migraine surgery

23 March 2024

Migraine Surgery: Why does it fail?

A recent review at Cureus Journal of Medical Science took a look at the success and failure of a certain type of surgery for migraine. One of the key questions was – why does migraine surgery fail?

At first, the statistics in the report look pretty good. Up to 80% of patients experienced “complete elimination of headaches”. Naturally, we should be suspicious of that “up to”. But also, remember that this is going to be a very specific group of migraine sufferers, those who were already likely to benefit from this type of surgery.

This type of surgery for chronic migraine sufferers focuses on trigger points, which may be different for each patient. The surgery works by relieving irritation to certain nerves, or by blocking pain signals from certain locations.

These are patients who have also tried other treatments, because surgery comes with its own risks and downsides.

But back to the study. The researchers also found that “up to” 35% of patients had no relief. So let’s say about 30% of surgeries failed. That’s a lot of time, trouble, and money for no result – especially considering that these patients have (hopefully) tried several other treatments already.

Why did the surgeries fail? It’s hard to tell from this review alone, but researchers found some common reasons:

The trigger points were not all dealt with. This could mean that the surgeon simply hadn’t detected all the problem areas, or that the surgery did not successfully relieve them.
Migraine headache was triggered from new trigger points after the surgery, or it was triggered again from the old trigger points (the success of the surgery was temporary?).
For an unknown reason, the surgery simply did not relieve the migraine attacks.

There is only so much you can do about #3, because it’s unknown. The second point is tricky as well, because we may not know ahead of time how the body will respond to the surgery.

To a certain extent, the first point can be addressed by finding a specialist with considerable experience in migraine surgery – a specialist who will take the time that is needed to get the surgery right.

But all that being said, it still seems to be common wisdom to find a good specialist and investigate other treatments before trying surgery. The search for a good treatment will likely take time – don’t expect a “cure” in two months. Being patient and going to an experienced headache specialist in the first place will greatly increase your chances of success.

25 August 2021

An Amazing Future Migraine Surgery?

James Information 0

Although this surgery isn’t likely to cure thousands more or completely change the landscape of migraine treatment, it is actually pretty amazing.

It’s actually a new way of doing something that we’ve been able to do for decades – and longer. Let me explain.

Migraine surgery tends to be a more drastic solution for people with chronic migraine who don’t respond well to the many other non-surgical and even non-drug solutions that are available. One of these surgeries involves actually decapacitating nerves that seem to be communicating your headache pain. There are several different ways to do this.

Now, when you think of surgery, you probably think of cutting open skin or cutting through bone. Today, we have some amazing “minimally invasive” surgeries, where surgeons can accomplish amazing things through only a small incision in the skin.

Take for example “pulsed radiofrequency ablation” (PRA). Pulsed radiofrequency treatments for pain started to replace an older method in the 1990s, because it was less invasive. In this surgery for migraine, a probe is inserted through the skin, and radio waves create heat, which basically burns a nerve. If this nerve is involved in transmitting headache pain – simply, it will no longer be able to do its job. For many patients (though not all), this can mean significant headache relief.

This relief is usually temporary, because the nerves usually regenerate. But it is relief that can last for months. So for some patients, this minimally invasive procedure can be a life-changer. (Read more about radiofrequency ablation for migraine here.)

There are other surgical methods that affect the nerves, but the new one that’s being investigated now is called pulsed focused ultrasound (PFU). And here’s the amazing part – no incision is needed to use this treatment. Like “magic”, it can decapacitate the nerves from outside the body, without inserting a probe, and without damaging the skin, or other parts of the body on the way to its target.

You’ve heard of ultrasound. It has many uses, including taking those amazing 3D images of unborn babies, so that Dad and Mom can discuss who the little gal or guy looks like. As you know, we want to be very gentle with Mom and baby, and ultrasound waves are perfect because they’re not damaging tissue.

But ultrasound can do more than take pictures. If there are more focused waves, it can do what PRA does – and disable a nerve. So here’s what happens – (harmless) waves come from various directions, passing through the tissue. They can meet at a precise location (the nerve), and affect only that nerve, and nothing else.

PFU is already being used for Parkinson’s Tremor. In this case, it’s focused on specific areas of the brain – again, an amazing breakthrough, because it can pass through other parts of the brain and focus on one tiny precise area.

This type of surgery may have applications beyond nerves. Could “brain surgery” be used to treat migraine, and other pain conditions?

This isn’t a treatment you’ll be able to use in the near future. But it is amazing to see the treatments that are being developed to treat a number of conditions – treatments that only a few years ago would truly seem like “magic”.

15 September 2014

Migraine Surgery – Should it be Banned?

James Information, News 2

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.

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.

7 February 2014

Patent foramen ovale closure – for children?

James Discoveries & Stats, Treatments 0

Patent foramen ovale closure is still being used as a treatment for migraine and other headaches in children. But is it worth the risk?

Patent foramen ovale (PFO) closure is the closing of a common “hole in the heart” that once was hoped to be a great new migraine treatment. So far, however, the surgery has not lived up to the original hype. Trials have failed to put this anywhere close to the top of the list when it comes to migraine treatment.

In spite of the general let-down, the treatment is still being used, even among children.

It has been estimated that one in four people have PFO, but most people have no symptoms at all. But in some people this does seem to contribute to migraine.

Pediatric Neurology recently published a study from the USA on PFO treatment for children in general. Children with both migraine and non-migraine headache usually reported an improvement after the surgery.

So far so good. However, the researchers have some concerns, and rightly so.

First, this study was not designed to see how effective PFO closure was in patients, and so it had a number of shortcomings which we won’t get into here. But there are some things that would be helpful to know. For example, did these patients have other symptoms besides headache or migraine that prompted them to see a cardiologist (in most cases, the procedure was recommended by a cardiologist)? If so, could it be that treating other conditions are actually helping with migraine symptoms?

Researchers are also concerned about long term effects of this surgery (it’s a generally safe surgery, but it’s still surgery), and the cost. If there are less-invasive treatments that work just as well or better, doctors should be cautious about recommending PFO closure.

This study highlights the need for further well-designed studies of PFO closure for migraine and headache. For example, I would like to see further study into type of migraine or headache vs type of PFO.

We’re still getting mixed answers about how helpful it is, and we need to be especially cautious before we recommend it for children.

For more information:

Should we give up on the PFO Closure Solution?
In Children, the PFO Solution Studied (a previous study)
Clinical Practice, Resource Utilization, and Outcomes of Device Closure of Patent Foramen Ovale in Pediatrics. (abstract of the above mentioned study)

14 October 2013

Rhizotomy for Migraine?

James Treatments 7

Rhizotomy is a surgical procedure which severs nerve roots, often in the spinal cord, in an attempt to relieve pain.

Has rhizotomy been used to fight migraine? Yes, but rarely.

Why rarely?

Surgical procedures are not recommended until many other treatments have been tried.
Rhizotomy is not always considered reliable for certain types of pain. It is much more common for back pain, cancer pain, and trigeminal neuralgia.
Rhizotomy is temporary, and usually not complete relief, and will need to be repeated every few months.
There are other types of surgery and treatment that can “block nerves” which can be tried in serious, previously untreatable cases of migraine.