Claire Wiseman / The Dallas Morning News

Swollen eyes, nausea, pressure so intense they feel their eyes might pop — migraine sufferers learn to describe the pain in many ways.

“It’s like everything’s closing in because you’re hurting so bad,” said Phyllis Little of Wichita Falls, Texas.

Little’s near-daily migraines and sensitivity to light and sound left her debilitated. Experts say there’s no cure for migraine, and like many chronic sufferers, Little tried many treatments before she found some relief.

Although there is no cure, people with occasional migraine headaches have many options, from medication to dietary changes. For chronic sufferers, there are more extreme measures.

Botox injections, which helped Little, have become mainstream in recent years. Some doctors offer less-proven surgical alternatives.

Thanks to a marketing push, one such surgery — implanted neurostimulation — has received attention in Dallas under the name Omega Procedure. Another option, nerve decompression surgery, is performed at a few major hospitals nationwide, including in Texas.

While practitioners point to success stories, the American Headache Society says the surgeries are unproved, so it’s important for patients to understand options and implications.


The most widely used of these procedures is a familiar fix for frown lines and wrinkles. Botox blocks nerve signals that cause muscles to contract. In patients with migraine, the treatment is usually a series of injections across the forehead, temples and the back of the neck.

“I like it in some cases,” said Dr. George Nissan, of the Baylor Headache Center, “but I don’t go to it first line.”

Nissan describes lines of defense against migraine. His initial treatment usually involves lifestyle changes, like avoiding trigger foods or adding an exercise routine, as well as preventive medication.

Nissan considers Botox a step beyond these early measures. The Food and Drug Administration approved the use of Botox for migraines in late 2010. Nissan says he’s been using the treatment for a decade.

This type of off-label treatment, involving drugs approved to treat other conditions such as seizures, is common.

Botox is approved to treat only migraine headaches designated as chronic — patients must document they’ve had 15 or more days with headaches a month, and that eight of those were severe. Before suggesting Botox, Nissan asks patients to keep a headache diary for close to three months.

He says the treatments can be prohibitively expensive. Each one, involving as many as 31 injections, can cost more than $1,000. The drug effects last only about three months.

Surgical alternatives

Unlike Botox, surgical treatment for migraine remains controversial.

Nerve decompression aims for complete relief, while neurostimulation aims to reduce pain levels. Doctors point to what they deem success stories, and ads promise relief.

Some experts are skeptical. According to a statement released last year by the American Headache Society, a professional organization of health care providers, “surgery for migraine is a last-resort option and is probably not appropriate for most sufferers. To date, there are no convincing or definitive data that show its long-term value.”

Dr. Elizabeth Loder, the society’s president-elect and the chief of the division of headache and pain in the department of neurology at Brigham and Women’s Hospital in Boston, says randomized, controlled, multicenter studies are the standard by which surgeries should be measured. Both treatments have under- gone randomized clinical trials published in medical journals, but Loder said nerve decompression in particular is unproved.

“It’s important to separate fact from wish, and the way to do that is to hold these treatments to the same standards that we hold other drugs,” Loder said.

Implanted neurostimulation

Implanted neurostimulation uses wires the width of spaghetti noodles to deliver electrical stimulation and ease migraine pain. The stimulators are implanted under the skin near the forehead or the back of the neck. They’re attached by wires to a battery pack, about the size of a silver dollar, placed in the chest wall or above the buttocks. Electrical impulses to targeted areas in the head and neck block pain in migraine patients, who can control the strength of those currents.

“It’s really like turning on and off a light switch for these people,” said Dr. Brian Flanagan, co-director of Baylor’s Center for Pain Management.

It isn’t FDA-approved to treat migraine and is not always covered by health insurance.

The treatment is advertised in the Dallas area by the Migraine Treatment Centers of America, which recommends patients to partner physicians such as Flanagan, who says the treatment has a good track record. “It’s probably been around for 15 to 20 years, and several of the pioneers in this were based in Dallas.”

Before doing surgery, Flanagan requires potential patients to do a brief trial. The device is attached for a few days while portions remain outside the body. If the trial reduces pain by more than 20 to 30 percent, Flanagan says he proceeds with the implantation.

Although Flanagan says the surgery is low-risk, he adds it’s often costly and does not completely eliminate symptoms. A 50 percent reduction in pain is considered a victory.

Nerve decompression

Nerve decompression surgery aims for an even higher rate of pain reduction. The newest of the three procedures, this surgery is performed by plastic surgeons and is based on the idea that pain can be treated by relieving pressure on nerves caused by surrounding tissue.

Before performing surgery, Dr. Jeffrey Janis, a plastic surgeon formerly with the University of Texas Southwestern Medical Center, uses Botox to weaken or paralyze muscles compressing nerves in the face, head and neck.

Numbing blocks can also be used in certain circumstances to diagnose trigger points. Janis says this procedure allows him to pinpoint the nerve that may be causing migraine symptoms.

Unlike a typical Botox treatment, this technique uses fewer injections and pinpoints specific trigger nerves. If Botox is successful in eliminating migraines, Janis says he discusses permanently decompressing those nerves through surgery.

“I’m using Botox as a test,” he said. “I’m using surgery as a treatment.”