Getting Rid of Migraine Pain and Why Surgery Works

Nearly 25% of women between 18 and 50 suffer from migraine headaches. As any of you who suffer from migraines knows, the total cost - of medications, ER visits, lost days at work, etc (not to mention time lost with your family and friends, which is irreplaceable) is enormous.

The commonly accepted theory as to why migraines happen is as follows:

A migraine trigger sends a depressive wave through the main part of the brain, which then releases chemical irritants. This causes sensory fibers in the meninges - the covering of the brain - to be activated, which is then felt as pain. If this process continues, a part of the brain and brainstem known as the trigeminal nucleus caudalis (TNC) becomes inflamed and starts a process called central sensitization (a "full blown" migraine). The main symptom of central sensitization is severe pain from things that are usually painless - brushing your hair, breathing through the nose on cool days, or having the shower water splash your face. Stopping the migraine headache at this point is difficult - commonly prescribed medications will "take the edge off", but will not completely stop the migraine. The key is to eliminate the migraine headache before it gets to this stage by blocking the inflammation and release of triggering chemicals. Imitrex and the other commonly used medications works at this point of the cycle.

As the frequency of migraine headaches increases, there can be anatomic changes in the brain as a result of drawn out sensitization of the nerves. It is thought that by eliminating the triggers (which are, essentially, fuel for the fire), the headaches will diminish in intensity, frequency, and duration. Hopefully, they will disappear altogether. It is at this point that surgery should be considered.

In plastic surgery, we are trained to work on and with nerves in the arms and legs. There are certain syndromes (like carpal tunnel syndrome) that we deal with often in our residency and fellowship training where we treat the results of prolonged nerve compression. It is theorized that surgery to treat migraine headaches works in a similar manner as that for carpal tunnel - releasing pressure on nerves from otherwise normal anatomy that unfortunately causes problems in some people but not in others.

There are quite a few areas in the head and neck where nerves can be compressed by surrounding tissue (muscles or the muscle covering, known as fascia). In individuals with a genetic predisposition to getting migraine headaches, these compression points can act as triggers that start the cascade towards central sensitization and chronic migraine headaches. By releasing these nerves from their compression points with surgery, the anatomic stimulus for the headache is removed, and the headaches either disappear or are greatly reduced. We are learning more about nerve compression points of the trigeminal nerve (the main sensory nerve of the head and neck, which gives sensation to your face and scalp through its numerous branches) each and every day.

Known compression points (which can be successfully treated with surgery) are:

- supraorbital and supratrochlear nerves
- zygomaticotemporal nerve
- auriculotemporal nerve
- greater occipital nerve
- lesser occipital nerve
- numerous small nerve branches of the nasal septum & turbinates

Not everyone suffering from migraine headaches will have these trigger points, and surgery is not the solution for all migraine headache sufferers. In a number of people, avoidance of known triggers and prescription medications is enough to limit or eliminate the headaches.

However, as we have seen in numerous publications, surgical decompression can lead to a drastic reduction or elimination of migraines in 80-90% of patients. I feel that it is a treatment that is backed by sound science and logical thinking, and should be considered as a treatment option for many people as the severity of their headaches increases.

For more information about surgical treatment of migraine headaches, and to see if you or someone you know may be a candidate for surgery, visit http://www.drjasonhall.com/ and fill in the "Learn More" section of the website.

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