An article by Mathew suggests that the evidence for migraine surgery is weak.1 Migraine surgery is being advertised by several plastic surgeons, although it is not a thoroughly tested, well-researched treatment.2 Many migraine surgery websites proclaim high rates of success with statements such as the following: “Of the 60% to 80% of patients who respond to Botox, 90% will benefit from migraine surgery.”
It is worth remembering several relevant points about migraine surgery. First, migraine involves genetics, brain chemistry, neuroinflammation, and behavior. It is a complicated syndrome, and it seems impossible that a simple surgery would easily cure most patients.
Second, a positive response to Botox, which most surgeons use as a guide, should not predict who might do well with the surgery. Botox’s mechanism of action is quite different than that of surgery; Botox probably involves an anti-inflammatory mechanism in the neuroimmune system.
The surgery is supposedly for refractory chronic migraine, but patients being operated on include those with new onset daily persistent headache (NDPH), post-traumatic headache, occipital neuralgia, and other headache syndromes. Patients with migraine or NDPH who have had few or no trials of medication are undergoing the surgery. Some of these patients have had headaches for less than one year and have not been under the care of a neurologist or headache specialist.
In my experience, migraineurs who have undergone various cranial cosmetic procedures that are similar to the surgery being promoted have not reported an improvement in head pain. After a failed surgery, patients may face not only a great financial burden, but also extreme frustration and disappointment. One young patient of ours with NDPH had improvement with Botox and medication. Although he had had headaches for only nine months, he insisted on undergoing migraine surgery because he was enthralled by the websites’ claims. The surgery failed to help, and this young man committed suicide. He had been severely depressed, but the disappointment may have been a contributing factor to his death.
In addition, the surgery’s side effects should not be minimized. These patients are highly sensitized, and many have allodynia. Some patients may experience new types of head pains, such as neuralgias, after surgery. When I assess the results from surgery that I have seen or heard about, the long-term success rate appears to be close to 10%, which is a far cry from the 90% success rate claimed by the websites.
Before condoning migraine surgery, we need to have multicenter trials that reliably assess efficacy and adverse events.
—Lawrence Robbins, MD,
Robbins Headache Clinic
Northbrook, IL