Significant improvements with surgical treatment for migraine

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In addition to reducing headache frequency and severity, surgical treatment for migraine leads to significant improvements in everyday functioning and coping ability, according to a study.

“Our study demonstrates the high functional disability experienced by migraine patients, compared to those with other pain conditions, ” comments American Society of Plastic Surgeons (ASPS) member surgeon William Gerald Austen, Jr, of Massachusetts General Hospital. “The results also show that migraine surgery can lead to dramatic improvements in functioning and coping ability, even in patients who are very disabled before surgery.”

Surgery has become recognised as an effective treatment option for selected patients with chronic, severe migraine headaches who do not respond to standard treatments. Developed by plastic surgeons who noticed that some migraine patients had fewer headaches after cosmetic forehead-lift, migraine surgery procedures address trigger sites linked to certain headache patterns.

However, most studies evaluating migraine surgery have relied on migraine-specific questionnaires. “Pain questionnaires used in the evaluation of better-understood and more common pain syndromes have not been applied to migraine surgery,” Austen and co-authors write.

The study evaluated the performance of one such questionnaire – the Pain Self Efficacy Questionnaire (PSEQ) – in migraine surgery patients. The PSEQ has been used to study treatment outcomes in patients with a wide range of pain conditions. It provides information not only on pain scores, but also on functional disability and ability to cope with pain when performing normal daily activities.

The study included 90 patients who underwent migraine surgery, performed by Austen, between 2013 and 2015. Before and after surgery, patients were evaluated on a standard migraine questionnaire (the Migraine Headache Inventory, or MHI) and on the PSEQ. The final analysis included 74 patients who completed both questionnaires at one-year follow-up after migraine surgery.

Before migraine surgery, the patients had “extremely poor” PSEQ scores, indicating a high level of disability. Preoperative pain coping scores in migraine patients were substantially lower than reported for patients with other types of chronic pain – for example, neuropathic (related to nerve damage) pain, arthritis, or lower back pain.

One year after migraine surgery, the patients had a very large percent improvement in average PSEQ score: on average, 112% higher than baseline. That was much higher than in studies of patients with other types of chronic pain: for example, an average 19% improvement after non-surgical treatment for low back pain.

Migraine surgery improved functioning and coping even in patients with very low initial PSEQ scores. That’s in contrast to patients with musculoskeletal problems such as low back pain, in whom low PSEQ scores predict poor treatment outcomes.

“It seems that migraine surgery patients can recover function and ability to cope with pain very well after surgery, in stark contrast to what has been shown in other pain conditions,” Austen and co-authors write. They note that surgery also led to an average 76% improvement in the migraine-specific MHI score, measuring outcomes like headache frequency, duration, and severity.

The new study shows “continued positive outcomes” after migraine surgery in appropriately selected patients, including large improvements in migraine-related disability.

Austen and colleagues conclude, “Chronic pain questionnaires such as the PSEQ add to our understanding of functional outcome after surgery and put pain in migraine surgery patients in perspective to better-known pain conditions.”

Background: Candidates for migraine surgery are chronic pain patients with significant disability. Currently, migraine-specific questionnaires are used to evaluate these patients. Analysis tools widely used in evaluation of better understood pain conditions are not typically applied. This is the first study to include a commonly used pain questionnaire, the Pain Self-Efficacy Questionnaire (PSEQ) that is used to determine patients’ pain coping abilities and function. It is an important predictor of pain intensity/disability in patients with musculoskeletal pain, as low scores have been associated with poor outcome.
Methods: Ninety patients were enrolled prospectively and completed the Migraine Headache Index and PSEQ preoperatively and at 12 months postoperatively. Scores were evaluated using paired t tests and Pearson correlation. Representative PSEQ scores for other pain conditions were chosen for score comparison.
Results: All scores improved significantly from baseline (p < 0.01). Mean preoperative pain coping score (PSEQ) was 18.2 ± 11.7, which is extremely poor compared with scores reported for other pain conditions. Improvement of PSEQ score after migraine surgery was higher than seen in other pain conditions after treatment (112 percent). Preoperative PSEQ scores did not influence postoperative outcome.
Conclusions: The PSEQ successfully demonstrates the extent of debility in migraine surgery patients by putting migraine pain in perspective with other known pain conditions. It further evaluates functional status, rather than improvement in migraine characteristics, which significantly adds to our understanding of outcome. Poor preoperative PSEQ scores do not influence outcome and should not be used to determine eligibility for migraine surgery.

Lisa Gfrerer, Jonathan Lans, Heather R Faulkner, Sjoerd Nota, Arjan GJ Bot, William Gerald Austen

Wolters Kluwer Health material
Plastic and Reconstructive Surgery abstract

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