Cutting the pain out

THE STUDY

The double-blind study,published in the journal Plastic and Reconstructive Surgery,found that over 80 per cent of patients who underwent surgery in one of three trigger sites significantly reduced their number of headaches compared with over 55 per cent of the group who had sham surgery. Over half the patients with the real surgery reported a complete elimination of headaches compared with about 4 per cent of the placebo group.

Forehead lifts are cosmetic procedures that plastic surgeons typically perform to smooth furrowed brows. But a decade ago,after some of his patients reported that their migraines improved post-operation,Dr Bahman Guyuron,a plastic surgeon and the lead author of the study,began to search for a surgical solution that could address migraine trigger points which he defines as where the headache begins and settles in the forehead,temples and the back of the head.

Headache specialists tend to be neurologists or internists,so Guyurons work has not always been taken seriously.

If I had a neurologist tell me theres a new way of doing a facelift,I would have been very skeptical about it also, said Guyuron,the chairman of the plastic surgery department at University Hospitals Case Medical Center in Cleveland. But honestly,I would have had an open mind.

Last month,the press has also made much of the fact that a single operation could relieve migraines and turn back the clock in one fell swoop. But it is the potential that surgery for migraines may offer a viable alternative to drugs that has migraine specialists intrigued.

A very large subset became headache-free and remained headache-free for a year that is a fantastic result, said Dr Richard B Lipton,the director of the Montefiore Headache Center in the Bronx.

Especially considering that in the field of migraines,success is defined as a reduction of 50 per cent of attacks, Cady said. Going from 10 episodes monthly to 5 is a welcome change,he added,but its still a lot of migraines.

THE operation

A classic forehead lift for cosmetic effect differs significantly from surgery for migraine sufferers. The latter removes frown muscles more thoroughly and entails padding nerves with fatty tissue,said Dr David A Branch,a plastic surgeon in Bangor,who performs migraine operations.

Sometimes,migraine surgery doesnt involve the forehead at all. It varies according to where the patients trigger sites are: forehead,temples or back of the head. If Guyuron operates on the temples,the eyebrows are rejuvenated,he said. It is only the surgery at the back of the head that has no added perk,he said.

The theory behind the surgery is that because some migraines are caused when sensitive nerve branches are squeezed and irritated by muscles,deactivating those muscles could bring prolonged relief. In the off-label use of Botox for migraines,those same muscles when paralysed with Botox injections have eased headaches in some patients for roughly three months.

Forehead lifts,Guyuron reasoned,might result in a longer-lasting,perhaps permanent,alleviation of pain. Only study participants who responded positively to Botox were offered the surgery.

Cady cautioned that the research on Botox as a treatment for chronic headaches is not yet ironclad. Allergan,Botoxs maker,is pursuing the approval of Botox as a treatment for chronic migraines by the Food and Drug Administration.

Many headache specialists,Lipton and Cady included,emphasise that this migraine surgery isnt applicable to most sufferers. Folks who are appropriate for this procedure they are the tip of the iceberg,not the vast majority, said Dr Jennifer S Kriegler,a neurologist and one of the studys authors who works at the Cleveland Clinics headache center.

At this stage,suitable candidates are those who endure frequent migraines and have failed more tried-and-true methods of controlling their headaches,several doctors said.

The bottom line,Lipton explained,is if you cant identify a point of irritation and if you dont respond to Botox,we dont know if this treatment works for you.

Some doctors fear that the surgery may be offered to inappropriate patients before further research confirms its efficacy for a broader group of patients. I dont want us to overshoot and start doing widespread surgeries in not very well selected patients until we are convinced that this is broadly effective, said Dr F Michael Cutrer,the chief of the headache division in the neurology department at the Mayo Clinic in Rochester,Minnesota. You can always stop a medication but you cant reverse a surgery.

As word of the surgery spreads,Cutrer said he anticipated pleas for referrals to the few plastic surgeons nationwide who offer the operations,but that until we maybe have studies that are a bit larger,and some longer follow-ups,Im going to be very cautious. So far,Guyuron has trained roughly 150 doctors,and other plastic surgeons are refining their own migraine operations,even though they barely advertise.

Its unclear whether or not the migraine sufferers whose pain had disappeared a year post-operation will remain headache-free for life.

My goal is zero headaches, said Dr Jeffrey E. Janis,a plastic surgeon in Dallas,who has performed roughly 100 operations in the last five years after training with Guyuron. I might be able to achieve that in some,not in all.

Complete elimination is a pretty strong claim after one year of follow-up, Cutrer said.

As a way of dampening expectations,Kriegler,who has referred patients to Guyuron,frequently tells them: Once a migraineur,always a migraineur.