Saturday, March 10, 2007

Plastic Surgery as a treatment for migraine headaches



A Cleavland Plastic Surgeon, Bahman Guyuron, made an interesting observation a few years ago when he was told by several of his brow lift patients that their migraine headaches went away after surgery. Working from that feedback he hypothesized that surgical release of several muscles that are divided to improve forehead wrinkle line act as trigger points for migraines. Eventually this led to the therapeutic use of BOTOX cosmetic for treating migraines, which has become quite a big business for neurologists.



Ironically, there were a number of Neurologists who initially aggressively protested that it was impossible for BOTOX to have an affect because Neurology dogma had migraines originating from central brain triggers rather then peripheral ones. However, the studies that have been published since have been overwhelmingly compelling for how effective this type of therapy can be in selected patients.

The graphic below demonstrates the classic central forehead/nasal injection pattern for paralyzing the procerus and corregator muscle groups which are the muscles divided in some brow lift procedures.



For several years in the Plastic Surgery literature we've been trying to better quantify who would be candidates for planned surgical division of 3 or 4 muscles for treating migraines with surgery for a permanent cure. The anatomy and refinements of surgical techniques for this are being developed by an acquaintance of mine, Dr. Jeff Janis (seen in picture at right), at the University of Texas-Southwestern in Dallas,TX. Jeff's been featured in a bunch of stories on this recently (see here)which is great for such a bright guy.

I ran into Dr. Janis at the Dallas Rhinoplasty meeting last week where he was about to commence a marathon cadaver dissection to study the anatomy in dozens of fresh human cadaver heads that had been used as part of the rhinoplasty course. The work he's doing is really developing an area that has tremendous potential to help some patients suffering from this terrible condition.

11 comments:

Pat said...

interesting concept, my daughter has frequent migraines...maybe surgery would help

Dr. Rob Oliver said...

Pat,

although I didn't make this clear in the synopsis, the way this should be done is to selectively paralyze one muscle group at a time to identify which are the triggers. If injections are effective, then you'd be a candidate for surgical relief by dividing several small muscle groups. I think right now, people doing BOTOX injections for headaches inject all the trigger points which is less then ideal for identifying surgical candidates.

Also, do not expect your insurance to cover this in the near future as it's likely going to be called "experimental" surgery.

Anonymous said...

Wow, This is exciting news. I suffer frequent severe migraine headaches. I had been thinking about a brow lift in the next couple of years anyway. Perhaps sooner would be better.

Thank you for sharing this info.

Laura

Emily said...

Pat, I had this surgery done 3 weeks ago by Dr.Guyuron. I'm frustrated. I've had a migraine almost everyday since the surgery. They said it could be a few months before I see relief. Is this common? Please give me some hope.

Dr. Rob Oliver said...

Emily,

As I understand it, yes there can be a period before you get signifigant relief. This type of surgery is still as much art as science as the technique becomes refined based on anatomy studies that my friend Dr. Janis is pursuing. Also rememeber that there are both peripheral (the muscles divided by this surgery) as well as central triggers (intra cranial) for migraines. While we can try to identify with BOTOX those most likely to benefit, there will still be people who continue to have migraines.

Jeff C. said...

I had my surgeries done in Cleveland, and for the life of me cannot remember the 2 Dr.'s names, I am sure you would know them, especiailly the one that did the actual brow lift.
To make a long story short, I had sufferd from horrid Migraines for years. When I was 40 (7 years ago) my vision was getting poor due vision. The surgeries went fine.
I did not realize it, or put the surg. with reduction of migraines until several years later when I read an article about Dr.Guyuron's
findings. I couln't believe it! Once I stopped to think about it, I realized my Migraines had decreased by at leat 85% The actual muscle that is removed in how his (and your) surg. was not removed, none the less, it was obviously moved enough to do something - would this make sense to you? I have recently highly recommend a friend of mine who suffers from severe Migraines to check out this site.
To me this was one of the most wonderful "side effects" I could ever hope for! Wish I could rember my surgeon's name so I could let him know the full extent my "brow lift" has given me.
Guess I was a pioneer in this and had no idea!!!
Jeff C

Anonymous said...

Emily has your migraines improved? We are considering the surgery for my son. Please post your progress.

Thanks,

Carl

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rkumari said...

I'm confused is it Botox injections or a surgical procedure, in which you get surgery done? Both are completely different things, please let me know.

Amy Williams said...

Dr Oliver, I have had chronic daily migraines for over 7 years. I had a stim at Reed headache center which was unsuccessful. I had a embolization of my temporal branch of my external carotid artery. This have me complete relief for 3 months. During the angiogram my interventional radiologist said that my vessels had an abnormal reaction to the slightest amount of increased pressure (contrast medium). He said the vessels "clamped down" or spasmed. My headaches have, since about 13 yo been in the same location. In my right temple and behind my right eye. My left eyelid droops significantly in relation to the severity of the pain on my right side. Another symptom/ effect with my eyes is a change in iris color. Normally dark brown, they become greener the greater the pain level I am at. I am prepared to have the procedure tomorrow, paying out of pocket for it. Can you give me any direction or advice?

Dr. Rob Oliver Jr. said...

Amy,

Your symptoms don't sound like the kind of headache that are amenable to this type of surgery as they don't really treat vascular phenomena.

Some people do get headaches from their superficial temporal arteries apparently from a phenomena called Temporal Arteritis (TA) or from the artery irritating adjacent sensoray neves (you can see a video of surgery for that at http://www.youtube.com/watch?v=MWI-uIB_qK4).

Based on your description, it sounds like you need to possibly have your temporal artery biopsied to exclude TA which can progress to blindness if untreated with anti-inflamatory medication and steroids.