Nearly 30 million Americans suffer from migraines, including 20% of women. The standard of treatment has been medication to reduce pain and symptoms. But an interesting phenomenon occurred among migraine patients who had Botox to treat their forehead wrinkles: not only did they look better, but their migraines improved, too.
Fifteen years ago, plastic surgeon Bahman Guyuron, MD, of Case Western Reserve University discovered the link between migraines and nerve compression by muscles, vessels and bones. He’d been getting anecdotal information from women who had forehead lifts and came back six months later saying they not only looked better but had relief from their migraines, too. In the mid 2000s, his landmark study found that by using Botox to paralyze the muscles that compress the forehead nerves, patients noticed significant improvement in migraine frequency, intensity and duration. Results were permanent.
“It’s very similar to carpal tunnel,” says Dr. Michael A. Howard, a plastic surgeon in Chicago and clinical assistant professor of surgery at the University of Chicago, Pritzker School of Medicine Division of Plastic Surgery. “You decompress the pressure on the nerve surgically and the stimulus for pain is gone.”
Botox — already an FDA-approved treatment for migraines — is now being used as a diagnostic tool to determine whether someone is a candidate for surgery. Surgical candidates include people who’ve been diagnosed with migraine by a neurologist and who suffer from frequent moderate to severe migraines that don’t respond well to current treatments.
Surgical candidates have trigger zones of the forehead, temple, below the eye, and/or back of scalp. Howard has his patients keep a record of their headaches for a month to determine their triggers, or their points of origin. He’ll then start serial injections of Botox. “We’ll start by injecting and wait another month to see whether Botox was effective,” he says. The whole work up takes a few months to best identify which surgical sites are at play.
If Botox was effective, then surgery is an option. The outpatient procedure is similar to a brow lift, but a little more invasive. An incision is made on the scalp using plastic surgery techniques. The nerve pathway is identified and the muscles around the nerves are released to decompress the pressure. The procedure takes a few hours, and after a two-to three-day recovery, patients gradually begin to notice improvement in migraine symptoms.
“The surgical procedure is appropriate for men and women in whom we can identify the anatomic basis for migraines,” says Howard. Women with menstrual migraines may not be candidates. Menstrual migraine can occasionally cause anatomical change and in that case, it might be appropriate.
Insurance doesn’t yet cover the surgery because it’s experimental.
For more information, contact Michael A. Howard, MD, Division of Plastic Surgery, NorthShore University Health System, 501 Skokie Blvd, Northbrook, IL 60062, 847-504-2300. http://plasticsurgery.northshore.org