A Life Changed by Migraine Surgery

Cosmetic surgery leads to possible pain relief from migraines

July 23, 2015 by Alison Bowen, Chicago Tribune

Bryan Kirsch knew something was wrong when the stairs moved. After roughhousing with his children in 2011, he was walking upstairs with one when, he remembered, “I look up the stairs, and the whole world is spinning.”

Thus began three years of near-constant pain from migraines. Kirsch is one of the first people in Chicago to undergo a surgery aiming to alleviate chronic migraine pain. Now, Kirsch says, he is essentially free of pain. “I couldn’t have sat out here,” he said as an elevated train rumbled and roared overhead. “It’s been night and day for me.”

Cleveland plastic surgeon Bahman Guyuron, who has trained about 50 doctors across the nation to perform this surgery, said he discovered a correlation by chance in 1999. He noticed that, among his patients, people with cosmetic forehead lifts also noted migraines ebbing.

“I thought that that was just a coincidence,” said Guyuron, emeritus professor of plastic surgery at Case Western Reserve University School of Medicine. “A couple of weeks later, another patient told me the same thing.”
Some doctors say certain types of chronic migraine headaches can be caused by nerve compression. Surgery can release the pressure on the nerve from surrounding tissue like muscle, which can then alleviate pain.

After nearly two decades and 24 studies by Guyuron’s team, doctors are working to get health insurance companies to recognize and cover the surgery – as well as build awareness about a procedure they say can alleviate debilitating head pain.
Guyuron says studies show as much as a 92 percent success rate. A 2011 article in the Journal of the American Society of Plastic Surgeons tracked patients five years after undergoing the surgery. It showed 61 of 69 patients reported improvement, and 29 percent reported a complete elimination of migraines.

Dr. Elizabeth Loder, chief of the Division of Headache and Pain at Brigham and Women’s Hospital in Boston, said migraines naturally wax and wane, making it difficult to tell whether change is due to a solution or simply time.

Loder is former president of the American Headache Society, which in 2013 cautioned against this type of surgery outside of a clinical trial.

Clinical trials are strictly controlled, and Loder said data with long-term follow-ups and a randomized, larger number of patients would amp up the research base.
So far, the database does not include as many patients as Loder would like, and she said it could benefit from measuring people who did and did not receive surgery. Also, the different pain locations make it difficult to equally study patients, she said.

“I think we do need additional trials, ideally done by people who are not invested in the outcomes,” she said. “It would certainly be interesting to see the results of these trials. No one is saying this shouldn’t be investigated further.”
Not everyone is a candidate, doctors who perform the surgery say. Typically, it can most help those with chronic pain, suffering about eight to 15 headaches a month not helped by medication.

Northwestern Memorial Hospital plastic surgeon Dr. Mohammed Alghoul has performed the surgery on four patients in Chicago so far; all of them saw a neurologist first. About 1,100 patients nationally have had the procedure, according to Guyuron’s office.

“(Patients) will tell you the pain is there all the time; it doesn’t really go away,” Alghoul said of surgical patients before their procedures. “It may be a 2, 3 out of 10 (on the pain scale), but there’s always pain happening” even when they aren’t having a typical migraine.
Doctors identify four different places, called trigger sites, on the head where this might occur: the forehead, temple, nose and back of the head. This surgery has been adapted to all the sites.

Patients get local or general anesthesia, depending where on the head the surgery is, and they generally spend about half a day in an outpatient surgery facility, according to Guyuron
The procedure involves making small incisions, then releasing nerve pressure.
Kirsch, 37, left the hospital the same day.

“The rest of my life’s back to normal,” he said. “Relief was almost instantaneous.”
The father of three still remembers exact dates of appointments and the day he first felt dizzy. He recounts a laundry list of answers sought – from a neurologist; neurosurgeon; neuro-ophthalmologist; an ear, nose and throat specialist – and about 10 different prescription medications he tried.

“I pretty much had tried every specialist under the sun,” he said. “Nothing was helping.”
He missed his kids’ birthday parties and his sister’s wedding reception because noise triggered pain. He was scared that he would have a dizzy spell while driving his children, so his wife took on chauffeuring duties. Sometimes, at home and at his office as an attorney, he’d have to just sit in a dark room, separated from the world.

