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WILLIAM G. AUSTEN JR., MD
CHIEF, DIVISION OF PLASTIC & RECONSTRUCTIVE SURGERY
CHIEF, DIVISION OF BURN SURGERY
MGH TRUSTEES CHAIR
Massachusetts General Hospital, Harvard Medical School
Deactivating Peripheral Nerve Triggers:
A Surgical Solution to Refractory Headaches
The Evolution of Ideas in Plastic Surgery
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Fat grafting 1982-2012
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Breast reconstruction 1972-2002
Interest over time
Migraine Surgery Publications
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6
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10
12
2000 2003 2006 2009 2012 2014
very early……..
> 40 Articles
> 1000 publications on migraine therapies/ year
1/3 of patients refractory
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08
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02
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99
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93
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88
Migraine publications
Schulman.,Headache. 2013
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1600
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90
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81
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72
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88
Migraine publications
SHOULD WE THINK ABOUT
ALTERNATIVES ?
Migraine Facts
324.1 million
1 in 4
1. Lipton et al. Neurology 2007; 68: 343-349.
2. SynerMed Communications. Clin Courier 2001; 19: 1-15.
3. World Health Organization. The Global Burden of Disease 2004 Update.
Geneva, Switzerland: World Health Organization: 2004.
Significance
35MILLION Americans
3 : 1
1. Stewart et al. J Clin Epidemiol 1995
2. Stewart et al. Cephalalgia 2008
Pathophysiology-TheoryMigraine = Brain
Olesen et al. Ann Neurol 1990
1.Leaõ et al. J Neurophysiol. 1944
2.Olesen et al. Lancet Neurol. 2009
Migraine Therapies
Side Effects
Contraindications
NON- Responders
1. Dodick et al. Headache 2005
2. Blumenfeld et al. Headache 2013
Pathophysiology
Nerve Irritation
(muscle, fascia, bone, vessels)
Substance P/ Cytokines
Inflammation/Pain
Frontal
Temporal
Occipital
Nasal
1. Janis et. al, PRS 2010
2. Janis et. al, PRS 2010
3. Janis et. al, PRS 2012
2009
2005
PLACEBO CONTROLLED TRIAL WITH SHAM SURGERY
83.7% real surgery
57.7% sham surgery
>50% reduction of migraine
2009
2005
PLACEBO CONTROLLED TRIAL WITH SHAM SURGERY
57.1 % real surgery
3.8 % sham surgery
TOTAL ELIMINATION OF
MIGRAINES
The art of identification
1. Establish diagnosis in refractory patient
1. Identification of specific trigger points
1. Clinical evaluation & diagnostic testing
Patient must HAVE BEEN followed by a NEUROLOGIST
The art of identification
1. Establish diagnosis in refractory patient
1. Identification of specific trigger points
1. Clinical evaluation & diagnostic testing
Patient must HAVE BEEN followed by a NEUROLOGIST
The art of identification
1. Establish diagnosis in refractory patient
1. Identification of specific trigger points
1. Clinical evaluation & diagnostic testing
Patient must HAVE BEEN followed by a NEUROLOGIST
Comparison from a surgeons view
Migraine
• ‘Deep’ undefined pain
• Starting point unclear
Nerve compression headache
• Specific pain points
• Starts at specific location
Frontal trigger-common history
• Pain above the eyebrows
• Tender to touch
• In the afternoon
• Deep frown lines
• Eyelid ptosis common
• Pressure/Compresses help
Temporal trigger- common history
• Pain starts at temple
• Patients wake up with pain
• Bruxism very common
• Often throbbing pain
• Pressure/ compresses help
Occipital trigger- common history
• Pain starts above GON
• No specific start time for pain
• History of trauma common
• Neck muscles tight
• Worse with exercise/ heavy lifting
Rhinogenic trigger-common history
• Pain starts behind the eye
• Patients are woken up by pain
• Menstrual cycle/ weather/ allergy can change pain
• Decongestants help
• Rhinorrhea common
• Septal deviation/ concha bullosa/ Haller’s cell common
The art of identification
1. Establish diagnosis in refractory patient
1. Identification of specific trigger points
1. Clinical evaluation & diagnostic testing
Patient must HAVE BEEN followed by a NEUROLOGIST
Doppler Ultrasound
Arterial versus non- arterial trigger
• Especially useful in identification of
minor triggers
• Too early to understand impact
History/ Nerve Block and/or Botox Injection/ Doppler/ Imaging
to identify trigger sites
✔✖
NEUROLOGYPAIN SERVICE ENT
Two Pathways
Results Migraine Headache Index
Migraine headache index =
Frequency (d) Duration (1/24) Severity (0-10)
Preop 99.4
postop 10.1
p<0.01
-90%
Positive Response Distribution
100%
> 80%
50- 80%51.3%
28.2%
20.5%
Migraine
Headache Index
Improvement
Neuropraxia
Shooting nerve pain/ numbness
Acute migraine attack
Hypertrophic scar
Additional surgery
Low Incidence of Adverse Events
Post-Op pain medication plan
Neurologist and PCP
Pain Specialist
Encourage:
• Patient to contact
Neurologist
• Patient to speak about their
surgery and result
Post-Op Management
Current Migraine Questionnaires
Migraine Specific Quality of
Life Questionnaire
The migraine work and productivity loss questionnaire
PHQ
9
PHQ
2
For Migraine
Prospective questionnaire study
Migraine
Headache
Index
& Chronic Pain
Pain Self Efficacy
Questionnaire
Preliminary Results Questionnaires
mean values; unpublished data
* p<0.01
**
Migraine Headache Frequency (days per month)
*
*
Preliminary Results Questionnaires
mean values; unpublished data
* p<0.01
**
Migraine Headache Duration (hours)
Preliminary Results Questionnaires
mean values; unpublished data
* p<0.01
**
Migraine Headache Severity (0-10)
**
Preliminary Results Questionnaires
mean values; unpublished data
* p<0.01
**
Migraine Headache Index
Frequency (d) Duration (1/24) Severity (0-10)
*
*
-85.7%
-93.5%
Comparison positive response distribution
39.4%
18.2%
Improvement
prospective retrospective
Improvement
42.4%
Pain Self Efficacy
Confidence in performing normal activities
low pain self efficacy = POOR outcomes
Kennedy SA et al.,
J Hand Microsurg. (2010)
Vranceanu AM et al., J Hand
Surg Am. 2010
Skidmore JR. at al.,
Clin J Pain. (2015)
Pain Self Efficacy
Treatment Comparison
Jan Paul Briet et al., Phys Ther. (2014) Maughan et. al., Eur Spine J. (2010)
Pre- Treatment Scores
MigraineMigraine
Chronic Back Pain
Carpal Tunnel Syndrome
unpublished
Pain Self Efficacy
Treatment Comparison
Jan Paul Briet et al., Phys Ther. (2014) Maughan et. al., Eur Spine J. (2010)
Post- Treatment Scores
unpublished
Carpal Tunnel Pre
Carpal Tunnel Post
Chronic Back Pain Pre
Chronic Back Pain Post
Migraine Pre
Migraine Post +147%
+13%
+8%
Predictive Variables Hot and Cold Compresses
hot and cold compresses help hot and cold compresses don’t help
p <0.05
Early days-Thermal Imaging
Pre-operative thermal image
Prediction & intraop
finding
Right- Supraorbital foramen
Left- Notch