Surgical Treatment Of Migraine Headaches Research Articles

Quality of online information about migraine headache surgery

Migraine headache is a debilitating disease that can lead to severe functional limitations and is the most common primary headache. In more than 30% of cases conservative therapies do not allow the control of symptoms or cause side effects. Peripheral nerve surgery should be considered in non-responsive chronic migraine or suspected peripheral origin. Nowadays Web has become one of the most important sources of knowledge for patients: the information available on the web is not subject to a control of the sources reliability but can influence the patient. The aim of the study is to evaluate the quality of information accessible on the Web about the surgical treatment of migraine headache. "Headache OR migraine treatment", "headache OR migraine surgery" were the keywords used on two main search engines (Google and Yahoo). Among the first 50 websites, 26 were suitable and we divided them into five groups (practitioners, hospitals, healthcare portals, professional societies, encyclopedias). We applied the expanded EQIP (Ensuring Quality Information for Patients) scale: the EQIP scale consists of 36 questions with three sections (content, identification data and structure). Although the overall average score was relatively high (22 out of 36), many lacks information were highlighted: overall, readability was not satisfactory in communicating information regarding migraine and its surgical treatment. Readability should be tested before medical online publication, in order to provide for its correct use by the patient and improving migraine knowledge.

The Evolution of Migraine Surgery: Two Decades of Continual Research. My Current Thoughts.

A mere serendipitous finding has culminated in a life-changing development for patients and a colossally fulfilling field for many surgeons. The surgical treatment of migraine headaches has been embraced by many plastic surgeons after numerous investigations ensuring that the risks are minimal and the rewards inestimable. Seldom has a plastic surgery procedure been the subject of such scrutiny. Through retrospective, prospective pilot, prospective randomized, prospective randomized with sham surgery, and 5-year follow-up studies, the safety, efficacy, and longevity of the given operation have been confirmed. Although the first decade of this journey was focused on investigating effectiveness and risk profile, the second decade was largely devoted to improving results, reducing invasiveness, and shortening recovery. Multiple publications in peer-reviewed journals over the past 20 years, several independent studies from reputable surgeons at recognized centers, and over 40 studies from the author's center have established the surgical treatment of headaches as a standard practice.

The Relationship of Psychiatric Variables in Patients Undergoing Peripheral Nerve Surgery for Migraine Headache

BACKGROUND: Patients seeking peripheral nerve surgery for their headaches often have debilitating symptoms that can affect both their functional and psychological well-being. Although prior studies have shown strong associations between psychiatric variables and migraine headaches, their associations in patients undergoing peripheral nerve surgery have not been fully elucidated. This study aims to explore the relationship of psychiatric comorbidities in patients undergoing peripheral nerve surgery for their headaches. METHODS: One hundred twenty-nine patients were enrolled prospectively and completed the Patient Health Questionnaire-2 (PHQ-2) and Migraine Headache Index (MHI) surveys preoperatively and at 12 months postoperatively. Data on psychiatric comorbidities were collected both via survey and via retrospective chart review. RESULTS: Preoperatively, 38% of patients self-reported a diagnosis of depression, whereas 45% of patients met PHQ2 criteria for likely major depressive disorder (PHQ-2 score of 3 or greater). Twenty-seven percent of patients reported a diagnosis of generalized anxiety disorder. Patients with depressive symptoms and self-reported anxiety were more likely to report a higher severity of migraine symptoms. At 1-year postoperatively, patients reported a significant decrease in their PHQ-2 score (P = 0.02), with 22% of patients reporting depressive symptoms, as compared to 45% preoperatively. The preoperative presence of anxiety or depression did not affect postoperative outcomes. CONCLUSION: There is a high prevalence of psychiatric ailment in patients undergoing migraine surgery. Comorbid psychiatric conditions do not appear to affect postsurgical outcomes. However, surgery is associated with a significant decrease in depressive symptoms. Prior studies have shown that the surgical treatment of migraine headaches is associated with improved headache symptoms and functionality. This study demonstrates that surgery is also associated with improved psychiatric symptoms.

