Migraine Surgery: What It Is and Why Many Neurologists Don’t Recommend It

Researchers are still learning what causes different kinds of migraine headaches. Some physicians say that migraine can start when nerves or blood vessels are irritated or compressed. These compression points are also called trigger points. There may be one or several, depending on your migraine attacks.

One type of migraine surgery aims to relieve that pressure by removing small sections of bone or tissue pressing on the nerves, or cutting the nerves themselves. Other types reduce the size of structures in your sinus area that could be making your migraine worse.

Laine Green, MD, FRCP(C), FAHS, a neurologist who specializes in treating headache disorders at the Mayo Clinic in Scottsdale, Arizona, explains that the evidence supporting surgical treatment for migraine is still far too limited for many physicians to recommend it.

“This is a tough subject because these surgical treatments aren’t well studied,” Green says. “On one hand, there are studies that suggest there may be subsets of people who may benefit from them. But with surgical studies it is hard to be thorough with trial design, so the results aren’t as robust as we’d like them to be. As headache specialists, we want to follow the best evidence.”

Likewise, the American Headache Society has urged patients and physicians not to pursue “surgical deactivation of migraine trigger points outside of a clinical trial.” The organization says there isn’t enough reliable research or information about possible harm from the surgery and virtually none about the long-term effects of these surgeries.

Read more information about migraine.

While neurologists and headache specialists do not recommend migraine surgery, some surgeons are performing these procedures. Here’s a brief look at each type of migraine surgery, along with a discussion of why it may or may not work for you.

Peripheral neurolysis

Peripheral neurolysis describes several surgeries that target nerves involved in migraine attacks. One type is known as nerve decompression or nerve liberation. A surgeon removes a small area of tissue or bone surrounding a nerve in your face, head, or neck. The goal is to relieve pressure on the nerve.

After the nerve has been liberated or decompressed, the surgeon plumps the area with fat to keep other structures from pressing on it in the future. In another type of nerve surgery, a surgeon cuts the nerve completely, burying the ends in nearby muscles.

Some of these procedures can be performed endoscopically, which means the surgeon operates with very small instruments inserted through a thin tube. Endoscopic surgeries are less invasive than those with larger, open incisions.

A 2020 research review of 39 articles concluded that the surgery was a valid treatment for migraine. The study notes that some patients had less severe, less frequent migraine attacks after surgery.

However, many neurologists and headache specialists feel it is too soon to say migraine surgery is a safe treatment option, in part because of the difficulty of carrying out high quality surgical studies to prove that these methods are safe and effective. There simply aren’t enough randomized, controlled studies to support them.

“The gold standard for a clinical trial is that everything besides the intervention you’re studying is kept the same,” Green says. “That means some people would have to undergo sham surgeries so you can compare the effects. The results, even within the existing studies, are mixed. Even where the study population has fewer or less severe headaches, it’s hard to know whether something else, such as anesthesia, caused the improvement in symptoms.”

Neuromodulation

Neuromodulation uses electromagnetic pulses to stimulate nerves that may trigger migraine headaches. The Food and Drug Administration (FDA) has approved the use of several external neuromodulating devices for the treatment of migraine headaches. These devices send electromagnetic pulses through your skin.

It’s also possible to have a neuromodulator surgically implanted beneath the skin, but there is some debate over whether the implanted devices are as safe and effective as the external devices. Though some implanted devices are being studied in clinical trials, there is currently more evidence supporting the use of external devices.

“These noninvasive electrical stimulation devices are FDA-approved for treating migraine,” Green says. “The transcutaneous devices don’t have the risks of surgery. We can use them at any point in the process as part of a multipronged approach [for treating migraine]. There are no medication side effects and no medication interactions, which is nice.”

Electrical stimulation devices can be used along with medications to treat migraine. But Green cautions that they’re not for everyone. Some patients don’t like the sensation that the device creates.

As far as the implanted devices go, Green says that while the risks of surgery are generally low, “with implanted neuromodulators, electrodes can move away from the target areas, and wires can break. That means some patients may have to have multiple procedures.”

Septoplasty

Septoplasty is surgery to correct a deviated septum. A deviated septum is when the “wall” separating your nostrils — the septum — leans to one side, blocking your airflow. When the airflow is blocked like this, it can lead to intense headaches.

Septoplasty repairs and reshapes the septum to open up your airways and relieve pressure or pain. These surgeries are often performed by doctors who specialize in ear, nose, and throat conditions.

It’s important to note that even when septoplasty successfully opens the airway, it doesn’t always relieve migraine. In one 10-year follow-up study, researchers said it was likely the headaches “may not be reduced even with surgical treatment.” It seemed certain, they said, that there would be more headaches in time.

Turbinectomy

Turbinectomy is a surgery that removes some of the bone and soft tissue inside your nose. These structures, called turbinates, warm and moisten the air you breathe in. When they grow too large, they can make it harder to breathe. They may also cause headaches.

There is some evidence that turbinectomy can help with severe headaches. In one large Taiwanese study, turbinectomy led to a 14.2 percent drop in the number of patients admitted to the hospital because of severe migraine. The patients involved in this study had a history of sinus problems.

Green explains it this way: “There is often some overlap between the ear, nose, throat, and migraine. Sometimes people have surgeries like septoplasties and turbinectomies to relieve what are believed to be sinus conditions, and then they discover that migraine has been in the background the whole time. That’s not uncommon.”

In a 2021 research review, researchers found that migraine and tension headaches caused most of the pain associated with sinus headaches.

Turbinectomies may help to reduce the severity or frequency of migraine headaches, but researchers say more high quality studies should be done to confirm the outcomes. For many people, headaches return after the surgery.

There are risks to any surgery or medical procedure. The risks of these surgeries are not fully known, but they are likely low.

With any surgery, there is a risk of bleeding, scarring, or infection. It’s also possible you’ll have some itching in the area.

With peripheral neurolysis, a neuroma or noncancerous tumor can form at the surgical site. Burying the nerve ending in muscle tends to reduce this risk.

With implanted neuromodulation, it’s possible the wires or leads could loosen and move away from the targeted nerve. Wires can also be damaged over time. These events could mean you’d have to undergo another procedure.

With septoplasty and turbinectomy, there’s a chance your sense of smell could be affected. These surgeries can change the shape of your nose, and your septum can be damaged in the process. You may have some sinus symptoms as a result of the surgery, including pain and nasal dryness.

Migraine surgery may be a treatment option for migraine, but it hasn’t been well studied yet. For that reason, many neurologists and headache specialists do not recommend it.

Green concludes, “The lack of high quality studies makes it hard to determine 1) Do these surgeries work or not? 2) Which population should they be offered to? and 3) When should they be offered? We want patients to have less frequent, less severe headaches with less duration, so people can have an increased quality of life. We want what works for them.”

If you want to learn more about FDA-approved treatment options that could reduce the duration, frequency, or intensity of your migraine headaches, talk with a headache specialist about what’s causing your migraine and what’s been proven to help.