Chronic headaches are extremely debilitating conditions which significantly impact the quality of life.
Dr Giorgio Pietramaggiori and Dr Saja Scherer of Global Medical Institute, Switzerland employ minimally invasive treatments such as targeted Botox injections, surgical release of nerves, and fat transfer, which aim to offer relief for people suffering from chronic headaches when pharmacological alternatives fail.
Read more in Research Features
Read the original research: doi.org/10.1097/prs.0000000000009777
Image Source: DepositPhotos / Maridav
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As an extremely debilitating condition, chronic headaches significantly impact the quality of life. Common causes include migraines, cluster headaches, and occipital neuralgia. There are many patients who do not respond to drug treatments and are adamant about making improvements to their lifestyle beyond medications.
Leading doctors in this research area, Dr Giorgio Pietramaggiori and Dr Saja Scherer of Global Medical Institute, Switzerland, investigate treatments such as targeted Botox injections, surgical release of nerves, and fat transfer – offering relief for people suffering from chronic headaches when pharmacological alternatives fail.
Migraines are a common condition, occurring in about one in seven people globally and with one in four households affected. Migraines often come with flashes of lights or blind spots and a tingling sensation on one side of the face. These symptoms, called ‘aura’, may precede a headache so bad that it can interfere with your normal life for hours or even days. This debilitating form of chronic headache can cause an intense, throbbing pain, usually on one side of the head.
Interestingly, migraine seems to be more common in women than men, with the reported lifetime prevalence being 33 percent and 13 percent, respectively. This may be due to hormonal differences between sexes, with some women more likely to experience a migraine around menstruation, while being protected during pregnancy.
Occipital neuralgia, on the other hand, is more mechanical and equally distributed between sexes. The pain in this disease is often continuous, starting in the back of the head and irradiating to the back of the scalp and sometimes felt behind the eyes and in the temples. This form of headache may be related to modern lifestyle, with too much time passed in front of a computer screen or with the neck flexed to look into a smartphone for hours. These postures stretch and irritate the nerves in the back of the head causing the neuralgic pain.
At the Global Medical Institute, Switzerland, Dr Giorgio Pietramaggiori and Dr Saja Scherer are on the quest to find minimally invasive treatments for both migraines and occipital neuralgia.
Drug treatments for migraines fall into two main categories. The first type aims to treat pain either after or just before the onset of a migraine. The second type of medication is taken regularly to reduce the frequency and intensity of migraine headaches. These are also called disease-modifying or preventative medications.
Typically, triptans are the drug of choice to stop a migraine attack and are effective for more than half of patients. Other pain-relieving drugs include analgesics or anti-inflammatory drugs such as paracetamol, ibuprofen, used alone or in combination with several other medications. The use of these drugs can have long-term side effects, such as dependency, medication-induced headaches, and the development of gastric ulcers with ibuprofen, or constipation with opioids.
Preventative medications include anti-epileptics, anti-hypertensive drugs, beta-blockers, and anti-depressants. Lately, drugs against calcitonin gene-related peptide, a molecule expressed during migraine, have been introduced as a disease-modifying treatment to reduce the burden of this disease.
However, drugs are not suitable for everyone. There are some people who take medications and try to improve their lifestyle with diet, sleep, and stress management, but the impact of migraines is still so debilitating that it severely reduces their quality of life.
So, what are the options for these people?
Botulinum neurotoxin, commonly known as Botox, has been used to improve migraine symptoms for extended periods of time without pharmacological side effects. Botox is administered via microscopic injections in the head, following well-established protocols which are adapted to each particular situation, and are usually effective for up to 12 weeks. When this approach works, patients regain pain-free days and reduce the use of drugs, in turn reducing their side effects. Sometimes, depending on the type of migraines, patients under the effects of Botulinum toxin are completely migraine-free. However, some conditions, such as occipital neuralgia, are less responsive to Botulinum toxin injections.
Occipital neuralgia or Arnold’s neuralgia is another form of chronic headache caused by inflammation of the occipital nerves. The occipital nerves are the structures that give sensation to the back of the head. Along their trajectory, these nerves can be pinched by the large muscles of the neck and shoulders that insert into the skull like the trapezius muscle. Occipital neuralgia is commonly confused with migraines or cluster headaches due to the similarity in symptoms, and to the fact that they can often occur together.
