Microsurgery for Migraines -- In-Depth Doctor's Interview
Ivan Ducic, M.D., Ph.D., chief of peripheral nerve surgery at the Georgetown University Hospital in Washington, D.C., talks about a new surgery to treat migraines.
What is a migraine headache?
Dr. Ducic: There are several definitions, but migraine headaches are pretty much headaches that are chronic and present despite the number of different regimens provided by headache specialized providers, be it neurologist or pain specialist.
What causes a migraine?
Dr. Ducic: We are still learning about it frankly, but some of the reasons can be hormonal, can be environmental, can be stress, can be noise, can be light, and also as we are learning more, can be nerve related problems due to the compression of the nerves that are sometimes simply providing sensory input to our scalp or front or side or back of our heads.
What kind of effect can chronic migraine have on a person?
Dr. Ducic: It makes them significantly dysfunctional. It makes them feel pain, not being able to complete their professional or personal duties. It is a type of severe headache that disables people from doing much. They can have visual symptoms. They can have sensory symptoms associated to the headache. Everybody has lived a different, individual approach.
What is the traditional way of treating migraines?
Dr. Ducic: The traditional way is to see headache specialized providers by means of a neurologist or a pain specialist who rules out possible organic causes of the headache in terms of the tumors or metabolic causes. Once those things could be addressed, medications are next in line for treatment. Most of the patients actually do respond to those things; unfortunately, a number of patients do not.
What percentage of patients does not respond to medicine?
Dr. Ducic: I do not know exactly. I know there are approximately 28 million Americans suffering from chronic migraines and over two-thirds of those are women. To my knowledge, there is no specific number of how many patients are responsive or not responsive to medications.
What do you do if you are a patient that does not respond to medicine?
Dr. Ducic: Unfortunately, some patients must be told there is no much else we can do about their migraine. Over the past few years, we've learned more and there are certain avenues that we can explore to help those patients. We need to find out the true identifiable problem that may be associated whether or not it is migraines or chronic headaches causing them.
Who are the people eligible for the microsurgery?
Dr. Ducic: The first criterion is to have a headache or migraine longer than six months. The second criterion is to be under the care of a headache specialized provider, either a neurologist or a pain specialist, who will exclude the possible organic or metabolic causes of the headache and prescribe proper first, second, or third line medical treatment regimens for their condition. If their symptoms are not going away or if they cannot tolerate medications well because of allergies or any kind of tolerance, something else must be done. If these patients have tenderness over the nerves (greater or lesser occipital, supraorbital/trochelar, zygomatico/auriculo-temporal nerves), it means the sensory nerve is compressed with the anatomical structures it goes through, thereby causing occipital neuralgia or fronto-temporal neuralgia related symptoms of a headache in the back, front, or side of the head. These patients are then candidates for evaluation for peripheral nerve surgery I perform.
Is there something physical within the person or is it just stress related?
Dr. Ducic: It is very difficult to differentiate those because your nerve may be compressed as it is, but it gets more compressed from extra stress or stimuli from the environment which takes you over the top. Then a full presentation of a chronic headache or a migraine that can then rehabilitate you in a couple of days or even constantly can show up.
What causes the nerve to be compressed?
Dr. Ducic: There are five possible sites where occipital nerves can be compressed on their way from the spine to the occipital scalp. One of the most common involved of occipital as well as for fronto-temporal nerves is nerves passage through or under the muscle. The muscle function pinches the nerve, compressing and irritating the nerve; subsequently, it will start protesting in one way that will be presented as a headache.
What are the two nerves you are talking about?
Dr. Ducic: In the back of the head, it is primarily the greater occipital nerve and occasionally the lesser occipital nerve. These two nerves can give you occipital neurologia related headache or migraines. In the front of the head, it is the supraorbital and supratrochlea, while on the side (temple) it is zygomatico and auriculo-temporal nerve.
How many different nerves could be affected?
Dr. Ducic: Two nerves in the back, two in the front, and two on side, bilaterally, can be affected.
What is happening to the nerve if it is causing you migraines?
Dr. Ducic: The nerve is truly compressed with the muscle function or the tunnels that pass through which subsequently causes the headache. That respective distribution can cause the pain as carpal tunnel in the hand which leads to a numbness in the wrist.
What causes the compression?
