1 History of Migraine Surgery
Scalding of the forehead in an attempt to treat frontal migraine headaches (MHs) during the 10th century is the first ablative measure.
Surgical attempts to mitigate MHs date back to 1923 when Jonnesco first removed the stellate ganglion.
Walter Dandy removed the inferior cervical and first thoracic sympathetic ganglions in two patients in 1931. Dickerson described success with ligation of middle meningeal artery in 1932.
In 1946, Rowbotham reported success with operation in three cases obtained by periarterial sympathectomy at the carotid bifurcation and excision of the superior cervical ganglion combined with ligation of the external carotid artery.
Resection of the greater superficial petrosal nerve for the treatment of various types of unilateral headaches was suggested by Gardner et al in 1946.
Total resection of the trigeminal nerve within the cranial base (trigeminal neurectomy) has also been tested. However, the morbidity was prohibitive.
Murillo, in 1968, suggested removal of the temporal neurovascular bundle for treatment of MHs.
An occipital neurectomy was suggested for patients with occipital MHs and neuritis by Murphy in 1969.
In 1992, Maxwell reported trigeminal ganglio-rhizolysis for treatment of MHs in eight male patients through percutaneous radiofrequency.
A retrospective study to validate the observation by patients that their headaches had disappeared after a forehead lift was completed in 2000 by Guyuron.
The first prospective pilot study to demonstrate the role of supraorbital and supratrochlear trigger site deactivation was published by Guyuron in 2002.
The role of single site botulinum toxin injection was report by Behmand and Guyuron in 2003.
Dirnberger confirmed Guyuron’s findings with a prospective study in 2004.
The first randomized prospective study in surgical treatment of MHs was published in 2005 by Guyuron et al.
Poggi also confirmed Guyuron’s findings in 2008.
The first prospective randomized migraine surgery study including sham surgery was reported in 2009 by Guyuron et al.
The long-term efficacy of migraine surgery was documented by Guyuron’s team with a 5-year follow-up study in 2011.
For the first time, Guyuron, through a collaborative effort between three departments and using proteomic analysis and electron microscopy, demonstrated that patients who have MHs have myelin deficiency in 2014.
The first retrospective study demonstrating the efficacy of surgical treatment in adolescent patients was completed in 2015.
Failure of medical treatments to provide sufficient lasting and predicable relief for many patients has prompted investigators to search for a more successful solution for migraine headaches (MHs). Going back centuries ago, scalding of the frontal migraine site with a hot rod was promoted by the Andalusian-born physician Abulcasis, also called Abu El Qasim, in the 10th century. It is hard to imagine the excruciating pain and exceedingly disturbing scene related to such a primitive, drastic measure. The far-reaching nature of this approach, however, underscores the severity of the pain that migraine patients endure and how desperate they are to consent to undergo such an extreme procedure. This demonstrates one other salient fact. That is, even this far back in history, it was believed that by stopping the migraine trigger sites in the periphery one would control MH.
Surgical attempts to mitigate MH date back to 1923 when Jonnesco first removed the stellate ganglion and other parts of the sympathetic nervous system for treatment of MH. Dandy (1931), Penfield (1932), and Craig (1935) reported relief after excision of the stellate ganglion, while Love and Adson (1936) reported improvement in 12/16 patients with this technique. 1 Walter Dandy, believing that “the actual pain of MHs, so perfectly restricted to one side of the head (unless both sides are involved), must indicate an affection of nerves which carry sensation,” removed the inferior cervical and first thoracic sympathetic ganglions in two patients. 2 Interestingly, he was able to eliminate MHs in both of these patients. However, this pioneer work lacked scientific significance due to a small patient sample size, absence of a control group, and an extremely short follow-up period.
Dickerson described success with ligation of the middle meningeal artery in 1932. However, Herbert Olivecrona reported failure in five of six patients who underwent ligation of the middle meningeal artery and he published discouraging results from denervation of the arteries. 3 Olivecrona also reported on tractotomy in 13 patients. Overall, 7 of 11 patients that were followed for a year had a satisfactory outcome.
