|Plastic Surgery May Also Ease Migraines [NYT]|
By CATHERINE SAINT LOUIS
Published: September 2, 2009
MANY of the nearly 30 million Americans who suffer from migraines end up feeling like guinea pigs. Chronic patients — those who are laid low 15 or more days a month — often cycle through drug after drug in search of relief. They also contend with side effects like mental sluggishness and stomach upset. Treatment involves guesswork because doctors have not pinpointed what causes migraines, nor do they know which drugs will best help which patients.
“It can be a merry-go-round going from medication to medication in pursuit of control,” said Dr. Roger K. Cady, the vice president of the board for the National Headache Foundation, a nonprofit organization devoted to patient education.
No wonder that earlier this month, news of a surgical “cure” that touts a high success rate ricocheted worldwide.
The double-blind study, published in the journal Plastic and Reconstructive Surgery, found that more than 80 percent of patients who underwent surgery in one of three “trigger sites” significantly reduced their number of headaches compared with more than 55 percent of the group who had sham surgery. More than half of the patients with the real surgery reported a “complete elimination” of headaches compared with about 4 percent of the placebo group.
Forehead lifts are cosmetic procedures that plastic surgeons typically perform to smooth furrowed brows. But a decade ago, after some of his patients reported that their migraines improved post-operation, Dr. Bahman Guyuron, a plastic surgeon and the lead author of the study, began to search for a surgical solution that could address migraine trigger points — which he defines as where the headache begins and settles — in the forehead, temples and the back of the head.
Headache specialists tend to be neurologists or internists, so Dr. Guyuron’s work has not always been taken seriously. “If I had a neurologist tell me there’s a new way of doing a facelift, I would have been very skeptical about it also,” said Dr. Guyuron, the chairman of the plastic surgery department at University Hospitals Case Medical Center in Cleveland. “But honestly I would have had an open mind.”
In the last month, the press has made much of the fact that a single operation could relieve migraines and turn back the clock in one fell swoop. But it is the potential that surgery for migraines may offer a viable alternative to drugs that has migraine specialists intrigued. “A very large subset became headache-free and remained headache-free for a year — that is a fantastic result,” said Dr. Richard B. Lipton, the director of the Montefiore Headache Center in the Bronx.
Especially considering that in the field of migraines, success is defined “as a reduction of 50 percent of attacks,” Dr. Cady said. Going from 10 episodes monthly to 5 is a welcome change, he added, but “it’s still a lot of migraines.”
The theory behind the surgery is that because some migraines are caused when sensitive nerve branches are squeezed and irritated by muscles, deactivating those muscles could bring prolonged relief. In the off-label use of Botox for migraines, those same muscles — when paralyzed with Botox injections — have eased headaches in some patients for roughly three months. Forehead lifts, Dr. Guyuron reasoned, might result in a longer-lasting, perhaps permanent, alleviation of pain. Only study participants who responded positively to Botox were offered the surgery.
(Dr. Cady cautioned that the research on Botox as a treatment for chronic headaches is not yet ironclad. Allergan, Botox’s maker, is pursuing the approval of Botox as a treatment for chronic migraines by the Food and Drug Administration.)
Many headache specialists, Dr. Lipton and Dr. Cady included, emphasize that this migraine surgery isn’t applicable to most sufferers. “Folks who are appropriate for this procedure — they are the tip of the iceberg, not the vast majority,” said Dr. Jennifer S. Kriegler, a neurologist who is one of the study’s authors and who works at the Cleveland Clinic’s headache center.
At this stage, suitable candidates are those who endure frequent migraines and have failed more tried-and-true methods of controlling their headaches, several doctors said. The bottom line, Dr. Lipton explained, is if you can’t identify a point of irritation and “if you don’t respond to Botox, we don’t know if this treatment works for you.”
Some doctors fear that the surgery may be offered to inappropriate patients before further research confirms its efficacy for a broader group of patients. “I don’t want us to overshoot and start doing widespread surgeries in not very well selected patients until we are convinced this is broadly effective,” said Dr. F. Michael Cutrer, the chief of the headache division in the neurology department at the Mayo Clinic in Rochester, Minn. “You can always stop a medication but you can’t reverse a surgery.”
As word of the surgery spreads, Dr. Cutrer said that he anticipated pleas for referrals to the few plastic surgeons nationwide who offer the operations, but that “until we maybe have studies that are a bit larger, and some longer follow-up I’m going to be very cautious.”
So far, Dr. Guyuron has trained roughly 150 doctors, and other plastic surgeons are refining their own migraine operations, even though they barely advertise.
Two years ago, an aunt told Shannon Byrne, from Mayfield Heights, Ohio, about Dr. Guyuron’s migraine surgery. Ms. Byrne said that she had already spent a decade on “every single medication you can think of.” Still, pain hammered her head more days than not. “You’re willing to try anything,” she said. Dr. Guyuron’s surgery, which she had 18 months ago, was a godsend. The migraines that led to her dropping out of college and to a stroke at 20 are gone. “My dad told me not to worry about the money,” Ms. Byrne, now 22, said of the thousands paid out of pocket.
A classic forehead lift for cosmetic effect differs significantly from surgery for migraine sufferers. The latter removes frown muscles more thoroughly and entails padding nerves with fatty tissue, said Dr. David A. Branch, a plastic surgeon in Bangor, Me., who performs migraine operations.
Sometimes, migraine surgery doesn’t involve the forehead at all. It varies according to where the patient’s trigger sites are: forehead, temples or back of the head. If Dr. Guyuron operates on the temples, the eyebrows are rejuvenated, he said. It is only the surgery at the back of the head that has no added perk, he said.
It’s unclear whether or not the migraine sufferers whose pain had disappeared a year post-operation will remain headache-free for life.
“My goal is zero headaches,” said Dr. Jeffrey E. Janis, a plastic surgeon in Dallas, who has performed roughly 100 operations in the last five years after training with Dr. Guyuron. “I might be able to achieve that in some, not in all.”
Complete elimination is “a pretty strong claim after one year of follow-up,” Dr. Cutrer said.
As a way of dampening expectations, Dr. Kriegler, who has referred patients to Dr. Guyuron, frequently tells them: “Once a migraineur, always a migraineur.”