Migraine News: Relieving Chronic Headaches With Nasal Surgery

Nasal surgery to relieve obstructed breathing can reduce or eliminate chronic headaches in selected patients, says a report in Plastic and Reconstructive Surgery. Eighty-five percent of patients undergoing functional nasal surgery had at least partial improvement in their headaches, according to a research summary and update by Ahmed M. Afifi, MD, and colleagues of University of Wisconsin, Madison. "These results suggest that the use of nasal surgery to improve headache symptoms is a viable treatment option in appropriately selected chronic headache patients."

The researchers analyzed available evidence from previous studies of nasal surgery to treat chronic headache. These procedures target "contact points" within the nose and sinuses, which are believed to serve as trigger points for chronic headaches. This type of surgery is often done as part of functional nasal surgery to relieve obstructed breathing. Functional nasal surgery has been shown to improve nasal airway breathing, allergy symptoms, and obstructive sleep apnea.

A systematic research review identified 39 studies reporting on 1,577 patients who underwent functional nasal surgery for treatment of headaches due to mucosal contact points. The most common procedures were surgery to address a deviated septum or excess sinus tissue. About half of the studies included endoscopic sinus surgery (ESS), often performed in patients with recurrent sinus infections. The data suggested that functional nasal surgery was highly effective in reducing or eliminating chronic headache symptoms. About 48 percent of patients reported that their headaches were cured after surgery, while another 37 percent had improvement in headache severity or frequency. Only 15 percent reported no change.

Improving Headaches

In a subset of studies, functional nasal surgery reduced the number of days with headache from approximately 22 to six days per month. Ratings of headache pain were also reduced. Sometimes patients are selected for functional nasal surgery by a local anesthetic nerve block. Patients who had a positive result - relief from headache pain - on this nerve block test were more likely to respond well to surgery. Outcomes also appeared better when ESS was performed as part of the surgery.

The paper is the first systematic review of evidence demonstrating that "nasal mucosal contact points may be a viable surgical target to help improve headaches in appropriately selected patients," Dr. Afifi and coauthors write. The good responses to nasal surgery suggest "an important relationship between intranasal anatomy and headache feedback loops. Taken together, these results underscore the importance of a thorough diagnostic workup to help tailor individualized surgical treatment to each patient's unique anatomy."

They emphasize that the specific procedures performed in the studies varied substantially, as well as the need for consistent diagnostic criteria to identify chronic headache patients who might benefit from functional nasal surgery. "Functional nasal surgery is a viable option to improve headache symptoms in appropriately selected patients," they conclude. They highlight the need for well-controlled randomized trials, including careful selection criteria to identify patients most likely to benefit from this surgical approach to treatment for chronic headache.

New Discovery Of Mechanisms That Cause Migraines

Researchers at CNRS, Université Côte d'Azur and Inserm have demonstrated a new mechanism related to the onset of migraine. They found how a mutation causes dysfunction in a protein which inhibits neuronal electrical activity and induces migraines. These results - published in Neuron - open a new path for the development of anti-migraine medicines.

Even though 15 percent of the adult population worldwide suffers from migraines, no long-term, effective, treatment has been marketed. Migraine episodes are related, among other factors, to electric hyperexcitability in sensory neurons. Their electrical activity is controlled by proteins that generate current called ion channels - specifically by the TRESK channel - which inhibits electrical activity. The researchers have shown that a mutation in the gene encoding for this protein causes a split between two dysfunctional proteins: one is inactive and the other targets other ion channels (K2P2.1) inducing a great stimulation of the neuronal electrical activity causing migraines.

Though researchers had already shown the hereditary nature of migraines, they did not know the mechanism underlying migraine. By demonstrating that the TRESK split induces hyperexcitability in sensory neurons leading to migraine, this work, carried out at the Institut de Biologie Valrose, opens new research path for the development of anti-migraine medicines. A patent application has been filed and the scope is targeting K2P2.1 channels to reduce the electrical activity of neurons and prevent migraines from being triggered. The researchers propose that this new genetical mechanism, causing the formation of two proteins instead of just one, has now to be considered for the study of other genetic diseases and for diagnosing them.

The Migraine Condition

Migraine headaches can strike any time. They affect approximately 12 percent of the population living in the U.S. and are three times more prevalent in women than men. Marc Lenaerts, director of outpatient neurology and a headache medicine specialist with UC Davis, recently discussed the condition and how to manage it. 

“Migraine is a condition or syndrome - not just a headache,” Lenaerts says. “Headache is a key symptom but not always present during a migraine. Someone with fewer than 15 headache days per month has episodic migraine while those who experience 15 or more headache days per month have chronic migraine. Migraine headache can be moderate or severe, with throbbing pain, unevenly distributed between each side of the head, made worse with physical activity. The pain is caused by nerve-controlled inflammation of the dura, or the membrane between the brain and the skull.” 

Symptoms can include cravings or loss of appetite, nausea, vomiting, diarrhea, sweating or cold extremities, lightheadedness, water retention or swelling and head congestion. Patients can also experience cognitive changes, such as difficulty putting sentences together or feeling confused.  Sensitivity to environmental stimuli such as lights, noises, smells, movements, heat or cold, is typical, and emotional symptoms such as irritability or depression are common.

