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Dr. Barry Eppley

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Surgeon Dr. Barry Eppley

Posts Tagged ‘migraine headaches’

Long-Term Effectiveness of Migraine Headache Surgery

Sunday, January 30th, 2011

Migraines are a common and frequently disabling headache condition that can be drug-resistant or responds very poorly to them. Even in those that do respond, there are side effects to all drugs that for some are problematic. Surgical techniques for migraines have been developed that deactivate migraine trigger sites. For some patients, these surgical techniques can be life-changing. But an interesting and very relevant question that I get from my Indianapolis migraine patients who are having this surgery is…how long will the results of this surgery last? Does this offer just short-term relief or are the results more long lasting? 

Developed by plastic surgeons, a study published in the February 2011 Plastic and Reconstructive Surgery journal looked at the long-term effectiveness of this type of migraine surgery. Nearly one hundred migraine patients were treated with surgery compared to twenty-five migraine patient volunteers in a prospective treatment study. Patients completed questionnaires before treatment and at one and five year follow-up. Treated patients received Botox to confirm the potential effectiveness of surgery and then went out to surgical deactivation if positive. Control patients received saline injections only. The comparative results were analyzed at one and five years.

Of the surgically treated patients, 88% of them experienced continued improvement in their migraine symptoms after five years. Nearly 30% had complete elimination of any further migraines while nearly 60% noticed a significant decrease. A little over 10% of the patients experienced no significant improvement. A few of the patients (10%) went on to have the release of additional trigger sites.

This landmark study done by the father of modern migraine surgery is significant in the annals of migraine headache therapies. The five year results provide strong evidence that surgical manipulation of one or more migraine trigger sites can either reduce or eliminate the frequency, duration and intensity of these headaches for a prolonged period of time. Given whom it was done by and the scientific analysis in which it was done by adds further credence to the meaning of this study.

This study provides data that allows one to provide good information about the effectiveness of migraine surgery to patients. First, it is not a magic cure-all and not every patient will be improved. But a near 90% level of some degree of symptom relief is reassuring that the surgery is worthwhile. Complete elimination of all migraine symptoms will not occur in most patients and should not be expected. Only about 1/3 of patients will have a near ‘cure’, most will have less frequent migraines that are less severe in intensity. Some patients will require additional trigger releases based on how many are done during the first surgery.

The deactivation of migraine trigger sites continues to prove that it can be effective at providing some patients a treatment that surpasses conventional drug therapy. Because of its relatively new development, there are many patients who would benefit from such migraine surgery that are unaware or uncertain of its effectiveness. Studies like this one provide clinical proof of what the early adopters of migraine surgery techniques are experiencing. 


Dr. Barry Eppley

Indianapolis, Indiana    

Headache Relief from Breast Reduction Surgery

Tuesday, January 12th, 2010

Breast reduction is well known to reduce a variety of musculoskeletal conditions, most prominently back, shoulder, and neck pain. It is this alleviation of pain that serves as the primary medical reason that insurance companies provide reimbursement for the operation.

In my Indianapolis plastic surgery practice, I occasionally will get a patient who will ask if breast reduction will help their headaches. They are usually referring to chronic-type headaches and occasionally that of migraines as well. My traditional answer has been…’if you get improvement great but I wouldn’t count on it.’ My belief was that upper trunk muscle strain and pain would be  relieved but not that of the upper neck.

In the January 2010 issue of Plastic and Reconstructive Surgery, the association of breast reduction and headache improvement was studied. This paper looked at 84 breast reduction patients of whom nearly 70% (58) reported headches prior to surgery. After surgery, half of these patients (31) reported a greater than 50% reduction in headache severity and frequency and just over 20% (12) stated that their headaches were completely gone.

This study shows that women with large painful breasts who have chronic headaches may experience some significant relief. The question becomes why and how? Like the rest of the musculosleletal symptoms from large hanging breasts, their downward weight orientation works against the muscles that help stabilize the back and neck. Just look at the posture of large-breasted women and you will often see slumped and rounded shoulders and an almost forward body tilt.

The authors postulate, and probably accurately so, that this same mechanism accounts for headache pain…and its subsequent relief after surgery. The downward pull on the muscles of the neck not only strains it but also applies pressure on the large occipital nerves that exit out through it as they come out from underneath the base of the skull. By being pulled down, the nerves are stretched and irritated. Such a point of traction could well be one reason that headaches (particularly those that eminate from the occipital region) may exist.

This new information provides hope for some breast reduction patients that their headaches may show some relief after surgery. It should be pointed out, however, that nearly half of the patients in this study showed no improvement so expectations should be tempered as possible but not absolute.

The use of headaches for insurance eligibility for breast reduction surgery is not an accepted criteria on its own at this time. This reported study is the first of its kind but I suspect it will be successfully reproduced by others. The anatomic mechanism is too appealing to not have some merit. Every breast reduction patient has numerous other sites of muscle pain and headache relief would be a bonus, not the determining factor of the operation’s success.    

Barry L. Eppley, M.D., D.M.D.

Indianapolis, Indiana

Surgical Treatment of Migraine Headaches – Sham vs. Actual Surgery

Wednesday, August 12th, 2009

Migraines are difficult treatment problems that are resistant to many standard drug therapies. Few migraine sufferers have one treatment approach that works consistently. Migraines that have a single or predominant trigger site, while is just a subset of migraine sufferers, have been undergoing novel non-surgical (Botox) and surgical (nerve decompression) treatments in some centers with fairly high rates of relief.