Finally, a neurologist at Northwestern suggested he meet Alghoul, who had just learned the procedure from Guyuron in Cleveland.

He was a bit concerned about surgery, he said, but felt comfortable with the explained risks, which can include infection, bleeding and numbness.
“At this point I’m like, ‘I’ll try anything and anybody,'” Kirsch said.
To see if he was a good candidate, Alghoul first administered Botox, which can weaken muscles and nerves. After that procedure, Kirsch said, he was pain-free for the first time in years. After the Botox helped, doctors said that was a sign he would be a good candidate to go through with the surgery.
The doctors hope more health insurance companies will cover the surgery. The cost can be about $3,000 to $4,000 per surgery site; patients often have multiple trigger sites. In June, Alghoul met with representatives from Blue Cross and Blue Shield, he said, presenting research in an effort to convince them that the surgery is past the experimental stage.
Kirsch’s surgery was not covered by health insurance. Although the cost was not small, he said it was a no-brainer if it meant being present at his kids’ birthday parties.
“My wife and I never even debated,” he said.
These days, Kirsch still takes earplugs to hockey games but said he does not experience migraines. He gets occasional headaches in the same spot, but he said it’s no different from what most people occasionally endure.
On his way to a baseball game after the surgery, a broken stitch left his still-numb head bleeding. But after years of not being able to enjoy loud stadiums, he simply found the first-aid station – and a bandage – and watched the game.

“My wife said, ‘It’s almost like having you back again,'” he said.


Why a plastic surgery procedure provides effective pain relief for most migraine patients

Study: Migraine Linked to Defective ‘Insulation’ Around Nerve Fibers

Differences in Nerve Structure and Function May Help to Explain How Migraine Headaches Occur, Suggests Study in Plastic and Reconstructive Surgery

Dr. Hochman Performing Surgery on Occipital Zone with Patient Sitting

Dr. Hochman Performing Surgery on Occipital Zone with Patient Sitting

Nerve specimens from patients with migraine show abnormalities of the myelin sheath that serves as “insulation” around the nerve fibers,” according to the study by ASPS Member Surgeon Bahman Guyuron, MD, of Case Western Reserve University, Cleveland. The findings help to explain why a plastic surgery procedure provides effective pain relief for migraine patients—and may provide useful clues for developing new approaches to migraine treatment.

Nerve Fiber Abnormalities in Patients with Migraine…

The researchers performed in-depth studies on tiny specimens of the trigeminal nerve (one of the cranial nerves), from 15 patients who underwent surgical treatment for migraine. Sample from 15 patients undergoing a cosmetic forehead lift procedure were studied for comparison. The study—conducted through collaboration by three independent departments at Case Western Reserve School of Medicine—included electron microscopy to assess nerve cell structure and proteomic analysis to assess the presence and function of proteins.

The results showed important differences in nerve structure between the migraine and cosmetic surgery patients.

“Essentially, the protective layer surrounding and insulating the normal nerves, called myelin, is missing or is defective on the nerves of the patients with migraine headaches,” said Dr. Guyuron.

He likens the myelin sheath to the plastic coating used as insulation material around electrical wires and cables.

“If the insulation becomes cracked or damaged by conditions in the environment, that’s going to affect the cable’s ability to perform its normal function,” said Dr Guyuron. “In a similar way, damage to the myelin sheath may make the nerves more prone to irritation by the dynamic structure surrounding them, such as muscle and blood vessels, potentially triggering migraine attacks.”

Organization of the cellular elements in nerve fibers also differed between groups. Healthy nerves were tightly organized with elements uniformly distributed through the nerve, while nerves from migraine patients showed discontinuous, “patchy” distribution.

…Suggest Reasons Why Migraine Surgery May Be Effective

Dr Guyuron developed migraine surgery techniques after noticing that some migraine patients had reduced headache activity after cosmetic forehead-lifting, which involved removal of some muscle and vessel tissue surrounding the cranial nerves.

