Surgical Interventions for the Management and Treatment of Chronic Migraine in Clinical Nursing Practice
Abstract
Background: Chronic migraine is a disabling neurological disorder characterized by frequent headache episodes and significant functional impairment. While pharmacological and behavioral therapies remain first-line treatments, a subset of patients continues to experience refractory symptoms that negatively impact quality of life.
Aim: This article aims to review and synthesize current evidence on surgical and procedural interventions for the management of chronic, drug-refractory migraine, with particular emphasis on their clinical relevance within nursing and interprofessional practice.
Methods: A narrative, evidence-based review was conducted using published clinical studies, anatomical and physiological research, and established diagnostic and therapeutic guidelines. The article examines migraine pathophysiology, indications and contraindications for surgery, and the effectiveness of interventions such as botulinum toxin injections, peripheral nerve decompression or neurectomy, rhinogenic surgery, and neuromodulation techniques.
Results: Surgical interventions targeting peripheral nerve compression sites demonstrate meaningful reductions in migraine frequency and intensity in carefully selected patients. Botulinum toxin serves both therapeutic and diagnostic roles by identifying trigger points and predicting surgical success. Peripheral neurolysis and neurectomy show sustained benefit in refractory cases, while neuromodulation—particularly occipital nerve stimulation—offers an alternative for patients unsuitable for decompression surgery. Complication rates are generally low when procedures are appropriately indicated and performed within multidisciplinary care models.
Conclusion: For patients with chronic migraine unresponsive to optimal medical therapy, targeted surgical and neuromodulatory interventions provide effective, individualized treatment options. Comprehensive evaluation, precise anatomical localization, and interprofessional collaboration are critical to achieving optimal outcomes.
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References
Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia : an international journal of headache. 2013 Jul:33(9):629-808. doi: 10.1177/0333102413485658.
Lipton RB, Bigal ME, Diamond M, Freitag F, Reed ML, Stewart WF, AMPP Advisory Group. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology. 2007 Jan 30:68(5):343-9
Martelletti P, Katsarava Z, Lampl C, Magis D, Bendtsen L, Negro A, Russell MB, Mitsikostas DD, Jensen RH. Refractory chronic migraine: a consensus statement on clinical definition from the European Headache Federation. The journal of headache and pain. 2014 Aug 28:15(1):47. doi: 10.1186/1129-2377-15-47.
Rahmann A, Wienecke T, Hansen JM, Fahrenkrug J, Olesen J, Ashina M. Vasoactive intestinal peptide causes marked cephalic vasodilation, but does not induce migraine. Cephalalgia : an international journal of headache. 2008 Mar:28(3):226-36. doi: 10.1111/j.1468-2982.2007.01497.x.
Kruuse C, Thomsen LL, Birk S, Olesen J. Migraine can be induced by sildenafil without changes in middle cerebral artery diameter. Brain : a journal of neurology. 2003 Jan:126(Pt 1):241-7
Welch KM, D'Andrea G, Tepley N, Barkley G, Ramadan NM. The concept of migraine as a state of central neuronal hyperexcitability. Neurologic clinics. 1990 Nov:8(4):817-28
Welch KM, Nagesh V, Aurora SK, Gelman N. Periaqueductal gray matter dysfunction in migraine: cause or the burden of illness? Headache. 2001 Jul-Aug:41(7):629-37
Parsons AA. Cortical spreading depression: its role in migraine pathogenesis and possible therapeutic intervention strategies. Current pain and headache reports. 2004 Oct:8(5):410-6
Fusco M, D'Andrea G, Miccichè F, Stecca A, Bernardini D, Cananzi AL. Neurogenic inflammation in primary headaches. Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology. 2003 May:24 Suppl 2():S61-4
Faizo E, Fallata A, Mirza I, Koshak AK, Bucklain YT, Alharbi R, Tasji A, Tasji T, Kabbarah A. The Efficacy of Trigger Site Surgery in the Elimination of Chronic Migraine Headache: An Update in the Rate of Success and Failure. Cureus. 2024 Feb:16(2):e54504. doi: 10.7759/cureus.54504.
