Chronic migraine headache sufferers have had only limited options for relief until physicians discovered the connection between Botox and compressed nerves. West Tennessee plastic surgeon Petros Konofaos, MD, is one of the first physicians taking Botox treatment one step further with a surgical, permanent migraine solution for many patients.
Physicians discovered the link between Botox injections and reductions in migraine severity and frequency about 15 years ago. Plastic surgeons noticed patients who suffered from migraines and were receiving Botox injections in the prefrontal cortex area were experiencing fewer and less severe migraines. Botox has relatively few side effects, but its effects are only temporary, wearing off a few months after injection.
Cleveland physician Bahman Guyuron observed that his patients with migraines improved after cosmetic brow lift surgery, where the supraorbital nerve was released. Physicians realized other nerves could also undergo decompression to reduce the severity and frequency of migraines.
Konofaos, of the UT University Plastic Surgeons practice of University Clinical Health, says that similar to carpal tunnel syndrome, many migraines can be treated by decompressing nerves in the brain. Botox injections work for migraines in the same way they do for wrinkles – temporarily paralyzing the muscle that is putting pressure on the nerve and causing pain. When physicians inject Botox into the muscle around the compressed nerve, it releases the pressure for four to six months, improving symptoms and in some cases providing full relief from headaches.
Patients suffering from migraine headaches daily or weekly with no relief from medications are candidates for Botox injections. Then, patients who respond to Botox but still experience occasional migraines are strong candidates for the nerve compression surgery.
Konofaos uses Botox injections as a screening test, seeing how patients respond to the injections and then planning surgery to permanently remove the compression on the nerve. Patients receive Botox injections in “trigger points,” Konofaos said. The frequency and severity of their migraines are then logged and monitored for a few weeks. The injections take two weeks to take full effect, and many patients see improvement in their migraines.
After observing the migraine patterns following Botox injections, Konofaos can identify which nerve is compressed and create a plan for surgery.
Four sensory nerves are most likely to have the compression that causes migraine headaches. These nerves are located near a powerful muscle, or could be compressed from a previous operation, tumor or accident. Depending on the location of the nerve, there are different surgical approaches through the eyelid or incisions above the nerve. The most common pain is in the forehead region, where the surgery is done through the scalp or by the transpalpebral (eyelid) approach. The other common nerve compression is the occipital, and the surgery is performed through a small incision, but not intracranial.
Sometimes, during the surgery to remove the compression, it is discovered that the nerve is not viable and has been damaged. In those cases, Konofaos either cuts the nerve or repairs it with a small graft. He estimates “75 percent of patients have immediate relief [and] another 25 percent have some relief.”
The surgery is performed as an outpatient procedure and Konofaos sees quality of life improvements for his patients, without the cost, pain and medication of other migraine treatments.
“Plastic surgeons have the unique combined skills and experiences of dealing with both the anatomy of nerves that control the face and dealing with the specifics of microsurgery for minimal or no visible scaring after surgery. Plastic Surgeons, those who are skilled in microsurgery, are highly specialized and are used to dealing with very precise cosmetic sensitivities of patients as well as very complex issues involving the nerves in the face and scalp,” said Konofaos.
Similar to compression of nerves in the brain, diabetic neuropathy is also a nerve compression that can be treated similarly to migraine headaches. In 2014, Memphis ranked second in the country for adult diabetes rates.
As a plastic surgeon, Konofaos is experienced not only with Botox and craniofacial surgery, but also has done research involving peripheral nerve injuries. A native of Greece, Konofaos moved to Tennessee in 2014 and works as the assistant professor of plastic surgery at the University of Tennessee Health Science Center in addition to practicing in East Memphis.
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