Decompression Surgery for Frontal Migraine Headache.

Introduction:Migraine headache (MH) is one of the most common diseases worldwide and pharmaceutical treatment is considered the gold standard. Nevertheless, one-third of patients suffering from migraine headaches are unresponsive to medical management and meet the criteria for “refractory migraines” classification. Surgical treatment of MH might represent a supplementary alternative for this category of patients when pharmaceutical treatment does not allow for satisfactory results. The goal of this article is to provide a comprehensive review of the literature regarding surgical treatment for site I migraine management.Methods:A literature search using PubMed, Medline, Cochrane and Google Scholar database according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines was conducted using the following MeSH terms: “frontal neuralgia,” “frontal trigger site treatment,” “frontal migraine surgery” and “frontal headache surgery” (period: 2000 -2020; last search on 12 March 2020).Results:Eighteen studies published between 2000 and 2019, with a total of 628 patients, were considered eligible. Between 68% and 93% of patients obtained satisfactory postoperative results. Complete migraine elimination rate ranged from 28.3% to 59%, and significant improvement (>50% reduction) rates varied from 26.5% to 60%.Conclusions:Our systematic review of the literature suggests that frontal trigger site nerve decompression could possibly be an effective strategy to treat migraine refractory patients, providing significant improvement of symptoms in a considerable percentage of patients.

Abstract 33: Psychiatric Conditions In Patients Undergoing Trigger Site Deactivation Surgery For Nerve Compression Headaches

Purpose: Patients seeking surgery for their nerve compression headaches often have debilitating symptoms that can affect both their functional and psychological well-being. Prior studies have shown strong associations between psychiatric conditions and migraine headaches. This correlation has not been investigated in patients undergoing surgery for headaches. Methods: One-hundred and twenty-nine patients were enrolled prospectively and completed the Patient Health Questionnaire-2 (PHQ-2) and Migraine Headache Index (MHI) surveys preoperatively and at twelve months postoperatively. Data on psychiatric comorbidities were collected both via survey and via retrospective chart review. Results: Preoperatively, 38% of patients self-reported a diagnosis of depression, while 45% of patients met PHQ-2 criteria for likely major depressive disorder (PHQ-2 score of three or greater). Twenty-seven percent of patients reported a diagnosis of generalized anxiety disorder. Patients with self-reported depression and anxiety were more likely to report a higher severity of migraine symptoms (P<0.01 and P=0.025, respectively). At one year postoperatively, patients reported a significant decrease in their PHQ-2 score (P=0.02), with 22% of patients reporting depressive symptoms, as compared to 45% preoperatively. The preoperative presence of anxiety or depression did not affect postoperative outcomes. Conclusion: There is a high prevalence of depression and generalized anxiety disorder in patients undergoing surgery for nerve compression headaches. Comorbid psychiatric conditions do not appear to affect postsurgical outcomes. However, surgery is associated with a significant decrease in depressive symptoms. Prior studies have shown that the surgical treatment of migraine headaches is associated with improved headache symptoms and functionality. This study demonstrates that surgery is also associated with improved mental health.

Direct Lateral Canthal Approach to the Zygomaticotemporal Branch of the Trigeminal Nerve for Surgical Treatment of Migraines.

Surgical treatment of migraine headaches involves avulsion or decompression of the affected peripheral nerves. One of the sites targeted is site II, the zygomaticotemporal branch of the trigeminal nerve. Although traditionally the procedure involved either an endoscopic or transpalpebral approach to access the nerve, both methods involve general anesthesia in an operating room. The senior authors developed a new technique to directly access the nerve by means of a transverse lateral canthal extension incision that can be performed under local anesthesia in an office setting. A cadaver dissection to assess safety and anatomical variability was performed with visualization and complete avulsion of the zygomaticotemporal branch of the trigeminal nerve in all cases, with no injury to surrounding structures. An office-based procedure for zygomaticotemporal branch of the trigeminal nerve compression can help reduce the risks and costs associated with a general anesthetic and can be used for patients with isolated migraines localized to the zygomaticotemporal branch of the trigeminal nerve or recurrent secondary triggers to that area. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

Discussion: Efficacy of Surgical Treatment of Migraine Headaches Involving the Auriculotemporal Nerve (Site V).

