Migraine Pain Goes
Under The Knife

By Paul Taylor
The Globe and Mail
Arlene Harris could not stand the pain any more. She suffered from debilitating migraine headaches that would last for days, even weeks.
"They would start in the back of my head," recalls the 53-year-old from Cleveland, Ohio. "It would feel like someone was stabbing me in the back of my head with a knife." To make matters worse, the frequency of the attacks was increasing at an alarming rate. "It seemed the older I got, the worse I got."
The drugs normally used to treat migraines barely made a dent in her pain. "I was at the point where I was willing to try anything," she recalled in a telephone interview.
So, when she saw a television news report about a Cleveland doctor who performed a unique migraine operation, Ms. Harris leaped at the opportunity. "I figured I had nothing to loose."
The operation, developed by Dr. Bahman Guyuron, a professor of plastic surgery at Case Western Reserve University, involves the surgical removal of tiny bits of muscle from the face and head to release pressure on particular nerves.
Although it may sound bizarre, the surgery works for some patients who can't get relief from conventional treatments. And it seems to be long lasting.
Three years after her surgery, Ms. Harris is still almost migraine-free. She might suffer a few attacks a year -- during particularly stressful periods -- rather than many episodes a month. "I don't miss time from work any more because of migraines. I can spend more time with my family. I can function like a normal human being," said Ms. Harris, who works in a tony fabric store.
Dr. Guyuron decided to explore a surgical solution to migraines after some of his patients reported that their headaches had suddenly stopped. They had undergone minor operations to have frown lines removed -- and surprisingly got rid of their migraines as well.
So he set out to systematically study which muscles and nerves seemed to play a role.
He identified several key areas for surgical intervention, including around the temples, forehead, nasal region and back of the neck.
Migraine sufferers are well aware that certain triggers, such as stress or particular foods, can bring on an attack. But the exact cause of the headaches is unknown.
According to one theory, highly sensitive brain cells send out signals leading to a dramatic constriction of certain blood vessels in the head. Then, the same brain cells send out the opposite message, forcing blood vessels to open wide. These extreme swings put huge stress and strain on blood vessels, nerves and muscles, provoking excruciating pain.
Dr. Guyuron's treatment essentially eases the pressure. Through tiny incisions, he removes bits of muscle wrapped tightly around specific nerves, then pads out the depression with fat taken from another part of the patient's body.
"When the muscle contracts, it is not able to pinch a nerve," the doctor explained. In certain cases, he also severs non-crucial sensory nerves, rather than tinker with an important muscle, such as those that control chewing.
Botox injections are used to help pinpoint the areas that require treatment. In fact, doctors have been using Botox for years to treat migraine sufferers. Botox, an extract from the botulinum toxin, deadens nerves and thus relaxes muscles. (That's why Botox is also used to smooth wrinkles and eliminate frown lines.) But within a few months, nerves grow back, so the relief is temporary.
Dr. Guyuron has found that patients who respond well to Botox injections are good candidates for his more lasting treatment. "Each patient may have a combination of trigger sites. We identify them and treat them surgically," he said.
Still, this type of surgery "is not for everyone," said Dr. Jennifer Kriegler, a neurologist who has collaborated with Dr. Guyuron on a recent study published in the journal Plastic and Reconstructive Surgery. "These are people who have really intractable migraines. They are significantly disabled."
A handful of other doctors across the United States are now doing the operations. There are none in Canada yet.
"Dr. Guyuron is clearly the man. And I am copying him as best I can," said Dr. David Branch, a plastic surgeon in Bangor, Me. "So far, so good."
Treatment can be pricey. Depending on how many nerves and muscles need surgical intervention, the price can range from $3,000 to $25,000 (U.S.). But Dr. Branch believes the treatment can save money in the long run because patients are no longer losing time from their jobs. As well, some do not have to take costly migraine drugs any more.
Some patients will experience numbness in certain areas as a result of the surgery, but this complication is usually temporary, said Dr. Guyuron.
And there is one side effect most patients welcome -- the loss of their frown lines.
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