MDNews - Cleveland-Akron-Canton

Through anatomical studies, Dr. Guyuron has identified multiple migraine headache trigger sites and developed surgical techniques to deactivate them. Illustrations courtesy of Dr. Bahman Guyuron. "Obviously, all patients knew ahead of time that they were participating in a study that might subject them to having a sham surgery, meaning the incision was made and the nerves and muscles were exposed but not altered," Dr. Guyuron says. "Those who served in the control group underwent the real surgery after the conclusion of the study." One year after surgery, 83 percent of those who received the real surgery reported at least a 50 percent reduction in migraines. By comparison, 57 percent of those in the control group reported a 50 percent reduction. However, 57 percent of those in the real surgery group reported complete elimination of their migraines, while only 4 percent of those in the sham group did. This study appeared in the peer-reviewed journal Plastic and Reconstructive Surgery. "We have now published about 24 articles in peer-reviewed journals on surgi- cal treatments for migraine headaches," says Dr. Guyuron. "The basic principles have not changed, but we have changed some of our techniques to simplify the procedures, and we have developed new techniques to deal with rare trigger sites." Defective Myelin — The Cause? In what may turn out to be a landmark study, the nerves of patients who have MH were compared to nerves of patients who do not have MH. This was done coop- eratively with the Department of Plastic Surgery at University Hospitals Case Medical Center and the Neurobiology and Proteomics Department at Case. The findings, which were published in Plastic and Reconstruction Surgery, indicated patients who have MH have deficiency in the myelin sheath protecting the nerve. "This is probably one of the most important evidences I can offer that the MH cascade starts from the peripheral branches and spreads centrally, which is why surgery on the peripheral nerves is efficacious," Dr. Guyuron says. "The deficit in the myelin is genetic in origin." For that reason, he points out, migraine surger y cannot be called a cure — it does not eliminate the pathology; it just prevents the nerve from being irritated by blood vessels, muscles or surround- ing structures. "The patient whose migraines have been eliminated may call surgery a cure, but sci- entifically, I cannot," Dr. Guyuron notes. Confirming Trigger Sites Dr. Guyuron's extensive experience with migraine surgery has led him to believe that failure to detect all of the trigger sites is the most common reason for incomplete response to surgery. "Originally, we thought there were four trigger sites, but we've found that there are several other sites, all running along the same nerve branches," Dr. Guyuron says. "The same nerve can be irritated close to the root or at the end of the branch." In 2012, Dr. Guyuron and his team of researchers began using transcranial Doppler ultrasound to confirm trigger sites. Patients are asked to place a fingertip on the spot from which they think their headaches most frequently originate, and that spot is explored with a Doppler. If an arterial Doppler signal is detected, that spot is considered a blood vessel trigger site. Over 90 percent of the time, the trigger site can be confirmed with Doppler, according to Dr. Guyuron. "This objective evidence further validates the role of peripheral mechanisms in MH," he says. He explains that for patients with an active migraine during an office visit, a nerve block with a local anesthetic may be used to confirm the trigger site. If the patient does not have pain at the time of the office visit, BT-A may be injected into the suspected trigger site. "While positive responses to BT-A and nerve blocks are very helpful and reliable in confirming trigger sites, negative responses must be interpreted with extreme caution," Dr. Guyuron says. For patients with a migraine originating from the retrobulbar site (behind the eyes), a CT scan of the paranasal sinuses is obtained to confirm rhinogenic trigger sites. "Accurate identification of trigger sites is essential," Dr. Guyuron says. Earlier this year, Dr. Guyuron retired from his department chairmanship at University Hospitals to devote his full time to scholarly and clinical practice. Half his time is focused on migraine surgery and research, and the other half on facial plastic surgery. "We've seen patients from 47 states, and we operate on patients from about 20 different countries every year," says Dr. Guyuron. "Our Migraine Center, with the help of Dr. Deborah Reed has become an international center for MH research." F o r m o r e i n f o r m a t i o n a b o u t Dr. Bahman Guyuron and his research, visit drbahmanguyuron.com or call 440-461-7999. ■ 8 | Cleveland/Akron/Canton MD NEWS ■ M D N E W S . CO M ■ J U LY/AU G U S T 2 0 1 5

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