Discussion: Efficacy of Surgical Treatment of Migraine Headaches Involving the Auriculotemporal Nerve (Site V).

Surgical Treatment of Migraine Headache: Back to the Future.

Understanding the history and evolution of ideas is key to developing an understanding of complex phenomena and is the foundation for surgical innovation. This historical review on migraine surgery takes us back to the beginnings of interventional management for migraine centuries ago, and reflects on present practices to highlight how far we have come. From Al-Zahrawi and Ambroise Paré to Bahman Guyuron, two common themes of the past and present have emerged in the treatment of migraine headache. Extracranial treatment of both nerves and vessels is being performed and analyzed, with no consensus among current practitioners as to which structure is involved. Knowledge of past theories and new insights will help guide our efforts in the future. One thing is clear: Where we are going, there are no roads. At least not yet.

Surgical treatment of migraine headaches.

The senior author (BG) introduced the modern concept of migraine surgery in 2000. Since then, over 40 articles have been published by eight centers across the US, Europe, and Asia, describing positive outcomes after surgery in 68-95% of cases. Surgeons, neurologists, and patients are increasingly interested in this new treatment method. However, the majority of publications on this topic are found in surgical literature, with few articles presented in neurology journals. This review is an introduction to migraine surgery for neurologists from a surgeons view. It discusses the surgical treatment of migraine headaches based on the discoveries made and articles published by the senior author. It outlines the current history of migraine surgery, presents evidence supporting its effectiveness, and tries to dispel claims that what we are seeing is a placebo effect. It further describes detection of trigger sites and outlines surgical techniques of peripheral nerve decompression. We hope that this review will generate a positive discussion between surgeons and neurologists and lead to more interdisciplinary collaboration for the benefit of the patients in the future.

Surgical Treatment of Migraine Headaches: A Review of Surgical Technique, Clinical, Anatomical and Radiological Studies

Surgical Treatment of Migraine Headaches: A Review of Surgical Technique, Clinical, Anatomical and Radiological Studies

A comparison of outcome of medical and surgical treatment of migraine headache: In 1 year follow-up.

Background:This study was designed to compare the efficacy of the medical treatment versus the surgical treatment approach to decompression of trigger point nerves in patients with migraine headaches.Materials and Methods:Fifty volunteers were randomly assigned to the medical treatment group (n = 25) or the surgical treatment group (n = 25) after examination by the team neurologist to ensure a diagnosis of migraine headache. All patients received botulinum toxin type A to confirm the trigger sites. The surgical treatment group underwent surgical deactivation of the trigger site(s). The medical treatment group underwent prophylactic pharmacologic interventions by the neurologist. Pretreatment and 12-month posttreatment migraine headache frequency, duration, and intensity were analyzed and compared to determine the success of the treatments.Results:Nineteen of the 25 patients (76%) in the surgical treatment group and 10 of the 25 patients (40%) in the medical treatment group experienced a successful outcome (at least a 50% decrease in migraine frequency, duration, or intensity) after 1 year from surgery. Surgical treatment had a significantly higher success rate than medical treatment (P < 0.001). Nine patients (36%) in the surgical treatment group and one patient (4%) in the medical treatment group experienced cessation of migraine headaches. The elimination rate was significantly higher in the surgical treatment group than in the medical treatment group (P < 0.001).Conclusions:Based on the 1-year follow-up data, there is strong evidence that surgical manipulation of one or more migraine trigger sites can successfully eliminate or reduce the frequency, duration, and intensity of migraine headaches in a lasting manner.

A review of current evidence in the surgical treatment of migraine headaches.

