Surgical, Nonsurgical Treatments for Chronic Migraine: Evidence and Relevancy
The newest pharmaceutical developments in the field, namely, anti-CGRP medications, invite the question of whether surgical alternatives are still relevant. Credit:SPL/Science Source
An estimated 2% to 4% of the global population experiences chronic migraine (CM) that is refractory to standard treatment.1,2 Surgically invasive and noninvasive treatments have been explored to provide relief for these patients, with mixed results.
Occipital Nerve Stimulation
Occipital nerve stimulation (ONS) is currently the leading surgical option for patients with chronic migraine that is refractory to multiple migraine therapies. Stephen Silberstein, MD, director of the Jefferson Headache Center in Philadelphia, Pennsylvania, told Neurology Advisor that greater ONS offers an effective therapy, but at a cost of substantial adverse effects. "New electrodes are being designed to avoid fibrosis and lead migration," he noted, addressing the major adverse events reported with this surgery.
Matthew S. Robbins, MD, FAAN, FAHS, chief of neurology at the Jack D. Weiler Hospital, Montefiore Medical Center, New York City, is less impressed with the results of ONS from clinical trials. Despite being "the most studied surgical intervention for migraine that has been refractory to treatment, with 3 randomized, sham controlled trials, there is still no great evidence for efficacy and frequent complications," he said.
All 3 clinical trials reported results within the last 2 years. 1-3 In a 2016 study of 53 patients with chronic migraine who had no success with 9 preventive treatments, Miller et al1 concluded that ONS was "a safe and efficacious treatment for highly intractable chronic migraine patients even after relatively prolonged follow up of a median of over 3 years." They reported a response rate of 45.3%, with a mean symptom improvement of 31.7%. Pain intensity, duration, and number of headache days were all improved, resulting in subjective reports of reduced disability and improved quality of life.1
A 2017 study by Rodrigo and colleagues2 reported "slightly better" outcomes that were maintained for as long as 7 years. They concluded that ONS may provide long-term benefits for patients with medically intractable chronic migraine. A third trial by Liu et al3 reported 50% response rates ranging from 36.36% to 40.91% across 3 frequencies of transcutaneous ONS, which were all significantly lower than the 63.64% seen for topiramate.
Vagus Nerve Stimulation
Dr Robbins observed a recent move away from ONS treatment with the development of alternative noninvasive stimulation devices, 3 of which have received US Food and Drug Administration clearances for migraine treatment. Noninvasive vagus nerve stimulation devices allow patients to stimulate the carotid vagus nerve via transdermal electrodes wired to a personal handheld device. Dr Silberstein was involved in the EVENT study, which provided class II evidence of the safety and tolerability of noninvasive vagus nerve stimulation for patients with CM.4 This pilot study of 15 patients with CM was not powered to evaluate efficacy and did not demonstrate significant effects on the number of headache days.4
In a 2017 review, however, Yuan and Silberstein5 observed that with long-term use, noninvasive vagus nerve stimulation provided an accumulated prophylactic effect for both CM and chronic cluster headache that pointed to neuromodulation of underlying mechanisms.
Alternative Surgical Options
An interesting alternative to invasive surgery for CM has increasingly been offered by plastic surgeons; namely, frontal nerve decompression or migraine trigger site deactivation surgery. "This procedure generally involves a surgical treatment where muscle and connective tissue around peripheral nerves in the scalp, face, or upper neck are stripped away from those sites deemed as triggers for headache," Dr Robbins explained. Such procedures are largely not advocated within the neurology field, he added, as "the studies looking at this operative treatment have been felt by the academic headache community to generally be flawed, with widespread misrepresentations by surgeons advertising this type of treatment as a cure."
A recent pilot study by Mauskop and Rothaus6 suggested potential benefits to autologous stem cell therapy for the treatment of refractory migraine in 9 patients. The authors concluded that the difficulty of surgically obtaining autologous stem cells warranted further study of stem cells derived from allogenic adipose, bone marrow, or placental tissue.6
Nonsurgical Treatments for CM
Dr Robbins pointed out that there are many procedural treatments for migraine that are effective and safe, including peripheral nerve blocks, trigger point injections, botulinum toxin injections, and sphenopalatine ganglion blocks. "Peripheral nerve blocks now have excellent evidence for short-term prevention and acute treatment of migraine, and botulinum toxin injections were approved for chronic migraine prevention in 2010," Dr Robbins noted. "Trigger point injections and sphenopalatine ganglion blocks have less robust evidence, but are useful for many patients in clinical practice," he said.
The newest pharmaceutical developments in the field beg the question of whether surgical alternatives are still relevant. "We are currently in a new era for migraine treatment," Dr Robbins said, "because patients who have been refractory to current therapies will mostly be eligible for the new preventive therapies that are now available; namely, monoclonal antibodies against CGRP or its receptor. Behavioral treatments for migraine are also highly evidence based, and also underutilized."
- Miller S, Watkins L, Matharu M. Long-term outcomes of occipital nerve stimulation for chronic migraine: a cohort of 53 patients. J Headache Pain. 2016;17:68.
- Rodrigo D, Acin P, Bermejo P. Occipital nerve stimulation for refractory chronic migraine: results of a long-term prospective study. Pain Physician. 2017;20:E151-E159.
- Liu Y, Dong Z, Wang R. Migraine prevention using different frequencies of transcutaneous occipital nerve stimulation: a randomized controlled trial. J Pain. 2017;18:1006-1015.
- Silberstein SD, Calhoun AH, Lipton RB, et al. Chronic migraine headache prevention with noninvasive vagus nerve stimulation: The EVENT study. Neurology. 2016;87:529-538.
- Yuan H, Silberstein SD. Vagus nerve stimulation and headache. Headache. 2017;57:29-33.
- Mauskop A, Rothaus KO. Stem cells in the treatment of refractory chronic migraines. Case Rep Neurol. 2017;9:149-155.