As many now know, microvascular decompression of several nerves in the head and neck is a proven successful therapy for the relief of migraine headaches. I was very happy to read the recent Policy Statement put forth but the American Society of Plastic Surgeons and the Plastic Surgery Research Foundation. This important paper provides an outstanding summary of research that supports the success of migraine surgery in providing long-term relief from migraine headaches. While I encourage everyone to read the entirety of the statement which can be found here, I would like to highlight some of the most important aspects of this landmark discussion:
In the United States, migraine headache is a severe disease associated with functional limitations in migraine patients. Based on recent data, migraine headache affects between 17% and 23% of the population.
Many studies of human anatomy have confirmed reliable patterns of compression and irritation in peripheral nerves. These “trigger sites” include the supratrochlear and supraorbital nerves, the zygomaticotemporal and auriculotemporal nerves, and nerves in the occipital region (greater, lesser, and third occipital nerves), as well as nerves in the nose.
The understanding of how migraine surgery works is based on the idea that “mechanical irritation” of peripheral nerves by other tissues (including blood vessels, muscle, bone, and connective tissue) produces migraine pain centrally in the brain. Removal of these irritating tissues (fascia, muscle, bone, blood vessels) eliminates the signals (stimuli) to the brain and therefore this reduces the likelihood that migraine pain occurs.
Dr. Guyuron’s prospective, randomized, placebo-controlled study was one of “great importance” that showed the effectiveness of migraine surgery in providing relief from migraine pain. “Of note, this type of IRB-approved study is very restricted in surgery and therefore rarely performed in surgical research.” The details of the study are well discussed in the Position Paper (again, can be found here) but the findings of the study showed that there was a very significant improvement found in patients that received migraine surgery as opposed to those that THOUGHT they had received the surgery but in fact did not. The five-year followup of patients who did have surgery showed persistent relief.
Extensive review of multiple studies and a “large body of peer-reviewed scientific evidence” was performed showing that peripheral nerve decompression surgery for chronic migraine headaches is safe and effective. This review found “substantial, extensively replicated, clinical data that demonstrate a significant reduction in migraine headache symptoms and frequency (even complete elimination of headache pain) following trigger site surgery.”
The Position Paper came to the following conclusion: “It is the position of the American Society of Plastic Surgeons that peripheral nerve trigger surgery for treatment of refractory chronic migraine headache in properly selected patients is not an experimental treatment and is considered a standard, accepted treatment given nearly 20 years of peer-reviewed published evidence in high impact factor journals. Targeted surgical deactivation should be integrated into the stratified care model for the treatment of chronic migraine patients and represent a covered service by all insurance carriers.”
The most important part of this statement was the following:
“Now is the time for all involved specialties to come together for the benefit of the patient, and to embrace surgical treatment of MH in properly selected patients.”
I sincerely hope that primary care physicians, neurologists, and pain doctors can appreciate the need to educate their migraine headache patients that migraine surgery is an effective means of finding pain relief. Moreover, I very much hope that the insurance community can come to do the right thing and provide financial assistance to migraine headache patients in their quest to reduce and eliminate their pain.
*All quotes are from the 2018 Policy Statement regarding Migraine Headache Surgery from the American Society of Plastic Surgeons and the Plastic Surgery Research Foundation that can be found at https://www.plasticsurgery.org/Documents/Health-Policy/Positions/ASPS-Statement_Migraine-Headache-Surgery.pdf
