More than 30,000,000 Americans (18% of females and 6% of males) suffer from migraine headaches that often seriously interfere with their lives, and current medication therapies only help about one-third of sufferers. Now, a recent 5- year study shows that innovative craniofacial surgery can offer a significantly better treatment approach.

In the study, “Five-Year Outcome of Surgical Treatment of Migraine Headaches” published in Plastic and Reconstructive Surgery, February 2011, 88% of 69 patients in the test group experienced a positive response to the surgery after 5 years. A total of 29% experienced a complete elimination of migraines, and 59% had a significant decrease in symptoms, defined as at least a 50% reduction in intensity, frequency and duration of migraine headache. Only 8% experienced no significant change.

The idea of using surgery to treat migraines started 11 years ago, when a forehead-lift patient reported to her plastic surgeon, Bahman Guyuron, MD, that her migraine headaches had completely disappeared. Since then, Dr. Guyuron has been the lead author of many studies showing promising results for migraine patients using “trigger site” surgery. Bahman Guyuron is Kiehn-DesPrez Professor and Chair, Department of Plastic Surgery at Case Western Reserve University and University Hospitals Case Medical Center.

According to the World Health Organization, migraine alone ranks 19^th among all causes of years lived with disability. A migraine is a serious headache disorder with a strong genetic predisposition. It can last for a few hours or up to 2-3 days at a time and can occur once or twice a year for some people or several times a month for others. Women are three times more likely to get a migraine than men. It can be preceded by an aura, or visual disturbances such as bright lights or blank patches. Migraine pain is often severe and debilitating, can be made worse by movement, may involve light and sound sensitivity, and sometimes leads to vomiting.

The causes of migraine are still not completely understood. In general, something activates a mechanism deep in the brain to cause an inflammatory response around the nerves and blood vessels of the head. Dr. Bahman Guyuron explains, “The current hypothesis is that the nerves of migraine patients are more vulnerable. There is a genetically-predisposed condition among those who get migraines: they have nerves that are more vulnerable to irritation than non-sufferers, so they are more prone to getting migraines.” His team is currently conducting an extensive study to examine more closely what is causing the vulnerability.

Migraine surgery involves removing some of the muscles around major nerves in one or more of four identified trigger sites – frontal, temporal, intranasal and occipital. A neurologist confirms a diagnosis of migraine in all patients before they are considered candidates for surgery. In the 5-year study, botulinum toxin (Botox) injections were used to identify one or more trigger sites specific for each patient. In practice now, however, Dr. Guyuron relies on an assessment of the patient’s constellation of symptoms and CT scan to determine the trigger sites with the same accuracy as the Botox detection method.

The surgery takes about 2.5 hours on average and is done on an outpatient basis. Patients can usually return to normal activities in about 3 weeks. In the study, the frequency of attacks decreased from about 11 to 4 per month, the average duration decreased from 34 to 8 hours and patients reported a significant decrease in the intensity of migraine pain. No serious complications were reported and side effects for some included occasional neck stiffness and skin numbness.

Dr. Guyuron says that the most common feedback he hears from patients after successful surgery is “you have given me control of my life.” He reports that they are more than willing to trade the risks of a little stiffness or numbness for the debilitating pain of migraine headaches. He says, “Migraine surgery doesn’t work for everybody, not every time, but we are working on improving the results all the time.”

CONNECT THE DOTS

Visit the American Headache Society for information and tools for patients and healthcare professionals, such as the MIDAS questionnaire, (Migraine Disability Assessment Test) which can help measure the impact headaches have had on your life over the last 3 months. Learn more about the Global Campaign to Reduce the Burden of Headache World-wide, a joint effort by WHO, World Headache Alliance, and International Headache Society.

Femoroacetabular impingement, or FAI, develops when there is a mechanical mismatch between the ball and socket sections of the hip joint. The femoral head develops into an egg shape rather than a ball, so it rubs against the socket in an irregular way, causing pain and damage to the cartilage and socket rim. People with FAI can experience limited flexion of the joint, pain when sitting, groin pain or interior hip pain.

Bryan Kelly, MD, Co-Director of the Center for Hip Pain and Preservation at the Hospital for Special Surgery in New York City says, “Some people are born with a genetic predisposition to develop FAI or it can develop over time, particularly among young athletes doing sports that require a lot of rotation through the hip joint. During the early teen years when bones are growing, extra load on the growth plates in the hip can cause remodeling to occur, producing an aspherical shape that no longer rotates smoothly in the socket.”

Kelly and another surgeon at the Hospital for Special Surgery compared surgical results for 60 male patients, all under the age of 40, and found that arthroscopy performs as well as open surgery to restore the mechanical range of motion for most cases of FAI. Their study is the first to compare mechanical outcomes and was recently published in The American Journal of Sports Medicine. Previous studies found that arthroscopy performs as well as open surgery for improving FAI symptoms, and can return athletes to their chosen sports in about half the recovery time.

Here’s how they did it: Kelly treated thirty FAI patients with arthroscopy, a minimally invasive technique where the surgeon inserts a camera tube into a small incision, and performs joint repair through other small incisions while referring to a video screen. His colleague, Ira Zaltz, MD, treated thirty other FAI patients using the open surgery technique, which requires a larger incision and more invasive procedures. Both surgeons sculpted or recontoured ball and socket sections to make them fit together smoothly, and repaired any existing cartilage damage. Radiographic images were taken before and after surgery; Kelly and Zaltz then evaluated and compared mechanical performance and range of motion by measuring the roundness of the femoral head and the degree of separation between the femoral head and the edge of the socket.

The CDC says that 1 in 4 people may develop painful hip arthritis over their lifetime. Kelly reports that in the U.S. there are 350-400,000 hip replacement surgeries done every year and about half of those patients require surgery to treat osteoarthritis that developed as a result of FAI. The ideal candidate for FAI arthroscopy is a young athlete, 15-25 years of age, without any significant cartilage damage in the hip joint, although Kelly says he will operate on someone up to the age of 50 if they have little other damage and are in good health. The earlier FAI is corrected, the better to prevent long-term damage to the hip joint.

CONNECT THE DOTS:

Learn more about the Hospital for Special Surgery in New York City, where more knee replacements and hip surgeries are performed than any other hospital in the U.S. Read a story about a young adult soccer player who had hip arthroscopy to address FAI. Learn more about hip osteoarthritis on the CDC site. You may also like our earlier posts, Hip Resurfacing: Better Than Hip Replacement? (which discusses the benefits of a hip resurfacing implant as an alternative to total hip replacement) and Advances in Knee Replacement Surgery for Active Baby Boomers.