The new study lends some important new clues for understanding the mechanisms by which migraine headaches occur. It also adds new evidence that the peripheral nerves play an important role in triggering the complex cascade of migraine attacks that ultimately involve the central nervous system.

By showing pathological changes of a cranial nerve involved in triggering migraine headaches, the study may help to explain why migraine surgery is effective. Dr Guyuron and coauthors write, “These findings may also lead to other opportunities to treat patients with migraine headaches non-invasively, or with less invasive procedures that repair the defective myelin around nerves, lending additional protection for the nerves.”

The new findings on nerve cell abnormalities associated with migraine are discussed in this month’s introductory video by Rod J. Rohrich, MD, Editor-in-Chief, on the Plastic and Reconstructive Surgery website. “This type of cutting edge research…is just one way plastic surgeons are constantly trying to improve patients’ outcomes,” Dr. Rohrich concludes.

Plastic and Reconstructive Surgery® is published by Lippincott Williams & Wilkins, part of Wolters Kluwer Health.

Migraine Triggers from “MyChronicMigraine.com”

My Chronic Migraine logo


Migraine may be aggravated or triggered by specific factors. In a study of 1207 migraine patients, about 3 out of 4 said they have triggers for their migraine attacks.4 When given a specific list of triggers to consider, almost 95% of the people said that their attacks were brought on by certain circumstances or environmental influences.

Common triggers may include:

•Physical exertion or activity
•Hormonal changes
•Skipping meals
•Sleep disturbances and sleeping late
•Weather changes
•Perfume or odor
•Neck pain

Manack A, Turkel C, Silberstein S. The evolution of chronic migraine: classification and nomenclature. Headache. 2009;49(8):1206-1213.

Early Signs of Migraine

early_signs_of migraine survey

In a survey at Migraine.com, on FaceBook, 300 migraneurs responded with what type of strange early signs they sometimes got before a migraine. Yawning was one of the first listed. See the rest here and take the survey yourself.

Did You Know There Are At Least 20 Different Types of Headaches/Migraines?

All you need to know about headaches and migraines

Amer Migraine Foundation photo






Types of Headaches/Migraines
• Abdominal Migraine
• Basilar-Type Migraines
• Cervicogenic Headache
• Chronic Migraine
• Cluster Headaches
• Hemicrania Continua
• Hemiplegic Migraine
• Hypnic Headache
• Ice Pick Headaches
• Intractable Headache
• Medication Overuse Headache
• Migraine and Aura
• New Daily Persistent Headache
• Occipital Neuralgia
• Orgasmic and Pre-orgasmic Headache
• Parosyxmal Hemicrania
• Post-Traumatic Headache
• Primary Exertional Headache
• Retinal Migraine
• Tension-type

     From the American Migraine Foundation
Amer Migraine Foundation logo

Facial Pain with Migraines

Migraines Responsible for Deaths in Women

New Research Shows Migraine Responsible for 13% of Deaths in Women

by Teri Robert / @trobert , Health Guide | August 27, 2014

Link between migraines & death

Link between migraines & death

For several years now, studies have shown an association between migraine and cardiovascular disease and incidents. Cardiovascular disease (CVD) and events include diseases and events related to the heart and blood vessels and include:

  • Heart attack, aka myocardial infarction;
  • Atherosclerosis: a condition in which plaque builds up in the walls of the arteries;
  • Heart failure;
  • Arrhythmias, which are abnormal heart rhythms;
  • Heart valve problems
  • Ischemic and hemorrhagic stroke;
  • Cerebrovascular disease: diseases of the blood vessels that supply the brain; and
  • Deep vein thrombosis and pulmonary embolism: blood clots in the veins of the leg, which can come lose and move to the heart and lungs.

At the American Headache Society’s annual scientific meeting in June 2014, a research poster was exhibited that significantly added to the body of evidence linking Migraine and cardiovascular diseases and events.
•Summary and Comments:

For several years, we’ve seen studies on the associations between migraine and cardiovascular and cerebrovascular disease and events such as stroke and myocardial infarction (heart attack). This is the first study to look at either association or causality of migraine in relation to deaths from all causes. Data from this type of study, which contained such a large number of participants and collected data over such a long time period is very strong.
•Summary and Conclusions

The conclusion that 13% of all deaths of women in this study were due to migraine is startling and should be a wake-up call to women with migraine. Panic or feeing defeated by this statistic is neither warranted nor helpful. Rather, this wake-up call should motivate women with migraine to have constructive conversations with our doctors regarding what we can do to reduce modifiable risk factors and other actions we can take to be healthier and stronger.

