Migraine headaches affect 18 percent of women, 6 percent of men and 10 percent of children, yet how they develop remains largely a mystery. While they were once thought of simply as a vascular condition, it is now understood that they may involve multiple causes and chains of events, including blood vessel constriction, excitation of nerve cells, generalized or systemic neuralgia, or nerve entrapment.
For those whose migraines stem from nerve entrapment by muscle, fascia, blood vessels or bone, nerve release (resection of the tissues impinging on the nerve) is a highly effective solution. As many as 92 percent of patients may find relief from their migraine headaches through this one-hour, outpatient procedure and about 35 percent achieve sustained elimination of migraines.
“As many as 92 percent of patients may find relief from their migraine headaches.”
Salam Kassis, M.D., assistant professor in the Department of Plastic Surgery at Vanderbilt University Medical Center, is one of few specialists around the country trained in nerve release procedures. “As successful as this surgery is, and with the endorsement of the American Society of Plastic Surgeons, there are very few centers offering it today. I am excited to see its availability expanded to more patients who have migraines due to nerve entrapment,” Kassis said.
An Individualized Procedure
Nerve entrapment is only one of many causes of migraine headaches, and the proportion of sufferers who are candidates for nerve release surgery is unknown. Kassis finds that patients tend to self-select, recognizing that their headaches originate in one or more of the trigger spots above or behind the eye, in the temple, or the neck. If their pain tends to be without a localized trigger site in the face or neck, it is likely to originate inside the brain, and nerve release would not be effective.
Single or multiple procedures may be done to release the nerves associated with common migraine trigger points, which include the supraorbital, supratrochlear, zygomaticotemporal, auriculotemporal and occipital nerves.
A benefit of having a plastic surgeon perform the procedures is that scarring is minimal. The supraorbital and supratrochlear nerve release procedures are done through the same incision as a blepharoplasty. The temporal and neck incisions are small and covered by hair regrowth and the intranasal trigger points are treated by a rhinoplasty incision.
While the surgery is outpatient, relatively short and carries a low risk of adverse events, it is not routine. “Every procedure is unique,” Kassis said. “Besides the common step of removing muscle tissue and fascia, I may need to widen a foramen, remove an artery that winds around the nerve or cushion the nerve with fat tissue.”
Ending Migraine Imprisonment
Patients may have some numbness near the site for up to six months, but Kassis says that most consider the recovery well worth the result of eliminating or improving their migraines. “More than one of my patients has said they would take a little numbness over a migraine any day,” Kassis said.
In addition to larger potential benefits in lowering medical costs and societal burden, Kassis finds the level of gratification from patients is rare, even in the plastic surgery world. “It’s my favorite procedure when I find a good candidate and see their lives totally change. Some of my patients have been imprisoned by migraines for 18 years or more, and suddenly, after a one-hour surgery, they’re free.”