Jeffrey E. Janis, MD, is on a mission. The professor of plastic surgery, surgery, neurosurgery and neurology at Ohio State University Wexner Medical Center in Columbus, Ohio, wants to convince neurologists of the safety and effectiveness of nerve decompression surgery for treatment-resistant headaches. But many neurologists are still unconvinced.

“Headache surgery is a viable alternative for patients with complex complaints who have failed medical treatment and who could benefit from this treatment approach. There is 24 years of evidence for this surgical technique in hundreds of different studies with different study designs,” said Janis. Medical news from Medscape.

But this treatment approach—operating on peripheral nerves rather than the brain or spinal cord—has found little support among neurologists. A look at the list of topics at the recent 2024 Annual Meeting of the American Headache Society showed that there were hardly any studies or presentations on the topic. And neurologists Medical news from Medscape The people we spoke to believe that the operation is experimental and unproven.

Experts agree that medications do not work for all migraine sufferers. Up to 30 percent of patients do not respond to the “long list of drugs” available to treat the condition, Janis said.

Many patients have also tried alternative treatment approaches such as massage, acupuncture, craniosacral therapy, transdermal patches, electrical stimulation, cryoablation, neurostimulation and radiofrequency ablation and have failed.

If nothing else helps, is surgery for headaches the solution?

Long-held theory

The idea that pinched, irritated, or compressed peripheral nerves can trigger migraine attacks has been around for nearly 25 years. Studies suggest that nerve compression can lead to other headache disorders in addition to migraines, including occipital neuralgia, supraorbital neuralgia, and post-traumatic headaches.

This has led to the development of surgical techniques to deactivate various pressure trigger sites – which Janis calls “pinch points” – which can be muscles, bones, fascia, blood vessels or scar tissue from previous trauma or surgery.

The procedure is mainly performed by plastic surgeons, but to a lesser extent also by neurosurgeons and ENT doctors.

Target nerves for surgery include those in the front of the head above the eye, the temple area, the neck area and the nose area. Affected areas are usually identified either through patient self-reporting or by applying a nerve blocker such as lidocaine or Botox to specific locations, Janis noted. When pain subsides after an injection, that location is marked as a target.

One of the obstacles to referring patients with complex medical conditions for surgery is that neurologists who evaluate migraine treatments “speak a different language” than the surgeons who perform the procedure, Janis says.

Neurologists tend to focus on reducing monthly migraine days (MMD), while surgeons typically use the Migraine Headache Index, which takes into account the frequency, intensity and duration of migraine attacks.

“Instead of trying to convince someone to speak another language, we thought: Why don’t we just learn their language so we can build bridges and break down barriers,” said Janis, co-author of a systematic review and meta-analysis recently published online in Plastic and reconstructive surgery.

In their review, the researchers examined 19 studies, including five randomized controlled trials (RCTs), published between January 2020 and September 2023. A total of 1,603 participants participated, mostly female and between 9 and 72 years old. The follow-up period of the studies ranged from 6 to 38 months. All but three studies were conducted in the United States, and six different compression sites were treated during surgery.

In several studies and using a range of measurements, researchers found that the frequency and severity of migraines improved after surgery.

MMD decreased by 36–92% and the total number of migraine attacks per month decreased by 25–87.5%. Patients also reported a reduction in attack duration by 41–75% and intensity by 28–82% in all studies.

“Even if you use the standard neurologist language, which is monthly migraine days, this surgery works,” Janis said. “This is documented in both the surgical and nonsurgical literature.”

The most common complications were ecchymosis, hair loss or thinning, pruritus, dryness, and rhinorrhea, all of which Janis described as “fairly minor.” Serious complications such as intraoperative bleeding and wound dehiscence were rare, occurring in 1% or less of participants.

“Once and done?”

These surgeries are usually performed on an outpatient basis and typically provide long-term results, Janis said.

“The idea is that it only happens once and then it’s over,” he said. “The literature on this type of surgery says that the effect you get after a year is probably permanent.”

The American Society of Plastic Surgeons agrees. A 2018 position paper developed by experts and commissioned by the society reports that the procedure is safe and effective for appropriate patients, based on a comprehensive literature search and review of a large amount of peer-reviewed scientific evidence.

“There is extensive, widely reproduced clinical data demonstrating significant reduction in migraine (MH) symptoms and frequency (even complete elimination of headaches) following trigger site surgery,” the authors noted.

Pamela Blake, a neurologist, board-certified headache specialist and medical director of the Headache Center of River Oaks in Houston, is an advocate of what she calls “life-saving” headache surgery.

“If a doctor told you that you can either treat this problem with medications that you have to take for the rest of your life, or that you can have an outpatient surgical procedure that is extremely low-risk and, in my experience, has a 75 percent chance of reducing or eliminating your pain, you would probably be interested in having surgery,” she said. Medical news from Medscape.

Persistent skepticism

However, other neurologists and clinicians seem skeptical about this procedure, including Dr. Hans-Christoph Diener, professor of neurology and director of the Essen Headache Center at the University of Duisburg-Essen in Germany.

During a debate on this topic ten years ago at the International Headache Congress, Diener argued that, given that migraine is a complex, multigene brain disease, it is illogical to assume that surgery could affect the epigenetics of 22 different genes.

He recently said Medical news from Medscape that his views have not changed.

The topic remains controversial, and some neurologists even feel uncomfortable discussing the procedure openly. Two clinicians who previously commented for this article later asked not to be mentioned.

A neurologist who wished to remain anonymous said Medical news from Medscape that Janis’ review article “is merely a review that summarizes 19 studies from the last 10+ years.”

The neurologist cites further limitations as the lack of consistency in the approaches used across studies and the inclusion of only four randomized controlled trials (RCTs). The most recent of these was published eight years ago. This suggests that “the study was probably conducted nine or ten years ago,” says the neurologist.

Blake suspects that the reluctance of some neurologists may be due to a lack of knowledge about the procedure, which is not discussed in detail at headache conferences and is covered primarily in plastic surgery journals rather than the neurological literature. Access to surgery is also limited by a shortage of specialists to perform the procedure and inconsistent insurance coverage.

Closer collaboration between neurologists and surgeons performing the procedure could benefit patients, Blake noted.

“The role of the headache physician is to determine who is a candidate for surgery and who meets the criteria for nerve compression. Then we provide postoperative care to the patient and monitor their medications, although we usually wean them off their medications,” she added.

From Janis’ perspective, things are starting to change.

“I certainly see neurologists feeling more comfortable understanding where this fits in the treatment algorithm, especially in complicated patients,” he said.

Janis receives royalties from Thieme and Springer Publishing. Blake reported no relevant conflicts of interest. Diener received research funding from the German Research Foundation and is a member of the editorial board of Headache, Lancet NeurologyAnd Medicinesand has received honoraria for participation in clinical trials, serving on advisory boards, or giving oral presentations from AbbVie, Lilly, Lundbeck, Novartis, Pfizer, Teva, Weber & Weber, and WebMD.