As many of you are likely aware, there is a general disagreement between plastic/peripheral nerve surgeons and neurologists with regard to nerve decompression or transection and implantation as a treatment for chronic headaches. The main issue stems from the fact that chronic headaches such as migraines are considered to be centrally-mediated. What that means is that the headaches arise from any number of complex mechanisms within the central nervous system (i.e. brain or spinal cord).
From the viewpoint of the neurology community, this concept of chronic headaches (e.g. migraines) accounts for the overwhelming majority of the various headache subtypes recognized clinically (e.g. cervicogenic headaches, new daily persistent headaches, etc.). In contrast, surgical decompression (e.g. of the occipital nerves) is performed on the peripheral nervous system (i.e. nerves outside the brain and spinal cord). The possibility that peripherally mediated factors can cause or contribute to chronic headaches is relatively new, but has been around for over 20 years.
Plastic/peripheral nerve surgeons who perform headache operations feel that in some patients (e.g. those that have failed traditional treatment modalities, those that respond to nerve blocks and those that have a specific set of findings on physical exam), peripheral nerve compression is a critical causative factor in headache symptoms. Historically, these two camps have been at odds, but that dictum may be changing.
In a recent article in a prominent neurology journal (Blake and Burstein, The Journal of Headache and Pain, (2019) 20:76), two prominent neurologists, discuss the concepts and science behind peripheral nerve factors in the generation of headaches. Furthermore, they elaborate on the fact that some patients who have what they term ‘unremitting head and/or neck pain’ (UHNP) share many clinical features of patients diagnosed with other headache disorders (e.g. chronic migraine, NDPH).
The authors conclude among other things, that we lack an accurate classification system and nomenclature to describe these patients and that peripheral nerve surgery may be a reasonable treatment option for this subgroup of people. The scientific possibilities underlying these conclusions are also discussed in some detail.
I cannot emphasize how critical this paper is to those of us who have been championing the concept of headache surgery as a viable treatment option. It is also a huge milestone for headache patients themselves. I believe this manuscript is one of the first cracks in the dam that separates neurologists from peripheral nerve surgeons and might ultimately lead to wider acceptance of peripheral nerve causes for chronic headaches.
Working together, both neurologists and peripheral nerve surgeons have the best chance of convincing their respective colleagues that this notion is valid and advocate/work together to lobby for better insurance coverage and more scientific studies to further refine the patient population who would best benefit from surgical intervention as a primary or adjunctive treatment modality. I applaud Pamela Blake and Rami Burstein for their courage in putting their thoughts to paper in what I am sure will be a somewhat controversial topic amongst their own neurology colleagues, but one which will ultimately benefit millions of headache patients.