Thursday, December 30, 2004

Miracle surgery for migraine?

BBC NEWS | Health | Surgery 'helps combat migraines'Coincidentally, I'd just finished an interesting CME on headache when I saw this:
Surgery and botox injections can help treat migraines, a US study says.

Researchers injected about 100 patients with botox to find out which muscles triggered the migraines and then used surgery to remove the muscles.

The surgery reduced the intensity and frequency of migraines in 92% of patients and eliminated them altogether for a third of people involved.

The research, published in Plastic and Reconstructive Surgery journal, also cut the number of sick days taken.

A 33% lifetime cure for migraine? That would be miraculous. I'm skeptical. My bet:

1. This was a very select group. They had to respond to botox before surgery. The BBC reporter missed this. Since about half the population gets migraines, I'd bet this is a small subgroup who have an unusual migraine trigger. So even if it works, perhaps 1/10 to 1/20 of identified chronic migraine patients would be candidates.

2. I'd be astounded if the results will be this good in f/u studies. We know that migraine, like most pain conditions, is very susceptible to "placebo" affects. (We don't know what this "placebo" affect is -- it's very powerful and if we could master it then it would be very valuable. It's hard to manage though.) I bet a randomized placebo-controlled trial will show benefit in about 1/3 of 1/15 migraineurs (1/50!) and longtime cure in 1/10 of those treated (1/150 of migraineurs).

Ok, maybe I'm a Grinch. I knew of some neurologists years ago who were quite keen on these types of therapy, including using pre-botox interventions to kill some of these peripheral nerves. ENT surgeons, esp. in the 60s and 70s, used various similar interventions for cluster headaches (some used cocaine back then -- but it had its own problems). This wouldn't be the first time that an old intervention would be shown to have real value. And, on the other hand, we know that migraine prophylaxis drugs basically suck. (They are so ineffective that one suspects the entire value of many of them is from the placebo effect.)

We'll see ...

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