APRIL 15, 2007
VOLUME 4 NO. 7

ADVANCES in MEDICINE

Botox shots pinpoint migraine culprits

Plastic surgeons, neuros team up for
injection-guided surgery


Plastic surgeons in the US are using Botox to treat migraine headaches — a debilitating neurological condition that, according to the Migraine Association of Canada, affects over three million Canadians and costs our economy around $500 million annually in absenteeism and lost productivity.

By injecting the neurotoxin into different muscles of the face and head, surgeons can assess whether any are compressing or irritating the surrounding nerves, thus causing migraine. If the paralysis of one of the muscles prevents or improves migraine symptoms, the targeted muscle is surgically removed.

"We're seeing improvement in a substantial number of patients — about 80% in those treated with Botox and 90% who receive surgery," says Dr Jeffrey E Janis, co-director of the plastic surgery residency program at the University of Texas Southwestern Medical Center, and one of the technique's co-developers. "There's improvement across the board in the frequency, duration and intensity of their headaches." In some rare but encouraging cases, he adds, patients are cured entirely.

TO BE PRECISE
The idea of using Botox to treat migraines is not a new one: many neurologists use it as an alternative to traditional medications, injecting it in a headband-like fashion around the skull. But with this method — what Dr Janis refers to as a "shotgun" approach — patients only get about three months of relief before having to come back for a second round of shots. In contrast, a pinpointed, diagnostic use of Botox followed by surgery provides a longer-lasting, if not permanent solution, he says.

Despite the deliberate precision of the methodology, Dr Janis admits the basis for the combined chemical and surgical technique was discovered quite by accident by a colleague, eminent plastic surgeon Dr Bahman Guyuron.

"Five years ago or so, [Dr Guyuron] noticed that, after doing cosmetic brow lifts, a couple of patients reported very excitedly that their migraines were gone The only explanation seemed to be that, during the procedure, he had removed the corrugator muscles, which might have relieved compression or irritation of the nerves around them," he explains.

He and Dr Guyuron began collaborating on cadaver head studies, closely analysing nerve and muscle anatomy to determine which would likely be involved in migraines. "We couldn't go and operate on everybody, but we could perform a sort of chemical surgery — that is, use Botox to paralyze a given muscle so that it can't contract against these nerves. It's like removing it, but with a needle instead of a knife," he said. After testing several injection points, they ended up with a sort of roadmap, which could guide them towards a focused surgical procedure.

MEETING OF MINDS
Treating headaches is clearly outside the normal scope of a plastic surgeon's practice, so Dr Janis requires that all patients be referred from a neurologist with an official diagnosis of migraine headache. Typically, he sees those for whom traditional treatment hasn't worked.

"I treat a lot of 'kitchen sink' patients — people who have been to many neurologists, tried an assortment of medications, modified their lifestyle and diet. They live in the dark, don't go out of their house, don't like strong smells. Basically, people who no longer enjoy life because they're dominated by migraine headaches," explains Dr Janis. "By the time I see them, they're looking for anything that can help them, because they've tried everything else medicine has to offer."

Such collaboration between plastic surgeons and neurologists isn't obvious. But Dr Janis insists the alternative he's offering should be seen as an adjunct to traditional treatment. "We're working with neurologists, not against them," he says.

Of course, his colleagues weren't always so gung-ho. "At first, people thought what we were doing was crazy. No neurologist wanted anything to do with me," he recalls. It took a lot of personal phone calls, but Dr Janis eventually forged an alliance. "This really is a collaborative effort that demands the expertise of both neurologists and plastic surgeons," he says, adding that the results, fortunately, speak for themselves.

FRINGE FACTOR
Dr Guyuron has published several studies over the course of ongoing clinical trials, showing significant improvement in a substantial number of patients. But despite its promise, the technique remains on the medical fringe, being practiced by only about 10 doctors in all of the US.

Dr Donald Lalonde, president of the Canadian Society of Plastic Surgeons, is unaware of any Canadian physicians using the technique. "Some plastic surgeons in Canada may have heard of it, but 99% probably haven't. Dr Guyuron is finishing his clinical trials of the procedure, so hopefully, once his findings are published, it will be more well known," he says.

To that end, Dr Guyuron has begun organizing annual migraine headache symposia, the first of which was held in October 2006 at Case Western Reserve University, Cleveland, where he serves as chairman. But Dr Lalonde suspects it'll take more than physician awareness to gain the interest of Canadian migraine sufferers. "I've discussed this treatment with some patients, and though several expressed interest initially, it ended once they found out that it wouldn't be covered by Medicare. Canadians aren't used to having to pay [out-of-pocket] for medical procedures," he says.

 

 

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