In a recent paper in the August 2009 issue of Plastic and Reconstructive Surgery, plastic surgeons from the Cleveland Clinic report on their experience with the surgical treatment of migraine headaches. Seventy-five (75) patients with moderate to severe headaches were studied who had a prior positive response to Botox injection therapy. Frontal, temporal and occipital trigger sites were identified and the patients were assigned  to receive either  actual or sham surgery on their predominant trigger site. Of the 75 patients, 58% in the sham group and 84% in the actual surgery group experienced at least 50% reduction in their migraine headaches. In the surgery group, 57% reported complete elimination of their migraine pain compared to just 4% in the sham group.

This reported study is one of, if not the most significant, clinical study ever performed in evaluating the relatively new surgical decompression techniques of external migraine trigger points. Being actually able to perform sham surgery on patients seems like a throwback from years ago and is a credit to the authors to having gotten this through their institutional IRB. Because of this study’s design, the outcomes are fairly convincing that surgical deactivation of peripheral migraine trigger sites works….even if the mechanism of its effects is not completely understood yet. While there was a significant response rate in the sham group,  few complete migraine eliminations were recorded unlike the actual surgery group.

No one knows exactly why migraines occur and many theories have been proposed. Surgical decompression of external migraine trigger points that course through cervicofacial muscles is based on the premise that peripheral nerve activation results in central brain sensitization. For some migraine patients, this published work and their previously reported studies provide solid evidence that this concept has merit.

Any potential patient reading this study should not necessarily assume that they are good candidates for these procedures. Patients should be thoroughly evaluated by a neurologist and have other causes for their migraines evaluated. Their migraine headache should be classified and, if appropriate, the effects of Botox on the trigger points should be done. Only if Botox injections produce significant relief should surgical nerve decompression of the trigger point be considered. 

Dr. Barry Eppley
Indianapolis, Indiana


Botox, Surgical Decompression and Migraine Headache Relief

Tuesday, July 1st, 2008

The treatment of migraine headache patients by Botox injections has been shown to be effective in specific patients who have identifiable triggers of the supraorbital and supratrochlear, zygomaticotemporal, greater occipital, and septal trigeminal nerves. The temporary relief from Botox has led to the concept that relieving pressure on the nerves by muscle resection (surgical decompression) can subsequently be effective and may provide a more long-term solution to the migraine problem.
Surgical decompression of migraines has shown that a high percentage of carefully-chosen patients may benefit. (> 90%) On average, most migraine patients experienced improvement at one year follow-up, needing less medications for management. While some patients do experience a ‘cure’, this is not the majority. A recent publication in the July 2008 issue of the journal Plastic and Reconstructive Surgery confirms these results in their own reported experience. One of the most interesting findings of their study was that two-thirds of the patients felt that surgery offered better relief than Botox injections.
Surgical decompression involves removing muscle that intertwines or lays against the nerve. In the frontal area, this can be done endoscopically (like an endoscopic brow lift) or directly through an upper eyelid incision. As of now, this is a surgeon’s choice and the evidence that one method is superior over the other remains to be conclusively proven. For the zygomaticotemporal, greater occipital and septal trigeminal nerves, a direct open approach is used.
For those patients whose migraine headaches are of sufficient frequency and are not well controlled by medication, surgical decompression of trigger points offers potential for improving their lives.
Dr. Barry Eppley

Indianapolis, Indiana

Botox Injections for Migraine Headaches

Wednesday, January 23rd, 2008

Botox is Effective in the Treatment of Specific Types of Migraine Headaches


Botox is the single greatest non-surgical aesthetic treatment that has been discovered to date. It is a near 1 billion dollar drug in sales because of one simple fact…..it works and it works well. It effectively weakens select facial muscles so that certain undesireable facial expressions, such as frowning, are eliminated. In the process of weakening the facial muscles between the brows, know as the glabellar area, it has been observed that some patients’ migraines were improved or eliminated. I have observed this is in several of my patients here in Indianapolis and it has been observed in plastic surgery for many years.

While Botox is not approved by the FDA for the treatment of migraines, there is little clinical doubt from our experience in plastic surgery that it works. The exact way it works seems to be through relaxation of the forehead muscles that wrap around a sensory (feeling) nerve that comes out of the brow bone. (supraorbital/supratrochlear nerves) This is also a common area that gets Botox for cosmetic purposes. By relaxing the muscles, the nerve is no longer ‘pinched’ and the trigger for the migraine is temporaily removed. This same phenomenon works on migraines that start in the back of the head in the occipital region of the upper neck. In this area, the large occipital nerve (which provides feeling to the scalp on the back of the head) exits from the bone in the back of the skull up through the occipital muscle.

These observations do not mean that every migraine patient will get relief of their headaches with Botox injections. It appears that only a very specific type of migraine patient will get improvement. My belief is that those patients that have a ‘focal’ or specific origin of their migraine headache have a good chance to have a 3 -4 month relief, or as long as the Botox is working. If the migraine begins specifically in the brow region and spreads for there, this is a good sign that Botox will be effective. If Botox is effective, this also indicates that surgical decompression of the nerve (removing muscle from around the nerve) through an endoscopic approach may provide a more permanent cure. Botox, therefore, can be a pharmacologic treatment or a qualifier for possible surgical treatment.

Dr. Barry Eppley
Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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