Migraines affect 18% of women and 6% of men and result in an estimated $1 billion in medical costs and $16 billion productivity loss in the United States annually. Migraine headaches persist as a problem of this scale because pharmacologic treatments for migraines are frequently incompletely effective, resulting in a population of patients with significant residual disability. In the last decade, novel approaches to the treatment of migraines have been developed based on the theory that extracranial sensory branches of the trigeminal and cervical spinal nerves can be irritated, entrapped, or compressed at points throughout their anatomic course, ultimately leading to the cascade of physiologic events that results in migraine. Botulinum toxin (Botox) injection and surgical decompression of these trigger points have been shown to reduce or eliminate migraines in patients who are incompletely treated by traditional medical management. Despite the recent advances made with Botox, this treatment strategy most commonly results in only temporary migraine prevention. However, the evidence supporting the efficacy and safety of permanent surgical decompression of peripheral trigger points is accumulating rapidly, and the overall success rate of surgery has approached 90%. In addition, an abundance of literature investigating the precise anatomical dissections associated with trigger points has been published concurrently. This article reviews the most up-to-date clinical and anatomic evidence available and seeks to provide a comprehensive, concise resource for the current state of the art in the surgical treatment of migraine headaches.

Impact of Preoperative Narcotic Use on Outcomes in Migraine Surgery

This study focuses on the impact of preoperative narcotic medication use on outcomes of surgical treatment of migraine headaches. A retrospective comparative review was conducted with patients undergoing migraine surgery. Data gathered included demographic information, baseline migraine headache characteristics, migraine surgery sites, postoperative migraine headache characteristics 1 year or more following surgery, and preoperative migraine medication use. Patients were grouped based on preoperative narcotic medication use. The narcotic users were subdivided into low and high narcotic user groups. Preoperative migraine characteristics were comparable between groups and the outcomes of migraine surgery were compared between the groups. Outcomes in 90 narcotic users were compared with those for 112 patients not using narcotic medications preoperatively. Narcotic users showed statistically significantly less reduction in frequency, severity, and duration of migraine headaches after surgery. Narcotic users had clinical improvement in 66.7 percent of patients and elimination in 18.9 percent versus 86.6 and 36.6 percent, respectively, in the nonnarcotic group. The group that consumed narcotics had significantly lower rates of improvement in all migraine indices. Previous studies have discouraged the routine use of narcotic medications in the management of migraine medications. The authors' study demonstrates that narcotic medication use before migraine headache surgery may predispose patients to worse outcomes postoperatively. Because pain cannot be objectively documented, the question remains of whether this failure to improve the pain was indeed a suboptimal response to surgery or the need for narcotic substances. Risk, II.

A Socioeconomic Analysis of Surgical Treatment of Migraine Headaches

This study is meant to compare the direct and indirect cost of migraine headache care before and after migraine surgery and to evaluate any postoperative changes in patient participation in daily activities. Eighty-nine patients enrolled in a migraine surgery clinical trial completed the Migraine-Specific Quality-of-Life Questionnaire, the Migraine Disability Assessment questionnaire, and a financial cost report preoperatively and 5 years postoperatively. Mean follow-up was 63.0 months (range, 56.9 to 72.6 months). Migraine medication expenses were reduced by a median of $1997.26 annually. Median cost reduction for alternative treatment expenses was $450 annually. Patients had a median of three fewer annual primary care visits for the migraine headache treatment, resulting in a median cost reduction of $320 annually. Patients missed a median of 8.5 fewer days of work or childcare annually postoperatively, with a median regained income of $1525. The median total cost spent on migraine headache treatment was $5820 per year preoperatively, declining to $900 per year postoperatively. Total median cost reduction was $3949.70 per year postoperatively. The mean surgical cost was $8378. Significant improvements were demonstrated in all aspects of the Migraine-Specific Quality-of-Life Questionnaire and the Migraine Disability Assessment questionnaire. Surgical deactivation of migraine trigger sites has proven to be effective for the treatment of severe migraine headache. This study illustrates that the surgical treatment is a cost-effective modality, reducing direct and indirect costs. Patients may also expect improvements in the performance of and increased participation in activities of daily living. Therapeutic, IV.