Dr. Ducic: Compression of the nerve can be due to either the hyperactive muscles that can irritate the nerve for the long time or it can be a trauma. I see lots of patients with whiplash injuries, after motor vehicle accident or traumas who subsequently develop a headache because their nerves do not function normally anymore and cause migraine occurrent headaches.
Is it stress or something else?
Dr. Ducic: They can have associated or true migraine components of their headaches which can compress nerves to go back and forth between the two causative factors and create either true migraine or chronic headaches.
How long has it been known that compressed nerves cause migraines?
Dr. Ducic: It has been known for several years. I would say there were reports already published in the early 90s about nerves in this anatomic distribution that causes headaches. The biggest problem is that it may be difficult for an everyday physician to know exact inclusion criteria, who should qualify for the surgery and when it should be considered. It should be considered for anybody with chronic headaches, migraines for longer than six months despite the optimal care provided by headache specialist providers, or tenderness over the nerves when the nerve is pressed very vividly. If the nerve block is effective in that anatomical, their headaches can temporarily be controlled, relieved, or eliminated. That is an indirect sign that the nerves are truly involved into photogenesis of the headaches which makes them clear candidates for the surgery.
Is this a new surgery?
Dr. Ducic: I have been doing this for three and a half years myself. Some other physicians might have been doing this since about mid-late 90s. I have no answer as to why more people don't pick up on it.
Is it a difficult surgery?
Dr. Ducic: The surgery certainly requires technical skills to perform it safely, but it is not a particularly difficult surgery. What is very difficult is the coordination and care between the patient, the surgeon, and the neurologist or pain specialist who would channel these patients in a proper way so they are properly selected for the surgery. If the proper selection of patients is chosen, the outcome would certainly be very good.
What happens during the surgery?
Dr. Ducic: During the surgery, the nerves are decompressed. Surgeons can take a small cuff of muscle around the nerve that is pinching the nerve without affecting the muscle function or can widen the space that the nerve goes through tunnels. Hopefully, there was no previous mechanical injury to the nerve with either a nerve stimulators or direct trauma in a way that the nerves would be scarred in. Decompressing the scarred in nerves won't have much of a benefit. Then we have to excise those nerves, which in response would cause numbness. It is almost like a gift since they do not have a headache anymore.
How immediate is the relief?
Dr. Ducic: Everybody is a little bit different. It can be a couple of weeks before the responsive surgeries. Most of the patients do respond to surgery and will tell you what effect it had on them by about three months.
What percentage of people does the surgery not work for?
Dr. Ducic: Approximately 20 percent of the patients do not respond to surgery despite above proposed treatment plan. There are patients who continue to have tenderness over the nerve despite initial surgery. If I decompress the nerves and they still respond to the nerve blocks, I offer to excise the nerves if decompression didn't work. I find that the vast majority of these patients do get better. I only know about half a dozen of patients that didn't get better after second surgery.
The nerves are removed in the second surgery?
Dr. Ducic: Yes. They are taken out. This leaves the patient with numbness in the back of their head. These nerves have nothing to do with the function of your brain, arms, or legs; you cannot be paralyzed from them because they are purely sensory nerves providing sensation to the forehead, temple, or back of your head. There is no danger. Excising the nerve would not cause any of the permanent damages in terms of motor function or deficit.
Does the patient lose anything if the nerve is removed?
Dr. Ducic: Only sensation in this case.
Just sensation in parts of your head?
Dr. Ducic: Right. Over time body adapts to that. It is very well tolerated as some of the patients can pretty much conform on their own.
Where are the incisions made?
Dr. Ducic: The incisions are made in the back of the head. The way I designed the procedure is that I do not shave the patient's hair; the female population of the patients appreciates that. Surgery has been done in outpatient basis and takes less than an hour and a half of operative time. By about three weeks, sutures are removed. Depending upon what type of job hold, you can go back to work anywhere between ten to fourteen days. Again, granted you do not do heavy manual work.
Is it a one time thing or will compression happen again?
Dr. Ducic: It is a one time thing, unless the compression doesn't work at all and in that case, the excision can be planned subsequently.
If you release the pressure around this nerve, will you only have to do it once?
