Permanent solution for chronic migraines? Surgery offers promise, some urge caution
Frances White suffered from debilitating migraine headaches for 51 years and her husband can attest to her suffering.
The costs of migraines
A collective 112 million workdays a year are lost.
An estimated $14 billion in lost productivity.
The total annual cost to treat migraines is between $13 billion and $17 billion.
Source: Archives of Internal Medicine and American Journal of Managed Care
"I've seen her cry for weeks with migraine headaches," says Floyd White.
Before the pain starts
One or two days before a migraine, you may notice subtle changes that signify an oncoming migraine, including constipation, depression, food cravings, hyperactivity, irritability, neck stiffness and uncontrollable yawning.
Aura may occur before or during migraine headaches. Auras are nervous system symptoms that are usually visual disturbances, such as flashes of light. Sometimes auras also can be touching sensations (sensory), movement (motor) or speech (verbal) disturbances.
Most people experience migraine headaches without aura. Each of these symptoms usually begins gradually, builds up over several minutes, and then commonly lasts for 20 to 60 minutes.
Examples of aura include visual phenomena, such as seeing various shapes, bright spots or flashes of light; vision loss; pins and needles sensations in an arm or leg; speech or language problems (aphasia).
When untreated, a migraine usually lasts from four to 72 hours, but the frequency with which headaches occur varies from person to person. You may have migraines several times a month or much less often.
During a migraine, you may experience the following symptoms: pain on one side or both sides of your head; pain that has a pulsating, throbbing quality; sensitivity to light, sounds and sometimes smells; nausea and vomiting; blurred vision; lightheadedness sometimes followed by fainting.
The final phase, known as postdrome, occurs after a migraine attack. During this time you may feel drained and washed out, though some people report feeling mildly euphoric.
Source: Mayo Clinic
But after they saw a segment on the TV show "The Doctors" about a nerve decompression surgery for the relief of migraines performed by plastic surgeons, they sought out Dr. Marcelo Hochman of Facial Surgery Center in Charleston.
She had the surgery on Aug. 20, and the 70-year-old hasn't had a headache since then.
"It's like a miracle," says Frances. "It's just marvelous."
The hot zones
The surgery works, in theory, by relieving the irritation of the peripheral branches of the trigeminal nerve, caused by the compression of the nerve by muscles and blood vessels.
The hot zones
Basically, the surgery involves removing the muscle that constricts the nerve and replacing it with fat removed from the patient's abdominal region. The fat not only helps fill in the area lost from the muscle but provides a cushion for the nerve.
Hochman says those nerves surface in one of four areas of the head, the frontal area in notches within the eyebrow, the temporal zone within the hairline near the temples, the occipital zones at the back of the head and/or in the nasal cavity.
The zone Hochman targets for nerve decompression is based on where the migraines start, along with the severity and frequency.
"Universally, patients with chronic migraines know exactly where they start and every single place where they start is related to those four zones," says Hochman, who has performed surgeries on about 25 people in the past year.
Not everyone suffering from migraines gets a green light for the procedure, says Hochman, noting that patients must be diagnosed with chronic migraines by a neurologist in order to have it.
With media reports of plastic surgeons performing surgeries on migraines surfacing after limited studies, the American Headache Society has urged caution in using "surgical intervention in migraine treatment."
"Unfortunately, there is no cure for migraine. Many therapies, including medications, alternative therapies and surgical interventions, are aimed at reducing migraine frequency or stopping the pain and associated symptoms after they've begun, but none are 'cures,' " the society said in a statement issued in 2012.
"In our view, 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. Besides replacing the use of more appropriate treatments, surgical intervention also may produce side effects that are not reversible and carry the risks associated with any surgery. It also can be extremely expensive and may not be covered by insurance. Most importantly, it may not work for you at all."
The statement concluded that the "hallmarks of good therapies" include proven results in randomized controlled trials with adequate numbers of subjects, data reviewed and published in established peer-reviewed publications, reproducible results by other investigators, regulatory approval where appropriate and endorsement by key opinion leaders and professional organizations in the field of headache medicine and migraine.
Hochman chalked the Headache Society's position up to "push back to early acceptance" of the procedure and that medicine generally takes a cautious approach to new therapies "before you have the definitive study."
Proof to date
Hochman says his interest in migraines has been long-term because many of his family members suffer from them. When the literature started coming out that a plastic surgery technique was showing signs of relieving migraines, he naturally started following it.
Proof to date
A study, published in the February 2011 American Society of Plastic Surgeons' journal, Plastic and Reconstructive Surgery, followed 100 people five years after receiving the surgery. The incidence of a positive response, meaning at least a 50 percent reduction in migraines, was 90 percent. More than 70 percent showed complete elimination of the headaches.
"That was an important piece of information for me," says Hochman, saying the study prompted a trip to visit the study author and developer of the technique, Dr. Bahman Guyuron, in Cleveland and to train to perform the surgery.
"It wasn't a far reach from what I do on a day-to-day basis in terms of anatomy, exposures and approaches," says Hochman, noting the similarities between a brow lift and the migraine procedure.
Guyuron originally started investigating the procedure after a surgeon's wife had a browlift and then said she had not had a migraine since the surgery.
Too new for insurance
As expected, most insurance plans have yet to start covering the procedure, despite the fact that in an another study Guyuron demonstrated the cost benefits of the more permanent relief for migraines over medications and hospitalizations.
Too new for insurance
The study, published in the April 2012 edition of the same journal, found that five years after surgery, the median cost reduction for migraine medication expenses was nearly $2,000 a year and that patients, because of less lost time at work, gained a median of $1,525 in annual income.
Hochman estimates the out-of-pocket expenses of the surgery, if all four zones are operated on, at between $10,000 and $12,000.
Floyd White says of the expense, which he did not detail, "It was the best money I spent in my life."
New lease on life
Much like Frances White, 52-year-old John Halajcsik of North Charleston has experienced a life-changing event. He has been suffering from migraines since he was a child and still gets choked up when he recalls how his father used to help him overcome migraine headaches as a child.
New lease on life
"He would tell me to sit on the floor and tell me relax my neck, because it would get so tense and stiffen, and he'd massage it for often more than an hour," says Halajcsik, noting that his father was a big man with wrists the size of two-by-fours.
"He knew I was in so much pain and eventually I would fall asleep."
The debilitating, recurring migraines continued to plague Halajcsik, like so many of the estimated 36 million sufferers in the United States, through his youth and early middle age. Like some chronic migraine sufferers, his headaches were usually triggered by changes in the weather and the resulting shifts in barometric pressure.
Despite that, he managed to work as a master painter at a Porsche car facility in North Charleston for 17 years and, more recently, on airplanes at the Boeing plant.
Over the years, he tried a litany of medications, many of which left him feeling loopy. The drug known commonly by its trademarked name, Imitrex, provided him relief, but the job change, and subsequent insurance change, limited it to nine pills a month.
Botox injections later gave temporary relief.
On Nov. 5, Hochman performed surgery on Halajcsik and it provided the relief he needed.
"The pain is gone," says Halajcsik.
Reach David Quick at 937-5516.