A Comparison of Outcome of Surgical Treatment of Migraine Headaches Using a Constellation of Symptoms versus Botulinum Toxin Type A to Identify the Trigger Sites

This study was designed to assess whether preoperative trigger-site confirmation using botulinum toxin type A injections significantly improved migraine surgery outcomes. The medical charts of 335 migraine surgery patients were reviewed. Patients who received stepwise diagnostic botulinum toxin type A injections were placed in the botulinum toxin type A group (n = 245). Patients who did not receive botulinum toxin type A or received only therapeutic botulinum toxin type A were placed in the control group (n = 90). The preoperative and 12-month postoperative migraine headache frequency, duration, and intensity were compared to determine the success of the operations. Seventy-two of 90 control patients (80 percent) experienced a significant improvement (a decrease of at least 50 percent in migraine headache frequency, duration, or intensity) at 12 months after surgery, with 29 (32 percent) reporting complete elimination. Of the 245 botulinum toxin type A patients, 207 (84 percent) experienced a significant improvement, with 89 (36 percent) experiencing complete elimination. The surgical success rate of the botulinum toxin type A group was not significantly higher than that of the control group (p = 0.33). Confirmation of trigger sites using botulinum toxin type A does not significantly improve the outcome of migraine surgery. Although botulinum toxin type A can be a useful diagnostic tool, this study demonstrates that there is no statistically significant difference between the injection of botulinum toxin type A and the use of a constellation of symptoms to identify trigger sites. Therapeutic, III.

Five-Year Outcome of Surgical Treatment of Migraine Headaches

Sir:FigureWe particularly appreciated the article entitled “Five-Year Outcome of Surgical Treatment of Migraine Headaches” by Drs. Guyuron, Kriegler, Davis, and Amini (Plast Reconstr Surg. 2011;127:603–608). We read with interest about different techniques used in treatment of migraine headaches. The authors discussed the role of surgery in the amelioration of this disabling condition and attempted to determine pathophysiologic reasons for the surgical success their patients have been enjoying, affirming that many questions are still unanswered. We agree with the consideration that an accurate identification of trigger sites is of critical importance, and we focused our attention particularly on reading about surgical techniques used by the authors for occipital trigger point. We would like to report our experience in treating chronic headaches related to occipital neuralgia and explain what, in our opinion, is the pathophysiologic reason for the success of our technique. Occipital neuralgia is frequently resistant to pharmacologic and surgical approaches. Often, important anatomical variations related to occipital neuralgia can be found, compromising the effectiveness of procedures such as surgical decompression or nerve block.1,2 Encouraged by our experience in using autologous fat graft in scar outcomes,3,4 we decided to use this technique in a case of severe unresponsive posttraumatic occipital neuralgia with cicatricial entrapment of the greater occipital nerve. Autologous fat graft, harvested from trochanteric areas and centrifuged at 3000 rpm for 3 minutes, was injected at the clinical trigger point (indicated by the patient with manual palpation) and the point of anatomical scar entrapment. The stable, long-term success of this procedure has been documented by asking the patient to indicate the pain level using a visual analogue scale (preoperative level, 8; 1-month postoperative level, 3), and by performing magnetic resonance imaging. Preoperative examination showed a thinning of subcutaneous adipose tissue and the presence of cicatricial fibrous tissue, whereas examination at 3 months postoperatively showed restored appearance of subcutaneous adipose tissue in the treated area. Considering the results obtained, we used this technique in other cases of occipital neuralgia not related to posttraumatic scars, and always obtained a reduction of frequency, duration, and intensity of headache episodes. We are now conducting an important clinical study with long-term follow-up in all treated patients. Our hypothesis is that, in many cases of chronic headache related to occipital neuralgia, a pathologic thinning of the subcutaneous fat layer in this area is involved, making possible the contact between occipital nerves and other anatomical structures—such as occipital arteries—and thus conditioning development of pain. The autologous fat graft procedure allows the subcutaneous adipose tissue layer to be thickened, possibly acting as a “decompression neurolysis.” Furthermore, as shown in our other studies,3–5 adipose tissue has regenerative properties and, first of all, an analgesic effect. The biological reasons of these properties are still unclear but appear to be related to the therapeutic success we achieve in treatment of chronic headaches. Considering also the simplicity of the procedure, the absence of residual scars, and the virtual lack of complications, we believe that autologous fat graft is an excellent option for the treatment of migraine headaches. Fabio Caviggioli, M.D. Università degli Studi di Milano, U.O. Chirurgia Plastica, IRCCS Multimedica Group Milano, Sesto San Giovanni, Milan, Italy Silvia Giannasi, M.D. Valeriano Vinci, M.D. Guido Cornegliani, M.D. Università degli Studi di Milano, U.O. Chirurgia Plastica 2, IRCCS Istituto Clinico Humanitas, Rozzano, Milan, Italy Daniel Levi, M.D. Paolo Gaetani, M.D. Università degli Studi di Milano, U.O. Neurochirurgia, IRCCS Istituto Clinico Humanitas, Rozzano, Milan, Italy