Stewart WF, Lipton RB, Kolodner KB, Sawyer J, Lee C, Liberman JN. Validity of the Migraine Disability Assessment (MIDAS) score in comparison to a diary-based measure in a population sample of migraine sufferers. Pain. 2000 Oct:88(1):41-52. doi: 10.1016/S0304-3959(00)00305-5.
Ramadan NM, Schultz LL, Gilkey SJ. Migraine prophylactic drugs: proof of efficacy, utilization and cost. Cephalalgia : an international journal of headache. 1997 Apr:17(2):73-80
Hepp Z, Dodick DW, Varon SF, Gillard P, Hansen RN, Devine EB. Adherence to oral migraine-preventive medications among patients with chronic migraine. Cephalalgia : an international journal of headache. 2015 May:35(6):478-88. doi: 10.1177/0333102414547138.
Scott AB. Botulinum toxin injection of eye muscles to correct strabismus. Transactions of the American Ophthalmological Society. 1981:79():734-70
Erbguth FJ, Naumann M. Historical aspects of botulinum toxin: Justinus Kerner (1786-1862) and the "sausage poison". Neurology. 1999 Nov 10:53(8):1850-3
Ababneh OH, Cetinkaya A, Kulwin DR. Long-term efficacy and safety of botulinum toxin A injections to treat blepharospasm and hemifacial spasm. Clinical & experimental ophthalmology. 2014 Apr:42(3):254-61. doi: 10.1111/ceo.12165.
Truong D, Comella C, Fernandez HH, Ondo WG, Dysport Benign Essential Blepharospasm Study Group. Efficacy and safety of purified botulinum toxin type A (Dysport) for the treatment of benign essential blepharospasm: a randomized, placebo-controlled, phase II trial. Parkinsonism & related disorders. 2008:14(5):407-14. doi: 10.1016/j.parkreldis.2007.11.003.
Tsui JK, Eisen A, Stoessl AJ, Calne S, Calne DB. Double-blind study of botulinum toxin in spasmodic torticollis. Lancet (London, England). 1986 Aug 2:2(8501):245-7
Greene P, Kang U, Fahn S, Brin M, Moskowitz C, Flaster E. Double-blind, placebo-controlled trial of botulinum toxin injections for the treatment of spasmodic torticollis. Neurology. 1990 Aug:40(8):1213-8
Jankovic J, Schwartz K, Donovan DT. Botulinum toxin treatment of cranial-cervical dystonia, spasmodic dysphonia, other focal dystonias and hemifacial spasm. Journal of neurology, neurosurgery, and psychiatry. 1990 Aug:53(8):633-9
Brin MF, Blitzer A, Fahn S, Gould W, Lovelace RE. Adductor laryngeal dystonia (spastic dysphonia): treatment with local injections of botulinum toxin (Botox). Movement disorders : official journal of the Movement Disorder Society. 1989:4(4):287-96
Brin MF, Fahn S, Moskowitz C, Friedman A, Shale HM, Greene PE, Blitzer A, List T, Lange D, Lovelace RE. Localized injections of botulinum toxin for the treatment of focal dystonia and hemifacial spasm. Movement disorders : official journal of the Movement Disorder Society. 1987:2(4):237-54
Lungu C, Karp BI, Alter K, Zolbrod R, Hallett M. Long-term follow-up of botulinum toxin therapy for focal hand dystonia: outcome at 10 years or more. Movement disorders : official journal of the Movement Disorder Society. 2011 Mar:26(4):750-3. doi: 10.1002/mds.23504.
