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Migraine-Related Surgery Proves Cause for Debate

A debate at the International Headache Congress during June in Boston, between a plastic surgeon and a neurologist, concluded with roughly 500 health professionals expressing skepticism about a surgical procedure for migraine. Bahman Guyuron, MD, of the University Hospitals and Case Medical Center in Cleveland, Ohio, and Hans-Christoph Diener, MD, PhD, a neurologist with the University of Essen in Germany, expressed far different views about the surgery, which Dr. Guyuron developed. It is performed by Dr. Guyuron and other physicians at several surgical centers throughout the U.S.

The surgery, according to Dr. Guyuron, releases nerves trapped by muscle fibers at various trigger points in the head and neck. He has performed nearly 1,000 of these surgeries and reported that this procedure has provided substantial relief for 80% of patients. He also reported that in a sham-controlled study of 75 migraineurs, the surgery eradicated the headaches in 57% who received the surgery compared to 1 of 26 participants who received sham surgery. Dr. Guyuron and colleagues have authored several articles about the procedure and the results, although none have been published in neurological journals, according to a report in Medpage Today.

Dr. Diener, however, believes strongly that the procedure should not be performed. During the discussion, he criticized several aspects of the study, including that the majority of the patients reported episodic migraine (migraine on 15 or fewer days per month), and the patients were then injected with Botox® into the trigger points. Those whose headaches resolved underwent the surgery. For Dr. Diener, this process was flawed because Botox is effective only in chronic migraine (migraine more than 15 days per month) and ineffective for episodic migraine. Dr. Diener said this process ensured that the true surgery sample had a high number of people who were responding to a placebo—albeit an expensive placebo.

The debate began and concluded with attendees raising their hands if they felt the evidence supported Dr. Guyuron’s procedure. Only a small fraction of the attendees raised their hands each time, indicating the debate had not influenced many of those in attendance.

At the conclusion of the debate, a participant as well as the moderator of the event called for independent randomized, sham-controlled trials of the procedure to determine its efficacy.

Arthur Elkind, MD, the President of the National Headache Foundation, noted the controversial nature of the surgery:

“The procedure will require a controlled multicenter study, possibly more than one such trial to determine its value,” he said. “Dr. Diener’s point about episodic and chronic migraine may require modification in the selection of subjects for such a study.”

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