Is surgery effective for treating headaches?

Surgery for Headaches: Effectiveness and Recommendations

Surgery is generally not recommended as a treatment for headaches alone, except in specific clinical scenarios where other treatments have failed and there is clear evidence of a surgical target. 1

General Approach to Surgical Management of Headaches

Idiopathic Intracranial Hypertension (IIH)

• CSF diversion surgery (shunting) is not recommended for headache management alone in IIH 1
• Following CSF diversion, 68% of patients continue to have headaches at 6 months and 79% by 2 years 1
• 28% of patients can develop iatrogenic low-pressure headaches after shunting procedures 1
• CSF diversion should only be considered in a multidisciplinary setting after intracranial pressure monitoring 1

Neurovascular Stenting

• Neurovascular stenting is not currently recommended as a treatment for headache in IIH 1
• Evidence for stenting is limited by small sample sizes, selection bias, and lack of long-term follow-up 1

Migraine Surgery

• Trigger site decompression surgery for chronic migraine has been studied but lacks high-quality evidence 2
• While some studies report improvements in migraine frequency and intensity after surgery, the quality of evidence is consistently low or very low 2
• Surgical interventions for migraine are heterogeneous, including nerve decompression, nerve excision, artery resection, and nasal surgery 2

Specific Surgical Approaches

Chronic Cluster Headache

• Microvascular decompression of the trigeminal nerve with section of the nervus intermedius has been studied for chronic cluster headache 3
• Initial success rates of 73.3% drop to 46.6% at long-term follow-up 3
• Repeat procedures have poor success rates, with 7 of 8 failing at long-term follow-up 3

Trigger Point Deactivation

• Surgical trigger site deactivation aims to achieve lasting symptomatic improvement by addressing peripheral triggers 4
• Proper identification of trigger points and close collaboration with neurologists are essential for successful outcomes 4
• Patients who do not respond to or cannot tolerate medical treatment might be considered for this approach 4

Non-Surgical Approaches (Preferred First-Line)

Pharmacological Management

• NSAIDs are recommended as first-line treatment for mild to moderate migraine 1, 5
• Triptans are recommended for moderate to severe migraine 1, 5
• Corticosteroids are not first-line for routine migraine but may be beneficial for status migrainosus 5

Behavioral and Non-Pharmacological Approaches

• Behavioral treatments (relaxation, biofeedback, cognitive-behavioral therapy) have strong evidence for headache management 6
• Physical therapy is suggested for tension-type, migraine, or cervicogenic headache 1
• Aerobic exercise or progressive strength training is recommended for prevention of tension-type and migraine headache 1

Important Considerations and Pitfalls

• Patients with IIH often have coexisting migrainous headaches superimposed on headaches secondary to raised intracranial pressure 1
• Failure to optimize intracranial pressure may render migrainous headaches difficult to treat 1
• Surgical interventions carry risks of complications and neurological deficits 3, 2
• Patient selection is crucial - surgical options should only be considered after failure of appropriate medical management 4
• The quality of evidence for surgical interventions is generally low, with heterogeneous approaches and limited long-term follow-up 2

Decision Algorithm

1. Establish accurate headache diagnosis (migraine, tension, cluster, IIH) 1
2. Implement appropriate first-line pharmacological treatment based on headache type 1, 5
3. Add non-pharmacological approaches (behavioral therapy, physical therapy, lifestyle modifications) 1, 6
4. For refractory cases, consider specialized referral to headache centers 1
5. Consider surgical options only after failure of comprehensive medical management and when a clear surgical target exists 4