Migraine Surgery – Should it be Banned?
The debate about migraine surgery is nothing new, but it shows no signs of going away. Researchers in Germany recently fired a shot at migraine surgeries, using strong words starting with the title of their editorial, published in the journal Cephalalgia, Surgical treatment for migraine: Time to fight against the knife.
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Their article, which you can read for yourself, doesn’t hold back in criticizing treatments and studies that involve surgical intervention for migraine patients. They mention the dreaded word “placebo”, doubt if “treatment-refractory” migraine patients even exist (patients who don’t respond to treatment), conjure up images of Europeans gazing in horror at American websites about migraine treatments, and talk about the horrible effects that surgery can have.
Even if the authors of the article manage to offend just about everybody, their article should not be quickly ignored.
Sadly, there is an impression that when “all else fails” at least there’s a way to deal with the problem through surgery. Sure, it may be serious, but so is my pain.
But it’s not that simple. Surgery is no guaranteed cure for migraine (well, it’s not a cure at all – but there’s no guarantee that it will take the symptoms away), and surgery itself can cause more problems. And yes, those problems can be serious.
Authors Hans-Christoph Diener and Ulrike Bingel are right about one thing – the evidence for many – most migraine surgeries is not strong. Doctors are right to put surgery way at the bottom of the list of treatments to try for migraine.
There’s no doubt that many patients do not respond well to some migraine treatments. It takes many people many years to find a good treatment, if they find one at all.
But we can’t automatically assume that surgery is always out there, waiting to solve our problems once we’ve tried x number of medications.
Should we continue to study surgery as a migraine treatment? Many researchers think so, just as we should continue studying many migraine treatments. And no one that I know of is calling for a ban.
But we do need to take a closer look at the evidence before we recommend surgery to any patient. That means understanding the clinical trials, but also understanding the medical history of the patient, and taking time to understand which treatments have the best chance of working.
That’s what we all want, isn’t it?
Meanwhile, if you’re considering surgery for migraine, it’s worth your while taking a look at Diener and Bingel’s thoughts.
16 September 2014 @ 7:41 pm
James – I appreciate your comments, and agree with you. I’d actually raise you one…surgery is not a treatment for migraine.
The condition I’d argue surgery is beneficial for is for patients who have a missed diagnosis of nerve compression headaches. In my practice, it is not uncommon to have patients who come in with “chronic migraine” or some other migraine variant who, in actuality, have headaches due to nerve compression (commonly, occipital or supraorbital neuralgia). This condition is diagnosed by history (talking to a patient) and physical examination, and responds very well to surgical nerve decompression. So – do I “cure” their migraines? No. They don’t have migraine from the start, but are misdiagnosed because the diagnostic criteria for migraine are unclear. According to the ICHD criteria, migraine should be, essentially, a diagnosis of exclusion – everything, including nerve compression syndromes – should be ruled out before labeling someone a migraineur. Unfortunately, this is usually not the case, and is, in my opinion, at the heart of this debate.
The inflammatory article you review is written by two gentlemen who are both extremely biased and who have significant financial conflicts of interest when it comes to this discussion (Diener alone is a paid spokesman and researcher for at least 20 different drug manufacturers, most of whom make millions annually off of migraine drugs). Your readers need to keep this in mind when reading the opinions expressed in his article.
Thank you for bringing this to the attention of your readers, and for your insightful comments on the article.
23 November 2014 @ 11:31 am
Diener and Bingel’s “thoughts” are necessarily skewed by the sums they are paid as “researchers” and consultants to drug companies. These are mentioned at the end of their article. I was astonished to learn recently that some neurologists in the UK are paid £30,000 a year by Pfizer to “consult and research”. The only training historically given to neurology students on treatment of migraine, for decades, was drug treatment. They have no real authority to comment on surgical intervention but they feel free to write it off and would aim to block its availability.
I would agree with the other comment on this article that many “migraines” are in fact headache with multiple contributory factors and the physical involvement of nerves is often not understood or given adequate consideration.
I underwent decompression surgery of the corrugator muscle in 2009 (in Berlin) after the appropriate testing showed 90%+ improvement in pain levels and medication reduction. This allowed me a full professional working life for the following 3 years.
Over the last 2 years the headaches worsened again, possibly related to an episode of viral meningitis, possibly down to increased academic workload causing neck issues.
I went through the usual plethora of neurology appointments, drugs (both prophylactic and pain relievers) to little effect. Due to the fact that my diagnosed “severe, episodic migraines” were keeping me in bed only 7 or 8 days a month I did not qualify for botox treatment on the nhs.
Three months ago, after a severe rebound headache following an unsuccessful bilateral occipital nerve block I returned to the German surgeon from Berlin. His botox test into my neck produced similarly effective results to the first test years before.
I have recently returned from Berlin after surgery to decompress nerves in my neck and close arteries at my temples. I did not enter into these operations lightly; but because it could be demonstrated by a simple test that the effects would be excellent.
I know that I have experience pro and post-drome migraine symptoms, occasional visual aura, speech difficulties with “migraine”, gastric symptoms, occasional vomiting through pain, sensitivity to sound and smells and so on. I also have clear indicators of cervicogenic headache, which are all but ignored by the neurologists I have seen (with the exception of the pain team at St Thomas’s hospital).
I think that it is likely that many things contribute to my severe headaches but the pain level is sufficient for complete disablement and an inability to perform any activities of daily living and to be confined to bed. At seven days off work a month I could not continue.
Migraine surgery enabled me to have several years of productive working and functioning family life. Whilst not “life threatening” this condition leaves hundreds of UK residents confined to their homes for the majority of their lives, unable to perform the simplest of tasks and reliant on benefits. Online communities are full of thousands of despairing sufferers limping through life trying to hold onto jobs they are at risk of losing and care for families who do not understand the issues fully.
Neurologists, well meaning or otherwise, could not give me the ability to go back to work. Their drugs caused me to become zombie – like and despairing.
It should not be biased doctors (of whatever specialty) who make the decision on whether this surgery should be continued to be offered. Proper research, not funded or designed by drug companies, is sorely needed in this area.