If you’ve never had a migraine, count yourself lucky. I’ll never forget mine. The pain was so intense I had to call my ex to drive me to the emergency room, and I threw up in a wastebasket most of the way there. Since then, I’ve had real empathy for people who live with chronic headaches and migraines, their lives disrupted for sometimes days on end. So when I heard that a small but growing number of plastic surgeons are successfully performing migraine surgery and treating patients with chronic headaches, I wanted to find out more.

Here’s my conversation with one of the doctors helping lead this migraine surgery vanguard, San Francisco plastic surgeon Ziv Peled, MD. – Mari Malcolm

What is migraine surgery, and how many surgeons do it?

The idea that peripheral nerves in the head and neck could cause chronic headaches first arose almost 20 years ago, and the discovery was almost accidental. Dr. Bahman Guyuron, a famous aesthetic plastic surgeon, was doing endoscopic brow lifts. In that operation, you cut one small sensory nerve in the temples and remove a little bit of muscle in the glabella (the area between your eyebrows), just to help elevate everything.

A number of Dr. Guyuron’s patients were coming back to him saying, “I love how I look, but what’s really interesting is that I used to have horrible headaches, and they’re significantly better,” or even “they’re gone.”

To his credit, he went back to Case Western Reserve University as a professor of plastic surgery and investigated this issue. What he found is that the peripheral nerves in your head and neck can be pinched or irritated by spastic muscles, large blood vessels wrapping around a nerve like an anaconda, or tight connective tissue from a scar, such as you can get with a whiplash-type injury.

These factors can put pressure on a nerve or prevent it from gliding properly with head and neck movements, much like what happens in patients with carpal tunnel syndrome at the wrist. And when you alleviate that pressure, you can ease or even eliminate the pain.

There are about nine of us in the U.S. doing these procedures as a regular part of our practice now. A few of us, including Dr. Guyuron and I, are now teaching other plastic surgeons how to do them. To date, there are approximately 90 peer-reviewed publications documenting that this type of surgery is medically effective and very safe.

Some board-certified neurologists who specialize in headaches are also coming around to the concept that, in a significant subset of the chronic headache and migraine population, the problem is not a abnormal chemicals in the brain, but compressed nerves outside the skull.

Why aren’t more people doing migraine surgery?

A few reasons. First off, you really have to dedicate yourself to this craft. You can’t take a weekend course and just start doing these operations safely and with good results. I and other surgeons who frequently do peripheral nerve surgery believe that we need to teach other surgeons about this type of work in a very formal way. It’s a nascent field, so the bar for problems is set very high, and you want to have an extremely high success rate.

Not many people are willing to devote themselves to this, when they could be focusing on more lucrative operations, like cosmetic procedures.

Second, your patients are really in distress. They’ve been in pain for a very long time so they need a lot of support. You have to be willing to commit to that. Pay attention to these people, really talk to them.

Third, many people and even doctors simply don’t know these operations are possible.  

How can patients choose the right headache surgeon?

When you’re choosing a headache surgeon, you really have to ask a few key questions. What’s your training background? Do you have formal training in peripheral nerve surgery? How many of these types of cases have you done? Can I talk to some of your former patients, someone that’s a year or three years out?

You’ll also want to ask if they’re a member of the American Society for Peripheral Nerve (ASPN). You can’t become a member without the recommendation of two other members and without having published at least one peer-reviewed article on peripheral nerve surgery.

Their answers to all these questions will give you a sense of whether this type of work is really an integral part of your potential surgeon’s practice.

How safe and effective is migraine surgery?

With an experienced surgeon, the operations are extremely safe. Personally, I haven’t seen anyone back in my office who says they’re worse than they were when they came in, even after several hundred cases. I’ve had a few minor skin infections from ingrown hairs that were successfully treated with a short course of oral antibiotics.

Approximately 88-90% of my patients are success stories, which we define as at least a 50% reduction in the frequency, severity, and/or duration of their headaches. Many patients are much better than that, and about a third a migraine-free, permanently. Out of the 10-12% of patients that are “not successes,” many of these people are 30-40% better, which is life-changing for them. They’re still extremely grateful.

All of this being said, these are real operations. The anatomy can be challenging, and surgery on tiny nerves requires patience and skill. Any operation carries risk, and  operations on nerves can injure the nerves themselves. Your surgeon has to be able to fix any problems that might arise during the operation.

What makes people a good migraine surgery candidate?

Surgery is never the first option. Typically, we see people who’ve had symptoms for years, sometimes decades. They’ve already tried and failed a lot of standard therapies.

The first criteria is that a patient must have a good history for a pinched or irritated peripheral nerve in the head or neck causing their problem. This means that standard pharmacologic treatment with a number of different drugs from a number of different classes of drugs hasn’t worked. They’ve typically tried and failed other conventional modalities like physical therapy, massage, acupuncture, Botox or cervical epidural injections. They have negative MRI results of the brain and cervical spine, so we know they don’t have a brain tumor, an aneurysm, herniated disk pinching a nerve root or fractured spinal bones.

The second criteria is that a patient must have a good physical exam that suggests a pinched or irritated peripheral nerve in the head/neck is causing their problem. This exam can be quite nuanced, but when done properly, if you tap or press on a spot where you know a nerve could get pinched and the patient’s pain gets significantly worse, or if they get little shooting pains from where you’re tapping, that’s a sign (not 100%, of course, but a good sign) that there’s a nerve in trouble at that location.

Finally, the next step is to do a nerve block, an injection with local anesthetic—just like what you get when you go to the dentist and they give you the shot before they fill the cavity. I ask my patients to come into the office in literally as much pain as they can muster and still physically walk in to my office. If their headache is a nine, and I numb one, two, or three nerves and it goes to zero, that’s very compelling evidence that we’re on the right track and we have isolated the nerve that’s likely causing the pain.

If your pain level doesn’t change at all, that’s disappointing, but it’s also a very important piece of information: you now know peripheral nerves likely have little to do with your headaches and you’ve saved yourself an operation. However, most patients coming to the office have a good history, good physical exam and good results with nerve blocks. These people almost overwhelmingly have great results with surgery.  

Out of all the operations I perform, the successful headache/migraine patients are the happiest and most grateful. For the majority of them, it’s a new lease on life.