The symptoms of occipital neuralgia include shooting pain in the back of the head, accompanied by hypersensitivity, which is a burning or electric sensation felt in the scalp as well as behind the eyes. Since it is mainly caused by the mechanical irritation on the occipital nerves, pain is usually felt most of the time with attacks of higher intensity. Due to the frequent overlap of occipital neuralgia with migraines, the prevalence in the population remains unclear. But since it’s believed to be a consequence of modern lifestyle, such as long hours spent in front of computers or smartphones, the incidence of occipital neuralgia is on the rise.
Despite the condition being well-characterised, occipital neuralgia is often misdiagnosed and mistreated as it doesn’t respond to migraine treatments. If the symptoms don’t improve with standard medications, a topical infiltration in the pit between the muscles of the back of the head, usually identified as the starting point of the pain by the patients and corresponding to the zone of nerve compression, will improve the occipital neuralgia at least temporarily. This injection confirms the diagnosis of occipital neuralgia and opens the way to surgical decompression, if needed.
Drs Pietramaggiori and Scherer present a minimally invasive surgical intervention to decompress the occipital tension. Their surgical technique releases the compressed nerves and blood vessels located in the back of the scalp using a small incision, usually between 2.5 and 3.5 centimetres long. The procedure can be performed under both general and local anaesthesia, depending on the patient.
The impact of the procedure was determined retrospectively by assessing reduction in the number of headaches that participants experienced per month and the pain they reported as well as more quantitative methods, such as the amount of medication used for pain following the procedure.
91 percent of patients experienced a significant decrease of headache frequency, counted as a reduction of over 50 percent in number of headaches per month. A staggering 45 percent of patients reported that their occipital symptoms completely stopped. All other measures of pain – including drug use, days with pain per month, and chronic pain intensity – were reduced by at least 70 percent. An additional positive outcome was that only minor complications, such as scar issues, were reported in a small number of patients. Based on these results and the increasing number of patients coming to Switzerland to receive this surgery, Drs Pietramaggiori and Scherer hope that this minimally invasive decompression technique becomes the front-line treatment for patients with occipital neuralgia.
Drs Pietramaggiori and Scherer also report the effective use of autologous fat transfer for the treatment of occipital neuralgia and migraines. This approach is effective in patients bearing post-traumatic or post-surgical scar tissue. They have found that fat tissue reconstitutes the anatomy of the skin, reducing compression, tension, and irritation of nerve branches. Injection of fat from elsewhere in the body is a simple, effective, and permanent treatment for headaches. With their continued research, Drs Pietramaggiori and Scherer are hopeful for a future with even less invasive treatments for migraine, cluster headaches, and occipital neuralgia.
The doctors report that in their practice, they have discovered that about half of the patients with migraines can be satisfactorily managed with Botox for extended periods of time. Often, after months or years of treatment, patients ask to be operated, if possible, to achieve a permanent improvement without the need for recurrent injections. Botox injections are used as tests to evaluate whether a patient could benefit from a minimally invasive decompression of nerves around the head to improve their migraines.
Dr Pietramaggiori provided further insight into why some patients may not respond to drug treatments. He explains that there could be several reasons why patients are unsatisfied with drugs for their headaches. If the migraines are too frequent, requiring an almost daily use of triptans, the drugs start to lose their efficacy, the need for them increases, and the burden of side effects rises to the point that patients may develop headaches from them. There are also patients who have other medical conditions, such as vascular or cardiac issues, and may not be eligible for the use of migraine drugs, such as triptans. Additionally, some headaches, typically occipital neuralgia, have a mechanical origin and respond only marginally to medications, as the compression on the nerves must be released to stop the pain.
So, could minimally invasive procedures soon become the standard treatment for chronic headaches, rather than traditional drug treatments? Dr Pietramaggiori maintains that drugs will most certainly be attempted first, and for a number of patients, they will achieve the intended goal of allowing a normal life. In selected cases, like patients with occipital neuralgia or refractory or chronic migraines, a surgical approach will likely become the preferred approach as drugs are not effective for nerve compression syndromes. For these cases, the doctor envisions that minimally invasive surgical decompression will become the gold standard and preferred treatment. He offers carpal tunnel syndrome as an analogy where surgical decompression is the preferred approach once the diagnosis is confirmed.
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