Migraine Surgery: What It Is and Why Many Neurologists Don’t Recommend It

What is migraine surgery?

For some people, a migraine episode starts with nerve or blood vessel irritation or compression. These compression points are also called trigger points. You may have one or more of these, and that can affect your migraine attacks.

One type of migraine surgery aims to relieve this pressure by removing small sections of bone or tissue pressing on your nerves, or cutting the nerves.

Other surgeries reduce the size of structures in your sinus area, which could make your migraine worse. These procedures may be beneficial for people who have defined trigger points.

Laine Green, MD, FRCP(C), FAHS, a neurologist specializing in treating headache disorders at the Mayo Clinic in Scottsdale, Arizona, explains that the evidence supporting surgical migraine treatment is still far too limited for many physicians to recommend it.

“This is a tough subject because these surgical treatments aren’t well studied,” Green says. “On one hand, there are studies that suggest there may be subsets of people who may benefit from them. But with surgical studies it is hard to be thorough with trial design, so the results aren’t as robust as we’d like them to be. As headache specialists, we want to follow the best evidence.”

Not enough reliable research or information is available to inform possible harm from migraine surgery, and virtually none exists about the long-term effects of these surgeries.

What are the types of migraine surgery?

While neurologists and headache specialists do not typically recommend migraine surgery, some surgeons still perform these procedures.

Migraine surgery may work for some people, but the key feature of a successful outcome is a diagnosis of a condition that requires surgical intervention, such as a structural issue causing migraine.

Peripheral neurolysis

Peripheral neurolysis describes several types of surgical procedures that target nerves involved in migraine attacks.

One type is known as nerve decompression or nerve liberation. A surgeon removes a small area of tissue or bone surrounding a nerve in your face, head, or neck to relieve pressure on the nerve.

After decompression or liberation of the nerve, the surgeon plumps the area with fat to keep other structures from pressing on it. In another type of nerve surgery, a surgeon cuts the nerve completely, burying the ends in nearby muscles.

A 2020 research review of 39 articles concluded that this surgery was a valid treatment for migraine. The study notes that some patients had less severe and less frequent migraine attacks after surgery.

Many neurologists and headache specialists feel it’s too soon to say migraine surgery is a safe treatment option.

It’s difficult to complete high quality, randomized, controlled surgical studies to prove these methods are safe and effective.

“The gold standard for a clinical trial is that everything besides the intervention you’re studying is kept the same,” Green says. “That means some people would have to undergo sham surgeries so you can compare the effects. The results, even within the existing studies, are mixed. Even where the study population has fewer or less severe headaches, it’s hard to know whether something else, such as anesthesia, caused the improvement in symptoms.”

Neuromodulation

Neuromodulation uses electromagnetic pulses to stimulate nerves that may trigger migraine headaches.

The Food and Drug Administration (FDA) has approved the use of several external neuromodulating devices for the treatment of migraine. These devices send electromagnetic pulses through your skin.

It’s also possible to have a neuromodulator surgically implanted beneath your skin, but there’s some debate over whether the implanted devices are as safe and effective as the external devices.

Though some implanted devices are being studied in clinical trials, more evidence supports external devices.

“These noninvasive electrical stimulation devices are FDA-approved for treating migraine,” Green says. “The transcutaneous devices don’t have the risks of surgery. We can use them at any point in the process as part of a multipronged approach [for treating migraine]. There are no medication side effects and no medication interactions, which is nice.”

Electrical stimulation devices can be used along with medications to treat migraine. But Green cautions that they’re not for everyone, and some patients don’t like the sensation that the device creates.

Septoplasty

Septoplasty is surgery to correct a deviated septum, which may lead to intense headaches for some people who have symptoms associated with a deviated septum.

Septoplasty repairs and reshapes your septum to open your airways and relieve pressure or pain. Doctors who specialize in ear, nose, and throat conditions often perform these surgeries.

Even when septoplasty successfully opens your airway, it doesn’t always relieve migraine. In one 10-year follow-up study, researchers said it was likely the headaches “may not be reduced even with surgical treatment.”

Turbinectomy

Turbinectomy removes some of the bone and soft tissue inside your nose. These structures, called turbinates, warm and moisten the air you breathe. When they grow too large, they may make it harder to breathe and cause headaches.

Some evidence suggests turbinectomy may help with severe headaches.

Participants in a large Taiwanese study experienced a 14% drop in the number of hospital admissions due to severe migraine after surgery. The participants had a history of sinus problems.

Green explains: “There is often some overlap between the ear, nose, throat, and migraine. Sometimes people have surgeries like septoplasties and turbinectomies to relieve what are believed to be sinus conditions, and then they discover that migraine has been in the background the whole time. That’s not uncommon.”

In a 2021 research review, researchers found that migraine and tension headaches may cause most of the pain associated with sinus headaches.

Turbinectomies may help reduce the severity or frequency of migraine headaches, but researchers say more high quality studies are needed to confirm the outcomes. For many people, headaches return after surgery.

What are the risks of migraine surgery?

There’s a risk of bleeding, scarring, or infection after any surgery. But the risks of migraine surgeries are not fully known.

With peripheral neurolysis, a neuroma or noncancerous tumor may form at the surgical site. Burying the nerve ending in muscle tends to reduce this risk.

With implanted neuromodulation, Green says that while the risks of surgery are generally low, “with implanted neuromodulators, electrodes can move away from the target areas, and wires can break. That means some patients may have to have multiple procedures.”

Septoplasty and turbinectomy may affect your sense of smell. These surgeries can change the shape of your nose and damage your septum. You may have sinus symptoms, including pain and nasal dryness, due to the surgery.

Takeaway

Migraine surgery may be a treatment option for migraine, but it isn’t well-studied. Many neurologists and headache specialists typically do not recommend it.

Green concludes, “The lack of high quality studies makes it hard to determine 1) Do these surgeries work or not? 2) Which population should they be offered to? and 3) When should they be offered? We want patients to have less frequent, less severe headaches with less duration, so people can have an increased quality of life. We want what works for them.”

If you want to learn more about FDA-approved treatment options that could reduce the duration, frequency, or intensity of your migraine headaches, talk with a headache specialist.