Migraine Relief: Stopping Pain & Relieving Pressure

Meredith Messerli is thankful she can study without pain.
The college freshman spent two years of her life battling severe migraines.
"Just walking, I could hear my steps, they would hurt my head. I would just lay in a dark room all day and not really talk to anyone," Meredith Messerli said.
She saw 30 doctors and tried nearly 50 different medications, but her mom says nothing worked. She even withdrew from high school.
"It was horrible. It was a nightmare for the whole entire family," said Shelly Messerli, Meredith's mom.
Bardia Amirlak, MD, Assistant Professor of Plastic Surgery at UT Southwestern Medical Center said patients like Meredith often experience pain because nerves in the head and neck become irritated.
"These nerves get compressed," Amirlak said.
To relieve the pressure, Amirlak makes small incisions around trigger points. He then decompresses nerves in the problem area by cutting the muscle and small vessels.
"What we do is essentially cut that pathway that sends the signal to the brain and that stops that migraine process," Amirlak said.
Most patients experience some relief, and about 60 percent have complete relief.
After two decompression surgeries - Meredith's headaches are gone. Now she can focus more on schoolwork , and less on pain.
"I have a life now!" she said.
"It was a miracle, it really was," her mom said.
Dr. Amirlak said between 80 and 90 percent of insurance companies cover the decompression procedure. This technique was accidentally discovered by a plastic surgeon in Cleveland who performed a forehead lift for cosmetic reasons. He started to notice that his forehead-lift patients also reported relief from migraine symptoms.

