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SURGERY FOR MIGRAINE RELIEF
CONTROVERSIAL NEW TREATMENT QUELLS HEADACHES -- BUT MANY QUESTIONS REMAIN

During the 35 years she suffered from frequent migraines so severe they made her vomit, Viera Bernat said she tried nearly every treatment imaginable. She changed her diet, practiced relaxation exercises and took a string of powerful drugs, from narcotic painkillers to Imitrex, one of a class of medications called triptans.

"Nothing really worked," said Bernat, 62, a family physician who practices in Solon, Ohio. Despite a high pain threshold, she said, "mostly I suffered."

Desperate for relief, Bernat tried a new and controversial remedy: plastic surgery.

Nearly three years ago, as part of an experimental study, Bernat had her forehead lifted and her nose reshaped by Cleveland plastic surgeon Bahman Guyuron. For several months before the outpatient surgery, Guyuron had injected the anti-wrinkle drug Botox, also known as botulinum toxin A, into sites on Bernat's face and the back of her neck to determine if the paralytic drug reduced her headaches. Based on the results of those injections, Guyuron decided that muscles or tissue underlying those spots should be surgically removed to treat her pain.

To Bernat's delight, the surgery worked. Although she occasionally gets minor headaches and her forehead still feels numb, her weekly migraines have stopped. "I feel that I have my life back," she said. "I am so grateful."

No one knows what causes migraines, which affect an estimated 28 million Americans, according to the National Institutes of Health. The condition, which often surfaces before age 35, appears to be a neurological problem linked to inherited abnormalities in genes that affect certain brain cells, rather than the dilation of blood vessels in the head, as scientists had long theorized.

Guyuron has another theory: that migraines are triggered by muscles that pinch the trigeminal nerve, which studies have shown is activated during a migraine attack. For the past six years he has pursued this theory, publishing in the peer-reviewed journal Plastic and Reconstructive Surgery several studies of the surgical treatment he pioneered. Guyuron said he got the idea after several patients casually told him that their migraines had vanished after they underwent cosmetic forehead surgery to smooth wrinkles and lift their brows.

In his most recent study, published in January, Guyuron said that 92 percent of 89 patients he operated on reported that the frequency, intensity and duration of their migraines was reduced by at least 50 percent. In 35 percent of these patients, including Bernat, surgery eliminated the migraines. In a control group of 25 patients who received saline injections, 15 percent reported a significant reduction in headaches, but none reported that their migraines were eliminated.

"It's too early to call it a cure," said Guyuron, a clinical professor of plastic surgery at Case Western Reserve University, who is following patients to see how they fare long-term.

But many neurologists say they are skeptical of Guyuron's hypothesis -- that removing muscles pressing on nerves will quell migraine pain -- as well as the methodology of his latest study, which assigned four times as many patients to the treatment group as to the control group.

Some critics point out that Guyuron performed a variety of procedures on the patients, making it impossible to evaluate the success of treatment. Nearly all had a forehead lift, which involved removing the corrugator muscles, while 70 percent had an operation to straighten a deviated nasal septum (the cartilage and bone that separates the nostrils) and 38 percent had a portion of the greater occipital muscle from the back of the neck removed.

Among the temporary side effects Guyuron and his team reported, most related to Botox injections, were hollowing of the muscles in the temple, which created a scooped-out appearance (23 percent); a drooping eyelid, also known as ptosis (10 percent); and intense scalp itching lasting an average of six months (9 percent).

Ivan S. Login, a migraine expert and professor of neurology at the University of Virginia, said he wasn't sure Guyuron's patients had migraines or a different type of headache caused by sinus or other problems. He also said that the success rate seemed unusually high. "Until these results are replicated, it's hard to know how much validity to put on this data," said Login.

Jennifer S. Kriegler, a neurologist and co-author of the January study, said that she diagnosed patients. All had migraines according to the standard medical definition.

"I will tell you I was as skeptical as anyone," she said. "To me the biggest issue is going to be long-term follow-up."

Surgery, she said, is not a first-line treatment. "These are people who have failed everything" or who cannot take triptans.

Cost is a major drawback, because insurance companies would consider the surgery, for which Guyuron charges $4,000 per site, cosmetic and ineligible for reimbursement, just as they do with Botox treatments for migraines. Most patients, according to Guyuron, need surgery on at least two sites.

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