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Originally published August 5, 2013 at 5:49 AM | Page modified August 5, 2013 at 7:13 AM

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Help for migraines

Chronic migraine sufferers have some options for relief, including Botox. But some headache experts advise caution on two surgeries intended to interfere with nerves that deliver migraine pain.

The Dallas Morning News

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Swollen eyes, nausea, sensitivity to light and sound, pressure so intense they feel their eyes might pop — migraine sufferers learn to describe the pain in many ways.

Although there is no cure, people with occasional migraine headaches have many options, from medication to dietary changes. For chronic sufferers, there are more extreme measures.

Botox injections have become mainstream in recent years. Some doctors offer less-proven surgical alternatives such as implanted neurostimulation and nerve decompression. While practitioners point to success stories, the American Headache Society says the surgeries are unproved. So it’s important for patients to understand options and implications.

Botox, the most widely used of these procedures, is a familiar fix for frown lines and wrinkles. Botox blocks nerve signals that cause muscles to contract. In patients with migraines, the treatment is usually a series of injections across the forehead, temples and the back of the neck.

“I like it in some cases,” says Dr. George Nissan of the Baylor Headache Center, “but I don’t go to it first line.”

Nissan’s initial treatment usually involves lifestyle changes, such as avoiding trigger foods or adding an exercise routine, as well as preventive medication. Nissan considers Botox a step beyond these early measures.

The Food and Drug Administration approved the use of Botox for migraines in late 2010, but only for migraines designated as chronic — patients must document they’ve had 15 or more headache days a month, and that eight of those were severe.

Each treatment, involving as many as 31 injections, can cost more than $1,000 and the drug effects last only about three months.

Surgical treatment for migraine remains controversial.

Nerve decompression aims for complete relief, while neurostimulation aims to reduce pain levels. Doctors point to what they deem success stories, and ads promise relief.

Some experts are skeptical. According to a statement released last year by the American Headache Society, a professional organization of health-care providers, “Surgery for migraine is a last-resort option and is probably not appropriate for most sufferers. To date, there are no convincing or definitive data that show its long-term value.”

Dr. Elizabeth Loder, the society’s president-elect and the chief of the division of headache and pain in the department of neurology at Brigham and Women’s Hospital in Boston, says randomized, controlled, multicenter studies are the standard by which surgeries should be measured. Both treatments have undergone randomized clinical trials published in medical journals, but Loder said nerve decompression in particular is unproved.

Nerve decompression is performed by plastic surgeons and is based on the idea that pain can be treated by relieving pressure on nerves caused by surrounding tissue.

Before performing surgery, Dr. Jeffrey Janis, a plastic surgeon formerly with the University of Texas Southwestern Medical Center, uses Botox to weaken or paralyze muscles compressing nerves in the face, head and neck.

Unlike a typical Botox treatment, this technique uses fewer injections and pinpoints specific trigger nerves. If Botox is successful in eliminating migraines, Janis says he discusses permanently decompressing those nerves through surgery.

“I’m using Botox as a test,” he says. “I’m using surgery as a treatment.”

Dr. Bahman Guyuron, a plastic surgeon at University Hospital Case Medical Center in Cleveland, pioneered the surgery. Guyuron discovered that patients who’d had the muscles between their eyebrows surgically removed during a brow lift often saw a reduction in migraines.

Janis, who recently accepted a position as executive vice chairman and professor of plastic surgery in the department of plastic surgery at the Ohio State University, says the procedure isn’t ideal for everyone. It usually isn’t covered by insurance and can cost as much as $20,000, Janis says. He treats only patients whose migraines have been officially diagnosed by neurologists.

Implanted neurostimulation uses wires the width of spaghetti noodles to deliver electrical stimulation and ease migraine pain. The stimulators are implanted under the skin near the forehead or the back of the neck. They’re attached by wires to a battery pack, about the size of a silver dollar, placed in the chest wall or above the buttocks. Electrical impulses to targeted areas in the head and neck block pain in migraine patients, who can control the strength of those currents.

It isn’t FDA-approved to treat migraines and is not always covered by health insurance.

Dr. Brian Flanagan, co-director of Baylor’s Center for Pain Management, says the surgery is low-risk but adds that it’s often costly and does not completely eliminate symptoms. A 50 percent reduction in pain is considered a victory.

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