Surgery for migraines

I just received an announcement for the “2nd Annual Surgical Treatment of Migraine Headaches.” The event is sponsored by Case Western Reserve University and presented by its Department of Plastic Surgery. Ten of the 12 speakers on the program are plastic surgeons. Their premise is that since Botox injections relieve migraines, why not go a step further and cut those muscles in the forehead for permanent relief.

When I asked my friend Ken Rothaus, a plastic surgeon at the New York Hospital, about this approach, he was not excited—despite the potential new pool of patients. Here is what he said: “I think that when there exists a relatively non-invasive procedure such as Botox that works so well and costs less than the corresponding surgical procedure, it represents the better first line choice for the patient. All surgery has risks and complications, Botox can be injected in all the involved areas not just the glabellar, and the cumulative cost of 3-5 years of Botox may be less than that one surgical procedure.”

Another strong argument against surgery is the very nature of migraines. They come and go for long periods of time, and on their own improve with age in most patients.

An additional reason, and perhaps the most compelling: Plastic surgeons lack training in diagnosing and treating headaches. They do not know how to properly diagnose different types of headaches, how to detect potential triggers, and how to combine different treatments into a comprehensive plan.

A case can be made that if a neurologist is also involved in the care of a patient receiving surgical migraine relief, it may be a reasonable approach. However, injecting Botox only into the forehead is ineffective for most patients. We usually also inject the temples, the back of the head and, at times, the jaw and neck muscles. Surgery cannot be done in these areas, and cutting only forehead muscles is not likely to have a significant effect.

Finally, while we have about 100 scientific articles published on the use of Botox for headaches, there has been only one small, uncontrolled study published on the use of plastic surgery for migraines.

So, surgery for migraines? In my opinion, this is a treatment that’s not quite ready for prime time.