Discussion: Five-Year Outcome of Surgical Treatment of Migraine Headaches

T latest installment to the literature on the surgical treatment of migraine headaches by Dr. Guyuron and colleagues once again adds important, relevant, and robust information to our existing knowledge and understanding of this disease. Up to this point, the concept has been elucidated, the anatomy described in detail, the algorithm for treatment suggested, and 1-year follow-up reported.1 However, for those of us who perform migraine surgery, we have always had to advise our patients up front that the longevity of the surgical benefit is unknown. Although theoretically the surgical intervention should result in permanent improvement, assuming a complete release of the involved trigger points, we have not had reported published data to back up this theory. That is, until now. With this article, we can now report to our patients with confidence that the surgical results can last up to 5 years and the clock is still ticking. Apprehensive patients who may have been reluctant to pursue surgery may have their fears allayed, given this new information. This is especially poignant given that “a bridge is burned” by transitioning from chemodenervation with botulinum toxin to surgical intervention, given that the target of the botulinum toxin (that is, the neuromuscular junction) is removed during the surgical decompression of the nerve through muscular resection. When weighing the pros and cons of proceeding with surgery in the hopes of making a temporary improvement permanent, the lack of convincing data on the longevity of the surgical effect has proven to be a major psychological hurdle for the patients. This report will help many patients jump that hurdle. Although the intent of the study was to report on the long-term results of surgical decompression in the same cohort of patients initially reported on in 2005, there are several other important items mentioned within the study that deserve highlighting. The first is Guyuron et al.’s explanation as to why the results of their surgical decompressions have improved over time. Although new trigger points have been described, such as the auriculotemporal nerve intersection with the superficial temporal artery,2 perhaps the greatest ground has been gained with improved understanding of existing trigger points.3–7 Through this clarity, more complete, thorough, and successful decompressions have been performed, which have improved the percentage of patients who not only obtain significant improvement ( 50 percent in frequency, intensity, and/or duration of their migraines) but also complete elimination. For instance, Guyuron et al. make the point to resect the “glabellar muscle group” and not just the corrugator supercillii muscle. Given that most of the patients were diagnosed with a frontal trigger point in this location (93 percent), this technical modification is paramount to the success of the surgery both in the short term and now the long term as reported in this article. Furthermore, a more complete release of the greater occipital nerve, now that we are aware of at least six points of possible compression (including the occipital artery), has led to improved outcomes not only for Dr. Guyuron’s group but for others as well.8 It should also be emphasized that most patients have more than one trigger point. In Guyuron et al.’s series, 63 of 69 patients (91.3 percent) had two or more. This will help guide the practitioner in examining for and isolating all trigger points in a given patient. In this article, Guyuron and colleagues reported that 10 of 79 patients followed for 5 years required additional surgery. It may be helpful to see a breakdown of what trigger

