Lasting outcome of the surgical treatment
of migraine headaches – a four year follow-up
Thomas Muehlberger, MD, Wolfgang Brittner, MD, Alexandra Buschmann, MD
and Nidal Toman, MD
INTRODUCTION: Migraine is an abnormal response to normal sensory input. Altered
processing of afferent signals in the brainstem accounts for many of the temporal
features of migraine. Peripheral and central sensitization of the meningeal
perivascular-trigeminal nociceptors and the trigeminal nucleus caudalis,
respectively, induce the neuronal hyper-excitability and concomitant neurogenic
inflammation. The ophthalmic division of the trigeminal nerve represents the
principal sensory pathway to the trigeminal nucleus (1). The surgical
decompression of pertinent extracranial sensory nerves through transpalpebral
resection of the corrugator muscles is thought to inhibit the instigating step of
a domino-effect leading to migraine headaches (2-4).
METHOD: Botulinum toxin injections into the corrugators (25 IU each) were
performed in 167 patients 8 weeks preceeding the operation as a prognostic
indicator. 96 patients with a pre-established baseline of migraine attack
frequency and intensity had the corrugator muscles resected preserving the
supratrochlear and supraorbital nerves. The postoperative follow-up period was 4
years. Alterations in attack frequency, pain intensity and dosage of medication
were considered relevant parameters. The Migraine Specific Questionnaire (MSQ)
and SF-36 were used preoperatively and twice postoperatively after one and four
years.
RESULTS: 106 of 167 patients who had botulinum toxin injected, responded with a
symptomatic improvement of more than 50%. Corrugator resection was performed in
98 of these 106 patients, additional decompression of the major occipital nerve
was performed as a second procedure in 12 patients. The 4 year follow-up period
was recorded in 96 patients. Complete, continuing remission was reported by 21 %
(n=20). 71% (n=68) reported a significant improvement of migraine intensity and
frequency. This group included patients (n=49) whose migraine had been replaced
by less severe non-migrainous headache without neurological or
gastroenterological symptoms. 8 patients (8%) experienced unsatisfactory results.
The questionnaire findings improved significantly following the operation
(p<0.018 MSQ, p<0.023 SF-36) and showed no significant alterations between one
and four years. Regression linkage analysis found the presence of allodynia
(p<0.038) to be a significant prognostic indicator of the success rate. The longterm symptomatic improvement after surgical decompression was identical with the
grade of symptomatic alterations previously induced by chemodenervation.
CONCLUSION: 92 % of patients in this study had lasting postoperative results with
marked symptomatic improvement. Allodynia, the clinical correlate of central
brainstem sensitization, was a significant prognostic parameter, indicating the
pivotal role of the trigeminal system in migraine (5). Four years following the
operation, most patients reported not the cessation of pain, but rather the
disappearance of the previously frightening awareness of a pending migraine
attack as their most important benefit. The surgical treatment of migraine
headaches yielded positive results in 88 out of the initial group of 167 patients
(53%) who received botulinum toxin, which highlights the crucial importance of
the selection process to identify the eligible patients for this therapeutic
option.
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