ASPS advances multipronged approach for migraine awareness

After decades of suffering from chronic migraine headaches and visits to multiple doctors who couldn't fix the problem, Barbara Eberlein and Sharri Racheter were able to get treatment – and relief – from the condition thanks to the help of plastic surgeons.

The two patients are featured in a video that's part of a new initiative by the Plastic Surgery Education Campaign (PSEC) to spread awareness of plastic surgeons' role in migraine treatment. As part of Migraine Awareness Month in June, ASPS rolled out a host of information for both patients and physicians about migraine surgery, including information on what makes a good candidate, costs, risks and recovery.

"In my mind, migraine surgery has remained under the radar to many patients despite nearly two decades' worth of supporting scientific evidence," says ASPS President Jeffrey Janis, MD, Columbus, Ohio. "Most people have been getting their information from 'Dr. Google,' which links them to people's individual websites with just a few paragraphs or brief descriptions of treatment."

With the exception of breast reconstruction campaigns, most PSEC initiatives have focused on cosmetic procedures. Migraine surgery again bucks that trend to deliver information to patients about treatment, but also to plastic surgeons about related innovations in patient care. ASPS Public Education Committee Chair Ash Patel, MD, says the idea of adding the migraine surgery page to plasticsurgery.org was to provide a comprehensive resource for both patients and surgeons seeking more information on the procedures.

"All of the patient education information on the page is written by plastic surgeons who have experience with migraine surgery," he says. "We should be the ones who take this information to the patient – whether it's through the informational video, a comprehensive set of questions to ask your surgeon, or safety and risk concerns associated with migraine surgery."

In addition to the updated, public information online, ASPS has made additional, multipronged efforts to raise awareness among members, the public and other physicians of the work surrounding migraine surgery. These include issuing a policy statement from the Public Education Committee created to examine the safety and efficacy of peripheral nerve/trigger site surgery for refractory chronic migraine headaches; creating an updated informed-consent template for members to use; approving the migraine surgery insurance criteria for coverage; and welcoming the Migraine Surgery Council as an affiliate member organization of ASPS.

The Migraine Surgery Council was formed in 2010 as an informal group of experts that would convene once a year around the time of Plastic Surgery The Meeting to discuss the latest science and advances in the field of migraine surgery. The meetings ultimately led to the creation of a more formal organization of surgeons who are doing migraine surgery across the country.

"ASPS and the Migraine Surgery Council have tried to do things that would add value for member surgeons who do this type of surgery," Dr. Janis says. "We're providing common forms that could be helpful in your practice or coding tips that could provide insight into how to properly code this type of surgery. We organized a prospective, multicenter, scientific, IRB-approved scientific trial to advance the science of the specialty and we partnered with the Migraine Surgery Foundation to increase awareness of the procedure."

According to data obtained by the Public Education Committee, migraine headaches affect 17-23 percent of the population, with the annual cost for treatment of chronic migraines at more than $10,000 per patient, and an estimated annual cost to society of more than $13 billion. Although migraines have long been described as a neurovascular disorder that originates in the central nervous system, more recent data suggests the addition of peripheral/extracranial sensory nerve compression or irritation within head and neck muscular, fascial, bony and vascular sites as potential triggers.

In 2000, ASPS member and migraine surgery pioneer Bahman Guyuron, MD, reported his experience relieving migraine symptoms in patients who underwent browlift surgery with excision of the corrugator muscle. Ten years later, the FDA approved onabotulinum toxin type-A as a treatment for chronic migraines.

Nevertheless, the costs associated with chronic migraines and lingering questions about the treatment have spurred new advocacy efforts, which is one of the key aspects of linking together with the Migraine Surgery Council. In addition to some insurance carriers saying that migraine treatment is "experimental" – 19 years after Dr. Guyuron's report and several peer-reviewed papers backing up this theory published across several medical journals – Dr. Janis notes that several insurance carriers do not reimburse or cover treatment involving plastic surgeons injecting botulinum toxin for migraines, or disallow the procedures entirely as a policy exclusion.

"Some insurance carriers say you have to be a neurologist, anesthesiologist, pain-management specialist or one who has taken a fellowship in headache medicine," he says. "All of those are non-surgical and this excludes the surgeons who are well-versed and well-trained in nerves of the head and neck – precisely what we're operating on."

In addition to bringing the Migraine Surgery Council on as an affiliate organization, Dr. Janis says ASPS is also working with the American College of Surgeons to combine its advocacy efforts against these insurance carriers' policies.

"Why are non-surgeons making decisions about surgery without surgeons around the table?" he asks. "We work closely with neurologists. We're not competing. We're not in the business of diagnosing migraines, we're in the business of treating migraines that are refractory to traditional treatment."

In addition to the new content available online, a popular PSEN-U webinar focusing on migraine surgery that drew interest globally is still available at psenetwork.org. There will also be a migraine surgery preconference symposium at Plastic Surgery The Meeting 2018 and a cadaver lab that will be used to help demonstrate certain techniques to attendees.

The breadth and detail of the information that the Society provides to its members and patients makes the information available at plasticsurgery.org one of the premier educational websites for the patient, Dr. Patel says.

"From an educational standpoint, we're not done yet," he adds. "We're going to add even more content to make this information even better."

If that translates to relief for some people who suffer from chronic migraines, it will go a long way, Dr. Janis says.

"Migraine surgery is not an option for everyone, but it is an option for some," he says. "The best way to determine if it is an option for you is to go see your board-certified plastic surgeon who has this type of expertise and be evaluated."