modification including adjusting sleep patterns.
In clinical practice, if a specific MTSDS is
ineffective for migraine treatment, a revision
surgery in the same area or multiple surgeries in
other locations are performed. MTSDS is not only
invasive, but can also be expensive with an out-ofpocket cost as high as $15,000 per procedure.
In patients who are evaluated for MTSDS,
surgeons will often perform BTX injections or
nerve block injections to confirm that a patient is
a good surgical candidate. This practice would be
similar to giving a patient ibuprofen for low back
pain, and if the pain improved, proceeding with
invasive spinal surgery. Clearly, there are many causes
of low back pain, ibuprofen is a non-specific pain
reliever, and surgical treatment is not indicated in
the vast majority of patients with low back pain.
In the literature, both BTX and nerve blocks have
proven effectiveness in the treatment of multiple
headache disorders through mechanisms that are not
necessarily related to nerve compression or overactive
muscles. If BTX and nerve block Injections are found
to be effective forms of treatment, continued treatment
with these modalities should be considered rather than
urging these migraine sufferers to proceed with surgery,
It is possible that some patients who reported
improvement of their pain with MTSDS, may have been
experiencing a different pain disorder of the head in
addition to their migraine, Such pain disorders include
contact point headache as well as occipital and other
neuralgias. The term, neuralgia, in this case refers to pain
in a particular location due to irritation of a specific nerve
outside of the brain. Neuralgia is very different from
the pain of migraine and its associated symptoms which
are generated within the brain. As such, future studies
should focus on the use of MRI and other imaging
techniques to determine whether nerve compression is
present. Pain due to nerve compression that is confirmed
on a scan, may respond to decompression surgery, rather
than blindly proceeding with other surgical procedures.
In conclusion, one of the longtime paradigms of
surgery is to perform elective surgery based on a favorable
risk-to-benefit ratio once best medical management
has failed. This paradigm has clearly not been followed
in clinical practice regarding MTSDS. The American
Headache Society does not endorse the treatment of
migraine with MTSDS. Any patients who wish to
pursue MTSDS should undergo an evaluation by a
headache specialist (someone who has completed a
headache medicine fellowship or is board certified in
headache medicine), and should be advised of the risks
of these procedures in the absence of any convincing
evidence of efficacy. MTSDS may be useful in a subset
of migraine patients, but further studies need to be
performed. Any surgeries that are performed should be
undertaken in the setting of a properly conducted study
in order to determine better screening tests for potential
surgical candidates Future studies may establish whether
certain migraine features when present may suggest
a better outcome, and determine which risk factors
may predict prolonged/permanent adverse events.
HW
Suggested reading:
Lipton RB, Diamond S, Reed M, Diamond ML, Stewart
WF. Migraine diagnosis and treatment: Results from the
American Migraine Study II. Headache 2001; 41:638-645.
Mathew PG. A critical evaluation of migraine trigger site
deactivation surgery. Headache 2014; 54: 142-152
www.headaches.org
142651_A_NHFHeadWise–June.indd 23
|
National Headache Foundation
23
6/2/14 8:10 PM