“Conversely, some feel elated, as if they’ve had a surge of energy,” Lenaerts continued. “Some migraine sufferers experience auras, seeing bright shimmers, zig-zag lines or other geometric shapes, such as a checkerboard. They may experience blank or blurred vision, or see their surroundings in one color such as yellow or pink. In more complex cases, visual hallucinations can occur. Auras can include tingling or numbness on one side of the body, usually hand and face, weakness, language or speech impairment, loss of balance, vertigo and even loss of consciousness.”  

Migraine Criteria

The International Classification of Headache Disorders has specific criteria for migraine - at least five headache attacks with known symptoms and no underlying cause. There is also a category of migraine attacks without head pain. There is no biological marker for migraine, such as a genetic test or imaging tool, and ultimately diagnosis is up to the provider. Because migraine can involve pain in the cheeks or areas near the sinuses, it can be confused with a “sinus headache,” which is not an official diagnosis but a symptom of sinusitis or acute sinus infection.

A so-called “tension headache” is characterized by non-descript head pain with mild, diffuse, pressure-type pain without other symptoms and rarely impairs patients. Cluster headache is rare, primarily affecting men and characterized by attacks of dreadful pain usually around one eye. Symptoms include sweating, teary eyes, drooped eyelid, congested or dripping nose. The attacks occur at particular times in clusters – such as in spring and fall, early morning. 

There can also be genetic causes of migraine and there are multiple triggers that, individually or collectively, precipitate a migraine attack. Common examples include estrogen level drop (pre-menstruation), alcohol use, stress, cold weather fronts and sleep deprivation.  Most migraines are trigger-less or the triggers are mischaracterized. Before a migraine, a patient may crave chocolate and experience a headache after eating it. The migraine is not actually “triggered” by the chocolate; rather the patient’s craving for chocolate can be a precursor symptom of the migraine episode.  Women are three times more likely to have migraine syndrome than men and more likely to develop chronic migraines. Women also are at higher risk for chronic migraine and stroke in their young adult years.               

Preventive Treatment

The American and international headache societies recommend preventive treatment when headaches occur weekly or more. Medications that treat hypertension, epilepsy or depression/anxiety can help prevent migraine when taken daily. They can take up to three months to take effect, so they’re not a quick fix. An anesthetic nerve block to cranial nerves above the eyebrow, upper neck and in the nose also can help. Non-pharmacologic approaches can prevent migraines, too. Procedures called biofeedback relaxation and cognitive behavioral therapy can also help. 

Until very recently, Botulinum toxin was the only FDA-approved medication for chronic migraine, injected into the skin of the patient’s temples, forehead, occipital area, upper neck and shoulders every three months. Studies show that people with chronic migraine experience approximately nine fewer headache days per month for three months after the injections.  The FDA has approved a new medication called Erenumab that demonstrated preventive efficacy for both episodic and chronic migraine.

Erenumab targets and blocks the GCRP receptor, which significantly contributes to pain signals during a migraine. Erenumab is a once-monthly self-injection with very limited side effects. Devices that stimulate the cranial nerves via a small electric current on the forehead or even magnetic current on the back of the head have shown benefit. A few stimulators are even implanted in the head. With miniaturization and technological advancement, we can expect flourishing options in this treatment category in the near future.  

Maintaining a healthy lifestyle - including eating an all-natural diet, regular exercise, sleep and a healthy weight - is important. Stress relief techniques such as yoga, Pilates and meditation can also be preventative. Migraine is a lifelong condition but symptoms occur most commonly between teenage years and about 60. Some patients’ migraine days will fade as they age; however some will continue to experience migraines well into their 80s.

Migraine Studies                                              

The application of gentle cooling and warming currents inside the ear canal can provide relief for migraine sufferers, says research from the University of Kent. Study volunteers who had a history of migraines experienced a significant reduction in the number of migraines they normally experienced in a month after using a technique known as caloric vestibular stimulation (CVS). CVS activates the balance organs which are believed to alter activity in the area of the brain - known as the brainstem - associated with the onset of migraine headaches. Dr. David Wilkinson, of the University's School of Psychology, helped lead the randomized, double-blinded, placebo-controlled trial carried out across the U.S. and UK, and involving 81 volunteers with a history of between four and 14 migraine attacks per month. The volunteers self-administered caloric vestibular stimulation daily for 20 minutes over a period of three months. The thermal currents were delivered by aluminum earpieces seated within padded headphones, powered and controlled by a small, hand-held device.

The findings demonstrated that the treatment reduced both the number of migraine days per month - the active treatment group experienced a reduction of 3.6 days compared to 0.9 days in the placebo group - as well as headache pain and the consequent need for migraine abortive prescription medications. The results indicated that vestibular stimulation may address the existing need for new preventative therapies for episodic migraine.

Are Migraines Associated With Type 2 Diabetes Risk In Women?

Migraine and type 2 diabetes are common conditions in women but an association between them remains unclear. A study of French women suggests a lower risk of type 2 diabetes was observed among women who reported current migraines compared with women with no history of them. The study involved a group of more 74,000 French women insured by a health plan that mostly covered teachers and who were followed up by questionnaire. The research was conducted by Guy Fagherazzi, Ph.D., of the Center for Research in Epidemiology and Population Health, Villejuif, France, and coauthors. The team observed a lower risk of type 2 diabetes among women with active migraine. A decrease in frequency of migraine was observed years before diabetes was diagnosed.

Potential reasons that could explain the observations by researchers are uncertain. The results of this study could have implications on the understanding of the underlying causes of these two common conditions and more research is needed to understand potential reasons that could explain these findings.


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