– See more at: http://www.healthcentral.com/migraine/c/123/171320/research-migraine-responsible




Dr. Hochman Performs Migraine Surgery with Patient Sitting

This is just one of the many reasons to choose Dr. Hochman for your migraine surgery.

Dr. Hochman Performing Migraine Surgery on Occipital Zone

Dr. Hochman Performing Surgery on Occipital Zone with Patient Sitting

If most of your headaches start in the back of the head and upper neck, here the greater occipital nerve is pinched by a muscle and by the greater occipital artery and vein. Surgery involves releasing the nerve from the compressing structures including the muscle and vessels. The surgery is done through an incision within the hairline just below the bump on the the skull which you can feel in the midline. Dr. Hochman is one of the few doctors in the country to perform surgery to the area with the patient in a sitting position which is far safer than turning a patient under general anesthesia. This is just one more reason to choose Dr. Hochman for migraine surgery.

Migraine and Stroke – What’s the Link?


Neuroscience and Neurology
Excerpts from Migraine and Stroke – What’s the Link?
On the surface, strokes and migraines do not seem to have much in common except that both of them can have serious psychological effects on the sufferers. But researchers say that a complex relationship exists between the two.Migraine is a neurological disorder characterized by the occurrence of throbbing and recurring headaches that can be so severe to interfere with the normal day to day life. Stroke is a medical emergency caused by a compromised blood supply to the brain. It could result in brain damage, eventually leading to complications and disability.Several studies have associated migraine in young adults, especially women, with ischemic stroke. A recent study relates migraine without aura in older people with subclinical stroke.

Generally, migraine with aura is associated with an increased risk of ischemic stroke, especially in young women. …when compared to women without migraine aura but the absolute risk (the overall likelihood of developing ischemic stroke) is actually small.

Researchers from the Northern Manhattan Study (NOMAS) reported that migraine sufferers had twice the risk of developing silent stroke when compared to people who did not report migraine episodes. This finding related more to the people who experienced migraine without aura. Silent stroke does cause permanent damage to the brain, but the damage is small, subtle and goes unnoticed. The reason for this is that silent stroke does not affect the main functional areas of the brain that lead to apparent symptoms when damaged. However, silent strokes can lead to cognitive disturbances and accumulation of such subtle damages can lead to gradual neurological deficits.

The researchers have emphasized the need for reducing the risk factors of stroke in such people. Similar concerns were also expressed in previous studies. Attention is especially needed to patients who have co-existing vascular risk factors like elevated blood pressure, elevated cholesterol level, diabetes, coronary heart disease, etc.



About Migraines from American Migraine Foundation

American Migraine Foundation logo

The Burden of Migraines
• Migraine costs the United States more than $20 billion each year. Costs are attributed to direct medical expenses (e.g. doctor visits, medications) and indirect expenses (e.g. missed work, lost productivity).

• Migraine is disabling. The World Health Organization places migraine as one of the 20 most disabling medical illnesses on the planet.

• Chronic migraine is even more disabling.

• Those with migraine are more likely to have depression, anxiety, sleep disorders, other pain conditions, and fatigue.

• People who have a history of experiencing an aura phase have been shown to be at an increased risk for stroke and heart attack.

Current Migraine Treatments are Inadequate
• There is no cure for migraine. Treatments are aimed at reducing headache frequency and stopping individual headaches when they occur.

• Prophylactic treatments (to reduce headache frequency) may include avoidance of migraine triggers, medications, physical therapies and behavioral therapies.

• Abortive treatments (taken when a patient has a headache) include over-the-counter pain relievers and prescription medications.

• Although prophylactic and abortive treatments help many people with migraine, they are far from perfect. Undoubtedly, better treatments are needed.

