Spring 2011
A cure for the migraine headache?

synapse: University of Nevada, Reno School of Medicine

Kayvan Khiabani, M.D.

Kayvan Khiabani, M.D., demonstrates how certain nerves located in the head and face, can be 'pinched' by muscles, causing migraine headaches in some patients. Photo by Edgar Antonio Nunez

Relief for patients who suffer from debilitating migraine headaches is potentially just an outpatient surgery treatment away.

Interview by Edgar Antonio Nunez

Migraine headaches can cause significant pain for hours or in some instances even days. There's currently no cure, but a new, groundbreaking surgical procedure for the treatment of migraines is offering patients hope.

Kayvan Khiabani, M.D., associate professor of surgery at the University of Nevada School of Medicine, is the only surgeon in Nevada performing the decompression procedure, delivering an excellent rate of success in minimizing or in some cases completely eliminating some patients' migraine headaches.

"When we first see these patients, they're suffering tremendously from severe migraine pain. To see them just days after the procedure with their pain under control is amazing," says Khiabani.

"This is exactly why clinical research is done, to improve the quality of a patient's life."

Synapse: What is the impact of migraine headaches on society?

Kayvan Khiabani, M.D: Migraine headaches as a problem is one that we call a multifactorial problem. It's impact is not only on the health of society, but [it] also has a rather large impact on our economy.

We know that about 30 million Americans suffer from migraine headaches. About 10 percent of the population have migraine headaches in some shape or form. The prevalence of it is about 14 percent in someone's lifetime, meaning, that you have a 14 percent chance of developing migraine headaches during our lifetimes.

It usually affects adults in their 30s or 40s and it is much more prevalent in women than it is in men.

The treatments that have been done for migraine headaches so far mostly constitute multiple medications and injections or hospitalizations of these patients when none of these medications work. These have been extremely costly on our economy and medical care of our population, particularly when these patients have to be hospitalized or have to be on expensive neurological medications for their entire lifetime.

The other impact of this problem is socioeconomic. It's unfortunately a problem that knocks people off of their routine lifestyles. If a patient gets a migraine headache, they're pretty much counted out from their work day and their regular life activities. So, we're losing many work days and work hours in our economy to this disease, unfortunately.

Synapse: What are the origins of migraine headache surgery?

Khiabani: Basically it comes down to the fact that now we are thinking that some of these nerves within the head and neck area are under severe compression and pressure from musculature.

The idea is that a nerve is being pressed by this muscle.

So, what happened was that there was a certain number of patients who were coming to plastic surgeons' offices to get Botox to relax some of the muscles, especially in the frown area so their foreheads look better. These patients would come back and report to their plastic surgeons that, not only do I look better, but my migraine headaches are better and some of them actually disappeared. So for the longest time this wasn't taken seriously. But, patient after patient after patient [would] tell you the same thing.

The plastic surgeons started talking to each other at national and international meetings. We kind of figured out that our patients were telling us [plastic surgeons] the same thing.

So it warrants a study at this point to look into what can be the cause of this.

A group in Cleveland did studies on the affects of the relaxation of muscles, if you'd like, with the use of Botox and their affect on migraine headaches and episodes of migraine headaches.

So, it was very successful to the extent that our neurological colleagues and our neurologists and headache specialists, for the most part, have embraced Botox as a very effective medication for [the] treatment of migraine headaches.

What they [headache specialists] do is that they inject Botox to the areas of the muscle, where these muscles are compressing the nerves, and kind of relax these muscles so the [nerve] isn't being compressed anymore.

This has been such a huge success, that the FDA [US Food and Drug Administration] just this past year, in mid-October, approved the use of Botox for migraine headache problems.

The idea behind surgery, where that came from, is that, in a way, there are surgical treatments where we can take the effects of Botox and make it last forever, for the rest of the life of the patient.

Because Botox injections don't last, they can last anywhere between three and four months, they have to be repeated for the lifetime of the patient. That is both inconvenient and very, very expensive.

The idea behind surgery is, if we know there's areas of compression, there's musculature that is tightening up around these nerves, why don't we go ahead and release these muscles, and let the nerve be free and never be compressed.

That's the involvement of reconstructive surgeons into the field of migraine surgery, because most of these techniques are coming from plastic and reconstructive surgery.

Synapse: Explain the surgical treatment of migraine headaches.

Khiabani: There's a variety of procedures [that are] available for decompression of nerves—nerves that are under pressure within the head and neck area—for migraine patients.

There are three of this operations, for example, that I can talk about.

One is for patients who have their migraines that come from the back of their neck. The idea is that we make very small incisions within the hairline, which will be invisible in a way after hair grows on top of it [incisions], and we go in and release what's called the greater occipital nerve or the nerve that is the culprit of being under pressure.

The release of that nerve has had the tremendous success in taking the frequency and duration of migraine headaches quite down for these patients.

Another operation that is available for patients to have are for migraines coming from their temples, and similarly another operation for people who have central forehead migraines that initiate from here and go back towards the rest of the head.

These operations at this point with the use of the techniques of plastic surgery are done with very small, tiny holes that we do under the skin and actually advancing the camera and doing the operation on a computer monitor. So very minimally invasive surgery, they are all outpatient surgery, they all last less than an hour to do.

Synapse: What is the success rate for migraine headache surgery?

Khiabani: The surgery for migraine headaches has been particularly successful and we have rates of decreasing the migraine headache—either their frequency of the migraine headache happening or the duration or the severity of the pain.

All three of these have been impacted by these surgeries and over 87 to 88 percent of patients respond positive.

So, that is much more effective than many medications on the market that are offered to these patients.

The side effects of these medications compared to the side effects of surgery is an interesting thing to look at.

The mainstay of treatment of migraine headaches is a class of medications named triptans, which have revolutionized, you know, medication-taking for these problems. However, you can't give triptans to anybody who has cardiovascular disease. As we know, people in their 30s, 40s and 50s are more and more finding out that they may have cardiovascular problems, so that excludes a big percentage of the population. So that medication cannot be given to them. Secondly, it's got side effects anywhere from weight gain to mood changes and other issues with these medications.

However, on the other side, the surgical procedures that we're proposing for migraine headaches are done through really small incisions that have nothing to do with the inside of the brain. These are incisions in the operations that are pretty much happening under the skin, [a] very superficial kind of an operation. For example, one of the side effects of our surgery for foreheads and temples is that actually the patient gets rejuvenation of their forehead area.