to the literature you have a less likely chance of having a positive response. Patients that have any psychological comorbidities, I'd like those to be optimized by their psychologists and treated. Any smokers, I won't operate on an active smoker, obviously. Just other general things that preclude surgery in an otherwise healthy patient.

(19:26):
So immediately after migraine surgery, I'll want you to have somebody with you for 24 hours because you've had a general anesthetic. Usually patients return normal activities of daily living within one week, probably a little bit earlier. Definitely majority of patients feel ready to return to work by the one week mark and then full activities at three weeks so you can get back to the gym if you wanted to. I'd like to see you one week after surgery just to check the incision sites and then give you the clearance like weight bearing restrictions at the three week mark. I would like to see you then. The most common thing that patients will complain of is numbness in the surgery site. That usually gets better over the course of the 2, 3, 4, 6 months. Sometimes there's an itchy sensation that's just the nerves that were being irritated with either retraction or just decompressing them.

(20:13):
And also, I think I mentioned this earlier, a lot of patients will report a migraine immediately after surgery that goes away within 24 hours. Most patients that have a positive response to surgery notice immediately, so in the month after surgery, they have fewer migraine days. I don't consider surgery as incomplete treatment, I mentioned this earlier until we've seen no improvement after about four to six months. On your day of surgery, you'll come to our state licensed ambulatory surgery center at Basu Aesthetics and Plastic Surgery. It's on Towne Lake and Cypress, Texas. You'll meet with our wonderful preoperative nurses who will get your IVs set up. They'll go through your charts, they'll go through all of your medical history just to confirm everything. You'll meet with our anesthesiologist that day who has already reviewed your lab work, your EKG if we ordered one, you'll go into our operating room, you'll take a nice little nap and then you'll recover in that same surgery center.

(21:18):
Your driver can stay at our surgery center. If they wanted to walk across the hall to our med spa to spend some time there, they're welcome to do that. Or they can just go home or go to eat. There's plenty of things to do in Cypress. We are right across the street from a wonderful outdoor mall with great restaurants. We're on the lake and there's also a boardwalk right nearby on that lake. Dr. Mary Ellen Firat is our board certified anesthesiologist who has worked with Dr. Basu for I think upwards of 15, 16 years. And she is the most lovely, smart, safe doctor I've ever met. And she takes great care of her patients and she makes patients feel extremely comfortable that they're being well taken care of. Patients who have had migraine surgery say that their life has been changed and they've been granted a whole new sense of control in their life. So you can book a consultation with me for migraine surgery at Basu Aesthetics and Plastic Surgery by calling or texting the phone number in the notes below.

Announcer (22:22):
Basu Plastic Surgery is located in Northwest Houston in the Towne Lake area of Cypress. To learn more about the practice or ask a question, go to basuplasticsurgery.com/podcast. On Instagram, follow Dr. Basu and the team @BasuPlasticSurgery. That's BASU Plastic Surgery. Behind the Double Doors is a production of The Axis, theaxis.io.