In 1946, Rowbotham reported success in three cases after periarterial sympathectomy at the carotid bifurcation and excision of the superior cervical ganglion combined with ligation of the external carotid artery, which may possibly have been responsible for the success of this technique.
Resection of the greater superficial petrosal nerve in the treatment of various types of unilateral headaches was suggested by Gardner et al in 1946. 4 Twenty-six patients underwent surgery, 9 of whom were felt to have unilateral MHs, including 7 women and 2 men. All patients with MHs observed either complete elimination or significant improvement. Two patients had initial improvement, but the MHs recurred after 7 to8 months. The authors concluded that the surgery was more successful in patients with MHs than in those with other indications. The patients, however, reported a reduction in tear production and dryness of the nose. Some patients developed corneal ulcerations. The fact that a diverse group of patients underwent the same procedure without sufficient follow-up and without controls diminishes the scientific merits of this study. Furthermore, dryness of the eyes and nose are major adverse consequences, and the former may lead to blindness, thus rendering this approach unjustifiable.
Total resection of the trigeminal nerve within the cranial base (trigeminal neurectomy) has also been advocated. Anesthesia of the ipsilateral hemiface, dryness of the cornea, corneal ulceration, and loss of vision may ensue such a complex procedure. This operation is still being performed in some centers only on patients with severe cluster-type MHs. Surgery of this magnitude is too radical and the associated morbidities are too grave. However, the effectiveness of the procedure is in accord with the contribution of a peripheral mechanism to MHs.
Murillo, in 1968, further emphasized the role of the neurovascular bundle in MH. 5 This surgery included resection of the superficial temporal artery and auriculotemporal nerve on 47 sites in 34 patients. The procedure was effective in elimination of MHs in 30 of 34 (88%) patients. This report, however, did not include the length of follow-up, nor was there a control group for this clinical trial. Wolf and his associates 6 demonstrated the role of vasomotor mechanisms in migraine-type pain in the 1940s, which supports the rationale for the surgical procedures that Murillo had suggested and those that we have devised. Additionally, Knight in 1968 suggested postauricular and auriculotemporal nerve resection for surgical treatment of MH. 7
An occipital neurectomy was suggested for patients with occipital MHs and neuritis by Murphy in 1969. 8 This operation was performed in 30 patients. Eighteen patients had excellent results, 7 had good results, 3 had fair results, and 2 patients had poor results. Many of these patients, however, had less than a year of follow-up. Murphy’s report did not indicate the incidence of anesthesia or paresthesia in the occipital region, nor did it outline any other adverse effects resulting from the surgery. Although neurectomy at this site is the last resort in our practice, it has been used in some practices as the first line of treatment by some. Nevertheless, the positive outcome of the surgery once more confirms the contribution from a peripheral mechanism in the pathogenesis of MH.
In 1992, Maxwell reported trigeminal ganglio-rhizolysis for treatment of MHs in eight male patients through percutaneous radiofrequency. 9 The patients had moderate to significant relief of MH with no reported complications. This study lacked a control group, adequate follow-up, and large enough patient sample size, similar to closure of patent foramen ovale. 10 Even techniques such as cryosurgery and injection of alcohol have been attempted for treatment of MHs. The unscientific manner in which these studies were conducted precluded any meaningful conclusions.
Statements by two patients that their MH disappeared after forehead rejuvenation at the end of 1999 prompted us to begin a study to validate this observation and the report was published in 2000. 11 After securing sufficient evidence to support what the patients reported, we designed a prospective pilot study that confirmed the role of MH surgery in 21 of 21 patients and this report was published in 2002. 12 A comprehensive study involving the four trigger sites that documented the efficacy and safety of the author’s designed procedures was reported in 2005. 13 The randomized study that included a sham surgery was published in 2009. 14 In 2011, we reported the 5-year outcomes of the comprehensive study published in 2005. 15 Our study comparing the nerves of patients who did not have MH to those who suffered from MH demonstrated that the nerves in patients with MH are deficient in myelin was reported in 2014. 16
We have demonstrated the effectiveness of peripheral trigger site deactivation on the pediatric population as well in an article that was published in 2015. 17