Migraines in children have been associated with anxiety and depression as well as physical and psychiatric morbidity. How can a new intervention for pediatric migraine improve and potentially eliminate these headache symptoms in the pediatric/adolescent population?
About 8% of pediatric patients experience migraine headaches, and those migraines are linked to increased physical and psychiatric morbidity as these children reach adulthood.
Another 10.6% of children aged 5 to 15 years and 28% of adolescents aged 15 to 19 years have reported suffering from at least 1 migraine-and migraines have been associated with psychosocial problems including anxiety and depression.
Pediatric migraines are poorly controlled through traditional therapies and a limited pool of medications, but a plastic surgeon has published a new study chronicling the success of a surgical intervention for migraines.
Bahman Guyuron, MD, FACS, a Cleveland, Ohio-based plastic surgeon and emeritus professor of plastic surgery at Case Western Reserve University School of Medicine, says he pioneered migraine surgery-also referred to as nerve decompression surgery-in 2000. Guyuron says his report is the first scientific publication to discuss surgical treatment of migraine headaches in the pediatric/adolescent population, whereas over 30 articles have been published in relation to the safety and efficacy on migraine headache in adults using the techniques that he developed and has been refining over the last 15 years. The report was published in the June 2015 issue of Plastic and Reconstructive Surgery.
Guyuron and colleagues conducted the retrospective study of 25 surgeries he performed on 14 patients aged younger than 18 years between 2000 and 2014.
The patients studied in the retrospective review all had been diagnosed with migraines by a pediatric neurologist, and they had family histories of pediatric migraines continuing through to adulthood. The average age of the patients at the time of surgery was 16 years, but the youngest patient was 9. The cohort consisted of 11 girls and 3 boys.
When asked about the frequency of their migraines an average of 38 months after their initial surgery, patients reported a decline in migraine occurrence from 25 to 5 migraines over a 30-day period. The migraine headache index also dropped, from 148.1 to 12.4, and the duration of the headaches dropped from 0.71 hours per 24-hour period to 0.25 hours. Patients also reported a decline in the severity of the headaches, from 8.2 to 4.3.
Five patients were completely migraine free after their surgeries, and 1 patient experienced shorter duration and less severity but no improvement in the frequency of headaches.
Pediatric migraine management is difficult for many reasons, Guyuron says. “When the adults suffer, they suffer themselves and, to a lesser degree, the spouses and the children,” he says. “When the children suffer, the parents are in as much pain or more.”
In addition, parents of pediatric migraine patients express concern over the amount of school the children miss related to their migraine symptoms, Guyuron says. Many of the medications that are very effective in treating migraines in adults have not been approved for the pediatric population, he notes.
The American Academy of Neurology currently recommends pharmacologic treatments for pediatric migraines such as ibuprofen, acetaminophen, or nasal sumatriptan. Topiramate is recommended for prevention of migraines, according to the guidelines, but it is not approved for children aged younger than 12 years.
Guyuron’s report also notes that in a recent study of adolescents under neurologist care for their migraines, 24% continued to suffer from migraine symptoms despite specialized medical treatment.
Surgical intervention for migraines has been proven effective in adults, Guyuron says, but a study has never been conducted on pediatric or adolescent cases.
The rationale behind the surgery is the idea that most migraines are triggered by irritation or compression of the peripheral branches of the trigeminal or occipital nerves. Migraine sufferers also have been shown to have myelin deficits, which Guyuron says in his report “further validates the role of peripheral mechanism in the complex migraine cascade.”
There are 6 migraine trigger sites:
• Frontal headaches involve supraorbital and supratrochlear nerves irritated/compressed by the glabellar muscles and the surrounding vessels or fascia bands. These are treated by resection of the glabellar muscle group to decompress the nerves.
• Temporal headaches involve the zygomaticotemporal branch of the trigeminal nerve being irritated/compressed by the temporalis muscle and concomitant vessels. This type is treated surgically by endoscopic resection of the zygomaticotemporal branch of the trigeminal nerve.
• Rhinogenic headaches occur when the contact points between the septum and turbinate, concha bullosa, Haller cell, or sinus inflammation may trigger migraines. Treatment includes septoplasty and turbinectomy.
• Occipital headaches result from compression or irritation of the greater occipital nerve by the semispinalis capitis muscle, fascia bands, or the main trunk or the branches of the occipital artery. They are treated by the removal of a segment of the semispinalis capitis muscle to decompress the occipital trigger site.
• Posterior temple headaches involve compression or irritation of the auriculotemporal nerve or its branches by the branches of the superficial temporal artery, and are treated by removing the temporal artery.
• Lesser occipital nerve headaches, which can be caused by irritation or compression by the fascial bands or surrounding vessels, can be treated with neurectomy of the lesser occipital nerve.
Prior to surgery, histories and physicals were taken on the patients, and family history was analyzed to ensure pediatric migraines wouldn’t resolve naturally by adulthood.
“Pediatric migraine headaches may cease when the children reach adulthood. It has been demonstrated that family history is a very reliable predictor of this course. If the parents or adult siblings demonstrate continuation of migraine headache from adolescence to adulthood, this pattern will likely be repeated in the child with migraine headache,” Guyuron wrote in the report.
The migraine trigger site is detected by asking the patient to record for 1 month where their headaches begin. In the diary, patients include frequency, severity, and duration of their headaches as well. An emerging method to detect trigger sites is also available, involving a Doppler signal in the most painful site of the headache or using a nerve block with 0.5 cc of ropivacaine if that patient is having a migraine at the time of examination. Computed tomography scans are useful in revealing contact points between turbinates and the septum in patients whose headaches begin in the retrobulbar area indicating nasal trigger sites, Guyuron notes.
“Surgery for refractory migraine headache in the adolescent population may improve and potentially completely ameliorate symptoms for some. There was a statistically significant improvement in frequency, severity, and duration of migraine headache; migraine index; and migraine days in our cohort of patients who underwent migraine surgery,” Guyuron wrote in his report. “It is always crucial to ensure the safety of any new procedure. In review of these charts, we identified no major or minor intraoperative or postoperative complications of surgery. This indicates, at least preliminarily, that surgery is safe in this population.”
Guyuron emphasizes the vulnerability of the adolescent group, noting additional hurdles of requiring a legal guardian for decision making and a lack of knowledge and experience compared with adult patients, and the fact that there are other medical issues or physical characteristics that may prevent some adolescents from being candidates for this surgery. He points out, however, that it still would be a beneficial treatment for this population. “Not only are migraine headache[s] detrimental to the adolescent patient from a pain and functioning standpoint, the headaches can also have an effect on long-term physical and mental health,” he wrote. “Furthermore, current medical treatment, although effective for some patients, offers few preventative options, and there remains a subset of patients with refractory symptoms following specialist treatment.”
In many cases, the benefits of the surgery are worth the risks, Guyuron says.
“The procedures are minimally invasive, outpatient with short recovery. We have not observed any complications related to the surgery in this group of patients, nor have we noticed any major complication in over 2,700 procedures,” Guyuron says. “We have had failures, a few [cases of] permanent numbness. All of these adverse effects have been carefully documented.”