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From Botox to headaches: The history and potential of migraine surgery

A Stanford plastic surgeon discusses a little-known treatment for migraines: surgery that involves decompressing a nerve.

Some 40 million Americans -- about 12% -- know the head-splitting, skull-pounding pain of a migraine.

I'm among that group. They started about 3½ years ago. My migraines began as a light throbbing feeling in the back of my head that most people might associate with the need to stretch or roll their neck. But I quickly learned that light pulsation would soon turn into a severe, radiating pain that traveled up my scalp and tunneled toward my right eye. It would wreck me for hours, if not all day.

After months of working with a neurologist to test out different drug treatments, we found a medication that decreased my daily episodes to once every two weeks. But it came with an unpleasant side effect -- namely, brain fog. I had a notable improvement with my migraines, but the brain fog was untenable. I forgot names and passwords; I couldn't watch a movie in one sitting; I got lost walking in my neighborhood. My doctor told me this was normal, and the key was not to panic. But my husband encouraged me to seek a more sustainable solution.

When I asked my neurologist about other treatments, she told me we had exhausted all the options. There wasn't anything else to try. It was frustrating and depressing to hear. But just a few weeks later, serendipitously, I attended a presentation by Catherine Curtin, MD, a Stanford Medicine plastic and reconstructive surgeon, who was speaking on occipital nerve decompression surgery.

Little did I know this would be my first introduction to the surgery that, quite literally, cured me of my migraines. I recently spoke with Curtin to learn more about the surgery, what it does for migraine sufferers and why it's often overlooked as a treatment option.

What is occipital nerve decompression surgery?

Occipital nerve decompression surgery is a procedure that can help treat a certain type of head pain. It's a relatively quick surgery during which we make a small incision in the back of your head, then free the nerve from any surrounding tissue that is pinching it and making it unhappy -- the cause of that pain.

What's the success rate for the surgery? What are the risks?

In my experience, about 60% of people get better, but still have some headaches. For about 20% of people, it's amazing and perfect. And for 20% of people, it doesn't work at all.

There are risks to any surgery such as bleeding, infection or scarring. These are very rare. The main risk is that the surgery does not adequately reduce your pain.

Why isn't this surgery more well-known among doctors and patients?

The doctor who has largely spearheaded the techniques of nerve decompression surgery for treating migraines, Bahman Guyuron, MD, is a plastic surgeon in Ohio. He noticed that after he performed face-lifts or treated patients with Botox, some patients mentioned that their migraines had greatly improved. He started studying this phenomenon and identified that compressed nerves were a source of severe headache pain.

He really dove into the research and did a randomized, controlled surgery study: Some people had the full nerve decompression surgery, and some didn't. Both groups of patients improved (because there is a real placebo effect), but the patients who had the decompression fared much better and the results persisted. 

Many neurologists were quite skeptical of the idea that surgery could help with migraines. They felt that migraines come from a more central problem such as abnormal blood flow or nerve activity in the brain. Some people discounted Guyuron's research because he focused on cosmetic surgery. A group of neurologists pretty aggressively lobbied against this surgery. To this day some insurance companies still don't cover occipital nerve decompression.

I'm a nerve surgeon, and I decompress painful pinched nerves all over the body. I've done carpal tunnel releases a zillion times. So, the idea that an unhappy pinched nerve can cause head pain, and that this pain could be helped through decompression, totally makes sense. This narrative that the nerves in the head are somehow unique and not at risk of nerve compression is baffling to me.

There's always tension between the surgical and nonsurgical specialties. I understand that non-surgeons want to protect their patients from unnecessary or risky procedures. But these protective instincts should not prevent treatments that could help patients get better.

Can anyone with migraines benefit from this procedure?

No, surgery is only for a subset of people with migraines or head pain. The trick is to tease out the people whose pain is caused by nerve compression.

Is migraine surgery a last-resort option? Or do you think it could benefit more patients as a first or second line of treatment?

You always start with conservative treatment before you try something invasive; it's a treatment ladder. If you're going to compare it to carpal tunnel (the condition for which nerve decompression surgery is most often used), you start with the brace, and if that doesn't work you consider injection. If that doesn't work, you turn to surgery. There's a percentage of people who find a permanent fix through noninvasive treatments, and that goes for head pain from nerve compression, too.

More information about occipital nerve decompression surgery can be found here.

Photo by Mehrpouya H 

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