Patient selection is the most important factor for successful surgical treatment of migraine headaches. Although it has been commonly known as migraine surgery, the treatment is meant to target a specific group of patients who are diagnosed with “chronic migraines”.  It is believed that many of the patients who are considered chronic migraineurs actually suffer from nerve compression headaches. Surgery aims at releasing nerve compression through small incisions.  Headache history is very critical in identifying surgical candidates. Here are some pointers on who could benefit from surgical treatment.

• Patients typically have 15 or more headaches per month. Patients with chronic migraines due to nerve compression have daily or almost daily and sometimes constant headache that is described as pressure, tightness or squeezing pain. There is often a lingering pain in between headache episodes that does not go away completely.
• Pain is located in one or more of four primary sites, forehead, temple, back of the head and behind the eyes. There are 4 primary trigger or compression points of specific nerves that correlate with these sites.
• Pain is poorly controlled by medications or patients cannot tolerate medications. Nerve compression headache doesn’t respond well to preventatives like Topiramate (Topamax). Patients have often tried numerous preventatives with out effect.
• Disability due to the severity and frequency of headaches.
• Tenderness over the involved nerves. For example, patients with headaches involving the back of the head have tenderness over the exit points of the occipital nerve under the skin. It often hurts the patient to put their head on the pillow and they wake up at night with head hurting.
• Favorable response to botox treatment is a positive sign that a patient may benefit from surgery. Also favorable response to nerve block is another positive sign that indicates nerve compression as the cause of pain.
• Patients with severe chronic headaches that have septal deviation or chronic nasal congestion.

These are general criteria of the type of headache that can benefit from surgery but are not necessarily present in all patients.  Every patient should be under the care of a neurologist who establishes the diagnosis and is actively treating the patient’s headaches. The plastic surgeon works closely with the neurologist for patient selection and for pain management after surgery.