Schnider P, Binder M, Auff E, Kittler H, Berger T, Wolff K. Double-blind trial of botulinum A toxin for the treatment of focal hyperhidrosis of the palms. The British journal of dermatology. 1997 Apr:136(4):548-52
Silberstein S, Mathew N, Saper J, Jenkins S. Botulinum toxin type A as a migraine preventive treatment. For the BOTOX Migraine Clinical Research Group. Headache. 2000 Jun:40(6):445-50
Durham PL, Cady R, Cady R. Regulation of calcitonin gene-related peptide secretion from trigeminal nerve cells by botulinum toxin type A: implications for migraine therapy. Headache. 2004 Jan:44(1):35-42; discussion 42-3
Binder WJ, Brin MF, Blitzer A, Schoenrock LD, Pogoda JM. Botulinum toxin type A (BOTOX) for treatment of migraine headaches: an open-label study. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2000 Dec:123(6):669-76
Freitag FG, Diamond S, Diamond M, Urban G. Botulinum Toxin Type A in the treatment of chronic migraine without medication overuse. Headache. 2008 Feb:48(2):201-9
Evers S, Vollmer-Haase J, Schwaag S, Rahmann A, Husstedt IW, Frese A. Botulinum toxin A in the prophylactic treatment of migraine--a randomized, double-blind, placebo-controlled study. Cephalalgia : an international journal of headache. 2004 Oct:24(10):838-43
Aurora SK, Gawel M, Brandes JL, Pokta S, Vandenburgh AM, BOTOX North American Episodic Migraine Study Group. Botulinum toxin type a prophylactic treatment of episodic migraine: a randomized, double-blind, placebo-controlled exploratory study. Headache. 2007 Apr:47(4):486-99
Coté TR, Mohan AK, Polder JA, Walton MK, Braun MM. Botulinum toxin type A injections: adverse events reported to the US Food and Drug Administration in therapeutic and cosmetic cases. Journal of the American Academy of Dermatology. 2005 Sep:53(3):407-15
Janis JE, Dhanik A, Howard JH. Validation of the peripheral trigger point theory of migraine headaches: single-surgeon experience using botulinum toxin and surgical decompression. Plastic and reconstructive surgery. 2011 Jul:128(1):123-131. doi: 10.1097/PRS.0b013e3182173d64.
Guyuron B, Varghai A, Michelow BJ, Thomas T, Davis J. Corrugator supercilii muscle resection and migraine headaches. Plastic and reconstructive surgery. 2000 Aug:106(2):429-34; discussion 435-7
Guyuron B, Tucker T, Davis J. Surgical treatment of migraine headaches. Plastic and reconstructive surgery. 2002 Jun:109(7):2183-9
Jose A, Nagori SA, Roychoudhury A. Surgical Management of Migraine Headache. The Journal of craniofacial surgery. 2018 Mar:29(2):e106-e108. doi: 10.1097/SCS.0000000000004078.
Bajaj J, Doddamani R, Chandra SP, Ratre S, Parihar V, Yadav Y, Sharma D. Comparison of Peripheral Neurectomy vs. Medical Treatment for Migraine: A Randomized Controlled Trial. Neurology India. 2021 Mar-Apr:69(Supplement):S110-S115. doi: 10.4103/0028-3886.315973.
Bovim G, Fredriksen TA, Stolt-Nielsen A, Sjaastad O. Neurolysis of the greater occipital nerve in cervicogenic headache. A follow up study. Headache. 1992 Apr:32(4):175-9
Khan S, Schoenen J, Ashina M. Sphenopalatine ganglion neuromodulation in migraine: what is the rationale? Cephalalgia : an international journal of headache. 2014 Apr:34(5):382-91. doi: 10.1177/0333102413512032.
Reed KL, Black SB, Banta CJ 2nd, Will KR. Combined occipital and supraorbital neurostimulation for the treatment of chronic migraine headaches: initial experience. Cephalalgia : an international journal of headache. 2010 Mar:30(3):260-71. doi: 10.1111/j.1468-2982.2009.01996.x.
Schoenen J, Vandersmissen B, Jeangette S, Herroelen L, Vandenheede M, Gérard P, Magis D. Migraine prevention with a supraorbital transcutaneous stimulator: a randomized controlled trial. Neurology. 2013 Feb 19:80(8):697-704. doi: 10.1212/WNL.0b013e3182825055.
