[1][2][3][4] Following the development of nerve decompression techniques for the relief of migraine pain in the year 2000, these procedures have been extensively studied and shown to be effective in appropriate candidates.
[17][18] Structures that are found pressing on the nerves here are released and may include bone at the upper orbit, fascia, blood vessels, or muscle tissue.
[8][11]Neurostimulation surgery, in which electrical stimulators are implemented over the occipital and/or superorbital nerves, has also been used to treat migraines, although there is scarce evidence for the effectiveness of this procedure.
Followup data has shown that 88% of migraine surgery patients experienced a positive response to the procedure after 5 years.
[27] Chronic daily headache is a major worldwide health problem that affects 3–5% of the population and results in substantial disability.
Use of the three-dimensional CT scan and the Doppler Flowmeter allows the surgeon to make use of the smallest possible incision, so the procedure is minimally invasive.
These vessels are subcutaneous (just under the skin) and the small incisions required to access them and the minimally invasive nature of the procedure means that the surgery can be done in a day facility.
As these vessels have no connection with the arterial supply to the brain, the Shevel Procedure is exceedingly safe with no unpleasant side effects.
Migraine headaches can start in one area depending on their corresponding trigger site and spread to the rest of the head.
It is important to identify the initial trigger sites rather than address all the areas of pain, after the inflammation involves the entire trigeminal tree.
Occipital migraine headaches: The posterior neck area where the greater occipital nerve passes through the semispinalis capitis muscle is addressed with an open surgical approach with resection of a small segment of the semispinalis muscle and shielding the nerves with a subcutaneous adipose flap.
[35] A further trigger point, not involving muscles, has been identified in the nose of patients who have significant nasal septum deviation with enlargement of the turbinates.
There is evidence that a link exists between migraine with aura and the presence of a patent foramen ovale (PFO), a hole between the upper chambers (the atria) of the heart.
[48] Because PFO closure continues to prove successful, new devices are being produced to make the surgery easier to perform and less invasive.
[46][51][52] Published reports from open-label studies have demonstrated possible efficacy of ONS in a variety of primary headache disorders, including chronic migraine.
[28][53] ONS for the treatment of medically intractable headaches was introduced by Weiner and Reed [54] ONS is typically performed with the equipment normally used for spinal cord stimulation (SCS), which includes electrodes and their leads, anchors to fasten the leads to connective tissue, and the implantable pulse generator (IPG).
Electrodes are placed subcutaneously (under the skin) superficial to the cervical muscle fascia, transverse to the affected occipital nerve trunk at the level of C1, usually using fluoroscopic guidance.
However, a recent report of a small case series described successful placement of ONS systems entirely under general anesthesia while still achieving the desired occipital region stimulation.
However, in primary headache syndromes, unlike in neuropathic pain, there can be a considerable delay of several weeks to months before the response emerges and therefore the utility of a stimulation trial in selecting patients for permanent implantation remains questionable for now.
Intra-oral appliance are designed to relax the pericranial muscles, which have been reported to be tender in 100% of migraine sufferers during an attack.
[60][61][62][63] Biofeedback is the process of gaining greater awareness of many physiological functions primarily using instruments that provide information on the activity of those same systems, with a goal of being able to manipulate them at will.
[64][65] Some of the processes that can be controlled include brainwaves, muscle tone, skin conductance, heart rate and pain perception.
[67][68] OnabotulinumtoxinA (trade name Botox) received FDA approval for treatment of chronic migraines (occurring more than 15 days per month) in 2010.
[69][70] Since then, several randomized control trials have shown Botulinum Toxin Type A to improve headache symptoms and quality of life when used prophylactically for patients with chronic migraine[71] Surgical cauterization of the superficial blood vessels of the scalp (the terminal branches of the external carotid artery) is only carried out if it has been established with certainty that these vessels are indeed the source of pain.
[72] Migraine surgery which involves decompression of certain nerves around the head and neck may be an option in certain people who do not improve with medications.
[78] Recent studies have advised caution, though, in relation to PFO closure for migraine, as insufficient evidence exists to justify this dangerous procedure.