Five-Year Outcome of Surgical Treatment of Migraine Headaches

This study was designed to assess the long-term efficacy of surgical deactivation of migraine headache trigger sites. One hundred twenty-five volunteers were randomly assigned to the treatment (n = 100) or control group (n = 25) after examination by the team neurologist to ensure a diagnosis of migraine headache. Patients were asked to complete the Medical Outcomes Study 36-Item Short Form Health Survey, Migraine-Specific Quality of Life, and Migraine Disability Assessment questionnaires before treatment and at 12- and 60-month postoperative follow-up. The treatment group received botulinum toxin to confirm the trigger sites; controls received saline injections. Treated patients underwent surgical deactivation of trigger site(s). Results were analyzed at 1 year (previously published) and 5 years postoperatively (the subject of this report). Eighty-nine of 100 patients in the treatment group underwent surgery, and 79 were followed for 5 years. Ten patients underwent deactivation of additional (different) trigger sites during the follow-up period and were not included in the data analysis. The final outcome with or without inclusion of these 10 patients was not statistically different. Sixty-one (88 percent) of 69 patients have experienced a positive response to the surgery after 5 years. Twenty (29 percent) reported complete elimination of migraine headache, 41 (59 percent) noticed a significant decrease, and eight (12 percent) experienced no significant change. When compared with the baseline values, all measured variables at 60 months improved significantly (p < 0.0001). Based on the 5-year follow-up data, there is strong evidence that surgical manipulation of one or more migraine trigger sites can successfully eliminate or reduce the frequency, duration, and intensity of migraine headache in a lasting manner.

Review of Pediatric Migraine Headaches Refractory to Medical Management

The surgical treatment of migraine headache is a recent innovation that has broadened the potential patient population who may benefit from craniofacial surgical techniques to millions of affected adults. However, the population at risk in the pediatric age group has not been clearly established. The present retrospective review was performed to provide demographic information of the adolescent migraine in a major children's hospital. This information is essential before considering surgical treatment of migraine in this age group. Five hundred eighty-eight charts of patients aged 12 to 18 years who presented to the pediatric neurology clinic with headache in 2006 were retrospectively reviewed to evaluate for the diagnosis of migraine. Data collected included headache location, frequency, duration, intensity, associated migraine symptoms, and headache precipitants, as well as the response to medical treatment. Two hundred ten (36%) of 588 patients had the diagnosis of migraine headache, and 51 patients (24%) were considered refractory to the medical treatment offered. In 101 of the 210 migraine patients, anatomic location of the headaches could be identified. Thirty-nine children (19%) with refractory migraines (mean age, 14.7 years [SD, 0.3 years]) reported definitive migraine triggers. A significant percentage of pediatric patients with migraine headache remain refractory to medical treatment. At present, there is no good treatment regimen for migraine headaches in the pediatric population. We believe that surgical treatment of migraine headaches may be a realistic option for these patients.

A Case of Successful Surgical Treatment of Migraine Headaches in a Patient with Sporadic Pulmonary Arteriovenous Malformations

Pulmonary arteriovenous malformations (PAVMs) are thin-walled aneurysms caused by abnormal communication between the pulmonary arteries and veins. Migraine headaches are sometimes the presenting clinical manifestation of PAVMs. Although embolotherapy, using detachable balloons or stainless steel coils, is generally accepted as the best choice for the treatment of multiple PAVMs, the mode of intervention for solitary PAVMs remains a subject of debate. We present a 43-yr-old woman with a 10-yr history of chronic migraines and dyspnea on exertion. She was discovered to have a large solitary centrally located PAVM, placing her at high risk of complications if she were to undergo percutaneous transcatheter embolization. She underwent successful surgical resection of her right middle lobe without complications, resulting in subsequent symptomatic improvement.