Mauskop A. Vagus nerve stimulation relieves chronic refractory migraine and cluster headaches. Cephalalgia : an international journal of headache. 2005 Feb:25(2):82-6
Hord ED, Evans MS, Mueed S, Adamolekun B, Naritoku DK. The effect of vagus nerve stimulation on migraines. The journal of pain. 2003 Nov:4(9):530-4
Cocores AN, Smirnoff L, Greco G, Herrera R, Monteith TS. Update on Neuromodulation for Migraine and Other Primary Headache Disorders: Recent Advances and New Indications. Current pain and headache reports. 2025 Feb 15:29(1):47. doi: 10.1007/s11916-024-01314-7.
Maxey BS, Pruitt JW, Deville A, Montgomery C, Kaye AD, Urits I. Occipital Nerve Stimulation: An Alternative Treatment of Chronic Migraine. Current pain and headache reports. 2022 Apr:26(4):337-346. doi: 10.1007/s11916-022-01026-w.
Popeney CA, Aló KM. Peripheral neurostimulation for the treatment of chronic, disabling transformed migraine. Headache. 2003 Apr:43(4):369-75
Saper JR, Dodick DW, Silberstein SD, McCarville S, Sun M, Goadsby PJ, ONSTIM Investigators. Occipital nerve stimulation for the treatment of intractable chronic migraine headache: ONSTIM feasibility study. Cephalalgia : an international journal of headache. 2011 Feb:31(3):271-85. doi: 10.1177/0333102410381142.
Silberstein SD, Dodick DW, Saper J, Huh B, Slavin KV, Sharan A, Reed K, Narouze S, Mogilner A, Goldstein J, Trentman T, Vaisman J, Ordia J, Weber P, Deer T, Levy R, Diaz RL, Washburn SN, Mekhail N. Safety and efficacy of peripheral nerve stimulation of the occipital nerves for the management of chronic migraine: results from a randomized, multicenter, double-blinded, controlled study. Cephalalgia : an international journal of headache. 2012 Dec:32(16):1165-79. doi: 10.1177/0333102412462642.
Mueller OM, Gaul C, Katsarava Z, Diener HC, Sure U, Gasser T. Occipital nerve stimulation for the treatment of chronic cluster headache - lessons learned from 18 months experience. Central European neurosurgery. 2011 May:72(2):84-9. doi: 10.1055/s-0030-1270476.
Chen G, You H, Juha H, Lou B, Zhong Y, Lian X, Peng Z, Xu T, Yuan L, Woralux P, Hugo AB, Jianliang C. Trigger areas nerve decompression for refractory chronic migraine. Clinical neurology and neurosurgery. 2021 Jul:206():106699. doi: 10.1016/j.clineuro.2021.106699.
Guyuron B, Kriegler JS, Davis J, Amini SB. Comprehensive surgical treatment of migraine headaches. Plastic and reconstructive surgery. 2005 Jan:115(1):1-9
Totonchi A, Guyuron B, Ansari H. Surgical Options for Migraine: An Overview. Neurology India. 2021 Mar-Apr:69(Supplement):S105-S109. doi: 10.4103/0028-3886.315999.
Alrahbeni T, Mahal A, Alkhouri A, Alotaibi HF, Rajagopal V, Behera A, Al-Mugheed K, Khatib MN, Gaidhane S, Zahiruddin QS, Shabil M, Bushi G, Rustagi S, Kukreti N, Satapathy P, Mohapatra RK, Dziedzic A, Padhi BK. Surgical interventions for intractable migraine: a systematic review and meta-analysis. International journal of surgery (London, England). 2024 Oct 1:110(10):6306-6313. doi: 10.1097/JS9.0000000000001480
Authors
Copyright (c) 2025 Maha Ali Essa, Fayez Sumayhan Hirab alharbi, Soad Hassan Fardos Ghanem, Anaam Hassan Hashem Alshakes, Hind Yahya Hassan Huraysi, Najla abdullah barzig, Aliah Abdullah Mohammed barzig, Rawia Hassan Maghfouri, Hamad Mohaimeed Hamad Alotaibi, Abdulmajeed Obaid Abdullah Alotaibi, Hayam Hammoud Safhi, Amal Abdullah Ali Majrashi
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