• Prophylactic medications reduce headache frequency by 1/2 in only about 40% of patients who take these medications.

• Medication side effects often limit the use of migraine medications.
From http://www.americanmigrainefoundation.org

Three Options for Migraine Sufferers Offered at Surgery4Migraines

You do not need to suffer with migraine pain any more. Here’s why:

Until recently there was little to offer for chronic migraines and other facial pains other than medications in the form of pills and injections. Nearly two-thirds of patients discontinue prescription medications due to inadequate relief and side effects.

But now there are procedures available in a treatment plan at Surgery4Migraines which provide temporary relief from migraines in the majority of patients as well as a surgery option for more permanent relief.

1. Botox® injections can temporarily relieve migraines for up to three months in some cases by “freezing” the muscles which encapsulate the nerves causing the pain.


2. SPHENOBLOCK® is a minimally invasive procedure designed to temporarily block a collection of nerves (the sphenopalatine ganglion – SPG), effectively delivering pain relief. The SPG lies in a bony cavity which is deep in the midface nasal cavity and is related to a variety of facial pain conditions, such as migraines, cluster headaches and atypical facial pain. It provides effective care for a difficult group of patients.

Because the SPG represents a “crossroad” of neurons involved in pain processing, clinicians using SPG blocks have reported its effectiveness in a variety of central pain syndromes, from complex regional pain syndrome to fibromyalgia.

Dr. Hochman administers the SPHENOBLOCK® to:

•Diagnose the cause of pain in the face and head
•Manage the pain of certain types of chronic headaches
•Manage sympathetically maintained facial pain

Sometimes during a SphenoBlock®, Dr. Hochman injects the pain-relieving medicine into the region where the ganglion lies with the use of the SphenoCath®. The SphenoCath® is a small soft tube designed to be the medication delivery device for SpenoBlock® , transforming it into a quick, simple procedure. This may reduce the release of the chemical norepinepherine activating the pain sensitive nerves and reduce the pain with long-lasting effects.

•Patient will not feel numbness in the face.
•Procedure is painless.
•Requires no X-rays.
•Takes about 30 minutes in the office.

Most insurance companies, as well as Medicare, cover the procedure. We will work with you if it is not covered.

SPHENOBLOCK® can often give immediate relief to an ongoing pain episode and/or help to give longer term relief by “resetting” this group of nerves (SPG).

If you’re currently taking medicine for migraines or other chronic facial pain, this simple procedure may over time replace the need for narcotics or other pain medications. It fits into the overall treatment plan with regard to medications, Botox injections and surgery for migraines.

3. The third Option is Surgery on the affected trigger points.


Botox for Migraines AND Depression?


Botox Takes a Shot at Treating Depression

botox-vial optIt may be time to add depression to the growing list of conditions that Botox (onabotulinumtoxinA) can help treat.

Two recent studies suggest that the neurotoxin may help alleviate symptoms of depression, and that this benefit may be more than skin deep.

In one study published in the Journal of Psychiatric Research, more than half of participants with moderate to severe depression showed a substantial improvement (greater than or equal to 50% of baseline) in depressive symptoms following one injection of Botox between the brows.

Depressive symptoms (as assessed by the Montgomery-Åsberg Depression Rating Scale scale) in the Botox treatment group decreased 47% after 6 weeks, compared to 21% in the placebo group. Moreover, 27% of individuals treated with Botox achieved remission, compared with 7% in the placebo group.

“This research is groundbreaking because it offers those who suffer from depression and their doctors an entirely new approach to treating the condition — one that doesn’t conflict with any other treatments,” says Norman E. Rosenthal, MD, clinical professor of psychiatry at Georgetown Medical School, in a news release. The study showed that Botox may help relieve depressive symptoms both as a stand-alone and an adjunctive treatment.

A related study presented at the annual meeting of the American Academy of Dermatology in Denver showed that botulinum treatments injected between the eyebrows had an anti-depressive effect that lasted longer than the wrinkle-relaxing results, suggesting that there may be a biological basis for the effect.

See more at: http://www.plasticsurgerypractice.com/2014/04/botox-takes-shot-treating-depression/#sthash.eAcyrkm5.dpuf