BACKGROUND: Migraines are the worst and most painful headaches. Those who suffer from them often experience the profound throbbing in the head and they become sensitive to sound and light. At times, migraines can last anywhere from a couple of hours to a couple of days. This excruciating headache may be accompanied with a tingling sensation in the arm or leg, blind spots, and flashes of light. (Source: http://www.mayoclinic.com/health/migraine-headache/DS00120)
TREATMENT:  There is no cure for migraines, but that does not mean that they cannot be relieved. Medication is usually prescribed by doctors to help alleviate the patient's symptoms and this is divided into two categories; preventative medications and pain-relieving medications. Preventive medications are designed to be taken daily and were created to cut down the number of headaches a patient has. Pain-relieving medications are only taken in the event that a migraine occurs to cease occurring symptoms. (Source: http://www.mayoclinic.com/health/migraine-headache/DS00120/DSECTION=treatments-and-drugs)
NEW TECHNOLOGY: A new way to treat migraines was actually discovered by accident. A plastic surgeon in Cleveland, Ohio was performing forehead lifts on patients, and found many were reporting that they no longer experienced any migraines. The procedure involved removing the muscle just above the eyes, which seemed to decompress the nerves which can send pain signals to the brain. They found if they performed this kind of decompression at major sites around the head and neck, migraine symptoms would generally stop. It is not, however, curing the underlying cause of the migraine. Instead, they simply cut the nerves and tissue around these sites, which stop the pain signal from being sent to the brain in the first place. The procedure is covered by 80 to 90 percent of insurance companies, and can run from about $5,000 to $10,000 per site. (Dr. Bardia Amirlak, http://migrainesurgerytreatment.com/)
Do you talk to a lot of people that come in with migraines?
Dr. Amirlak:  I do. A lot of times I talk to people from out of state, and I also talk to people from out of the country as well. Sometimes after I talk to them they fly in for an assessment. We have a talk with them before surgery to see if they're candidates for surgery or if they're candidates for other treatments, such as BOTOX.
And these people are pretty desperate, right?
Dr. Amirlak: The majority of them have tried multiple medications, multiple treatment modalities. Some have even tried acupuncture and different massage therapies, and some of them are on high doses of narcotics, unfortunately, because of the severe pain that they have. Migraines do cause a lot of problems with daily living. Sometimes people can't go to school, sometimes they can't leave the house, and they can't open the shades. Migraines also cause a lot of problems with relationships and social activities.
So when Meredith came to you what would she like?
Dr. Amirlak: Well she was absolutely miserable: she had a lot of pain in the forehead and temple, she was on multiple medications, she had a hard time going to school, and her hopes for going to college were very slim. She was very depressed, and I think at the same time anxious as well because of the amount of pain she was in.
Is every migraine because of compressed nerves?
Dr. Amirlak: It is an area that we are doing a lot of research in. Migraines are historically defined as being problems with the central nervous system. But what we have found through research, and through the observing that BOTOX, temporary nerve blocks, and surgery do work on some patients, is that these nerves get compressed. The compressed nerves then send signals to the brain, which is already very sensitive because of the underlying causes of migraines, and migraines are triggered, potentially leading to more global pain, all over the head, rather than just at the starting point. What we do is essentially cut the pathway that sends the signal to the brain, stopping the migraine process. It may not cure the underlying migraine cause; we're sort of cheating. We are preventing the signals from reaching the brain and causing this globalization of pain.
Does the brain rewire itself and put those pathways back into place?
Dr. Amirlak: That's a great question. One wonders what happens after we do the decompression. I always tell patients there's about a 10 to 15 percent chance that the surgery may not work, or it may not be as effective. One of the reasons, I think, is that the brain at times is so hungry for pain, it shifts the location where it receives the pain signals, and so the trigger sites change. For example, it may startin the forehead, but then either after the first surgery or BOTOX, it can shift to the back of the head, to the temple, or behind the eye, and if that happens, we can usually go after those triggers and deactivate them as well. Sometimes we don't know the exact location of some of the minor triggers and compression sites. For example, the nerve supply to the TMJ is an area that I am currently doing anatomical research on and, hopefully, we can come up with not only a better way to inject the TMJ with BOTOX, but also find a way to decompress the nerves in this area, whether they cause migraines or TMJ pain.
Why would Botox not work in Meredith, yet this works in Meredith?
Dr. Amirlak: In theory, BOTOX has the same sort of mechanism of action in deactivating these signals going to the brain, but it may not be strong enough to fight the nerve signals. The compression may not necessarily be caused by muscle problems but by fascia, bone, or vessels pressing on the nerves. BOTOX in theory works only on muscles; some studies show its effects directly on the nerve. The compression may be too severe or the nerve damage too much that I think BOTOX may not be effective. Some people just don't respond to BOTOX very well.
So what exactly do you do in the procedure?
Dr. Amirlak:  This surgery was initiated in Cleveland, Ohio, by plastic surgeon Dr Guyuron. It was an accidental discovery during forehead lift procedures. Using an endoscope on his patients to remove the frown muscle and by that apparently, he was decompressing these supratrochlear nerves, the nerves above the eye. Subsequently, patients reported that their migraines were gone or had been improved. I was fortunate enough to be in Cleveland during the critical stages of refining this surgery and was part of the team making these discoveries. We looked at these compression points in the back of the head and in the temple. In the back of the head the occipital nerves are decompressed by removing the muscle and fascia pressing on the nerves. I have modified the surgery in Dallas by using an endoscope in the back of the head to find small blood vessels that compress these nerves.  In the case of pain behind the eyes, these contact points inside the nose and sinuses are addressed. In the forehead where the corrugator (frown muscle) is compressing these nerves, the muscle is partially removed.
Are there any risks involved in the procedure?
Dr. Amirlak: The risks of surgery are minimal with this procedure. Of course, any time you undergo surgery, you have to be cognizant of the general risks. In this case, the morbidity and the associated risks are minimal. You may have some scarring, but usually the pain does not get worse; it's very rarely I've heard about this. Usually the pain gets better 50 percent of the time, or you get complete elimination of the pain, or it doesn't work. However, any time you undergo the knife, you have to be aware that complications can happen. That's why this surgery is reserved for people who have seen a neurologist, who have been treated, who have not experienced relief.
Is this still considered experimental?
Dr. Amirlak: Many believe that this surgery is not experimental and that we have enough patients and research and publications to support this. However, controversy still exists; more research needs to be done to identify who is the best candidate for the surgery. I think we know the surgery works, we've seen the results, we've seen how dramatic the results can be, and it gives back control to the patients and improves their lives. More research needs to be done in that area, however, as we are currently doing in Dallas and Cleveland
Who is not a candidate?
Dr. Amirlak: Before I would assess the patient, I would have to make sure that he/she has been seen by a neurologist, sometimes a couple of neurologists, and that every medication possible has been tried without improvement. I look at the patient and ask where the pain starts, which is the most important question. Is it in the forehead, temple, behind the eye, or behind the neck?
If a patients cannot tell me where the pain starts, I may use nerve blocks or BOTOX injection to try to figure this out. If they have significant medical problems or if they have high dependency on narcotics, I exert greater caution before offering surgery.
But the surgery is it covered yet?
Dr. Amirlak:  Approximately 80 to 90 percent of the insurance companies approve the surgery. This shows that from their perspective it's not experimental anymore. About 10 to 20 percent of the time the insurance companies deny the surgery. Depending on the site of the surgery it may cost about $5,000 to $10,000 per site. If you're doing all four sites, it may cost $15,000 to $20,000.The cost varies among institutions and individual cases. This cost includes surgery, operating room fees, as well as anesthesiology fees.

For more information, please contact:

Bardia Amirlak, MD