Dr. Ducic: That is correct, but I've seen patients who have had a headache for 20 to 30 or even 50 years. It is amazing to hear the number of people with 50-year-old headaches. It might be sometimes unrealistic to expect that the surgery can fix them and they will be completely fine afterwards. Because of the chronic nerve irritation and compression, the nerves might not have a capacity to regenerate anymore even after being decompressed. If they are not able to regenerate anymore, they will continue to have chronic headaches or a migraine despite performed decompression. That is why some of those patients require the excision later on.
What happens for most people when they first have surgery?
Dr. Ducic: The surgery works for close to 80 percent of the patients. It usually starts with the occipital area for the occipital neurologia related headache or migraine. That must be taken care of first. Then, the patient must be reevaluated in three months. If they have no problems in the back anymore but they continue to have problems in the front or side of the head, I would direct second stage surgery for front or side of the head.
What happens to the nerve after the surgery?
Dr. Ducic: After it has been decompressed, the nerve should regenerate and respond clinically to no headaches or at least diminish headaches after the surgery.
What are you doing when you actually go in for the first surgery?
Dr. Ducic: For the first surgery, a small portion of the muscles pinching the nerve is removed so that the nerve is not being compressed with that component of the muscle. The tunnel that nerve penetrates as it comes through the musculature, the place where they touch the occipital bone, is widened as well, as is the vasculature is found separated from the nerve since that can also be a cause of throbbing headaches and occipital neuralgia.
Are there any side effects or problems other than possibly needing a second step?
Dr. Ducic: I do not recall that anybody was made worse although some of the patients were certainly not made better and progressed to suffer with headaches. The only minor issue is the two out of three or four hundred patients had an infection around the incision. However, that is statistically really nearly nothing...two out of 400 patients.
How widely used is this by doctors and where do you think it is going to go?
Dr. Ducic: I do not have exact number of how widely it is being used. I do know that on a larger scale there are about few physicians in the country that do this on a daily basis. I'm sure a number of other physicians will slowly start picking up on that and will start doing it.
Are you teaching other doctors this technique?
Dr. Ducic: Currently, I do not have my own course, although I am a part of the faculty course that is teaching other doctors.
Do you think it is going to become a standard procedure over time?
Dr. Ducic: As with every other peripheral nerve surgery, the key part is educating the colleagues and patients when to operate and whom to operate. That is the critical part of success. If there is misunderstanding when to operate and on whom to operate, time wise and indication wise, the outcome and widespread application of the procedure can be significantly compromised.
As a doctor, how excited are you about this surgery?
Dr. Ducic: It is very cool to help somebody that had painful 20, 30, 40 or 50 years and have relatively simple procedure to help them live a normal life. It is actually very cool and rewarding; it is a real pleasure actually taking care of these patients.
What was Penny's situation?
Dr. Ducic: Penny was one of the patients who had initial decompression that unfortunately did not provide her relief. After the second surgery, I had to excise the occipital nerves. She stated that got her life back and she is very appreciative. She can truthfully say what she feels about the outcome of her surgery.
Is that from a clinical perspective?
Dr. Ducic: As far as I know, she does not have any more headaches. She used to have it. It is normal for every normal person to occasionally have a headache as all of us do sometimes, but it is not normal to have a headache everyday. It is an inconvenience when you have headache and have to stop doing everything for a couple of days. Bringing patients from that type of disability to back where they were before in terms of personal professional life is a tremendous award. It is also very beneficial for society in terms of healthcare costs.
How compressed was her nerve? What did it look like when you went in?
Dr. Ducic: Her nerve went straight through the muscle and was quite compromised. Under the microscope, I could not see that it had any normal ultra structure in terms of the anatomy. Normally, it would be less compromising on the other patients as it was on hers. That indirectly tells me why she did not respond initially to decompression of the first incision.
Was the nerve absorbed in the muscle?
Dr. Ducic: No. It was caught in the outer part of the muscle. The nerve did not look healthy. It was thin and transparent. The ultra structure of the nerve and the anatomy did not look right. The skin that was being rubbed was similar to a callus from three or four months where the skin does not become normal. It really looked like a comparison between the callus on the skin and very normal skin.
How compressed was her nerve?
Dr. Ducic: It was hardened and it was a tighter than normal nerve.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Ivan Ducic, MD, PhD
Georgetown University Hospital
Division of Plastic Surgery
Sign up for a free weekly e-mail on Medical Breakthroughs called
First to Know by clicking here.
To read the full report Microsurgery for Migraines, click here.