Headache Surgery for Migraine: What to Know About this Controversial Treatment

Migraine surgery is a relatively new option that involves nerve compression, but experts are split on whether data supports its effectiveness. Here’s what you need to know.

Diet, manage stress, journal about your triggers, lower stress with meditation, take a triptan — do these sound familiar?

These are standard, first-line solutions given to reduce migraine. But they don’t work for everyone.

If you’re in this camp, you might be curious about a controversial procedure that claims to relieve migraine pain. Advocates say it provides relief for people who don’t respond to typical migraine treatments, while opponents don’t feel there’s enough data. Others fall somewhere in the middle.

Read on to learn the theory behind why it might help, what the research does and doesn’t tell us, and tips for making the most informed, empowered decision possible.

Join the free Migraine community!

Connect with thousands of members and find support through daily live chats, curated resources, and one-to-one messaging.

Sign up

What is headache or migraine surgery?

There are different types of headache or migraine surgeries, but they operate under the unproven theory that nerve compression — or trigger points — can prompt a migraine attack.

Types of migraine surgery include:

• Peripheral neurolysis: Nerve decompression involving small incisions near the eyes, back of the head, or nose, depending on the compressed nerve location.
• Neuromodulation: Internal placement of electrodes to stimulate nerves that might trigger migraine.
• Septoplasty: Improves airflow obstruction that might occur from a deviated septum.
• Turbinectomy: Removal of bone and soft tissue from the nose that might trigger breathing issues and migraine.

Neurologist Emad Noor, MD, explains that the approach emerged as a potential treatment in the mid-2000s.

Surgery involves releasing nerves in the head and neck that may be compressed to prevent or reduce the severity of future migraine attacks. It’s typically performed by plastic surgeons with experience handling delicate surgery.

Neuromodulation surgery may involve invasive stimulation of the occipital nerves or sphenopalatine ganglion (SPG), a group of nerve cells linked to the trigeminal nerve. The trigeminal nerve is a primary nerve involved in migraine.

The procedure is typically performed on an outpatient basis, meaning you go home afterward. It usually lasts 1 to 4 hours and is performed under general or localized anesthesia.

Side effects and risks of migraine surgery

While it sounds simple, migraine surgery is controversial and has potential side effects.

Recovery can involve:

• bruising
• bleeding
• numbness
• soreness
• scarring
• itching

These effects usually last a few weeks.

Long-term effects of surgery may include issues with smell, nasal pain and dryness, and neuroma or noncancerous tumor at the surgical site. For neuromodulation, surgery may also need to be repeated to replace wires that become dislodged.

Why is migraine surgery controversial?

The medical community doesn’t agree on whether headache surgery is a safe, effective, and valid option.

“Migraine surgery, specifically nerve decompression, is a relatively new approach that has shown promise for some individuals with chronic migraine who haven’t found relief with other treatments,” Noor said.

Concerns include:

• a lack of standardized techniques
• cost and accessibility
• concerns about overstating benefits

Christopher Gottschalk, MD, a neurologist and neurology professor, notes that insurance companies consider it “experimental,” so coverage is rare. According to the American Society of Plastic Surgeons, costs can range from $5,000 to $15,000, but these estimates are based on informal surveys with surgeons.

A lack of formal, conclusive data is at the heart of the issue.

Combing through the research

A 2024 meta-analysis and review of more than 1,600 people ages 6 to 72 suggested that migraine severity and frequency improved postsurgery. Follow-ups after the study ranged from 6 to 36 months.

A 2020 review of 39 studies indicated that surgery to decompress the peripheral (outer) nerves in the head, neck, and face was valid, linked it with a “high level of safety,” and that some people noticed fewer and less severe migraine. People who participated reported less severe and less frequent migraine. 

One 2020 follow-up study suggested that septoplasty to repair a deviated septum, the wall between the nostrils, may be considered as one potential treatment option. A review from 2019 suggested that turbinectomies could assist with migraine relief but called for higher quality research.

When it comes to neuromodulation, a 2020 review of 38 articles noted that invasive occipital nerve stimulation (ONS) has been shown to be effective in preventing migraine, although there was significant variability in how well it worked for different individuals. The authors also noted that the quality of the evidence was very poor.

In a 2022 study, 86% of people who underwent surgery at the occipital trigger site had a complete recovery, 32% of people who underwent surgery to the frontal trigger site had a complete recovery, and 50% of people who underwent surgery at the temporal trigger site had a complete recovery.

The study authors noted that the surgeries had a “high rate of positive results with a low percentage of minor complications.”

What do neurologists and headache specialists think?

It depends on who you ask. Gottschalk does not recommend it.

“If there were a properly designed trial that had a clear method of identifying potential candidates, I might consider it,” Gottschalk said.

Others, including Jeffrey E. Janis, MD, a professor of plastic surgery, surgery, neurosurgery, and neurology, believe that more than 2 decades of research support its use for the right people.

“I understand people see things through different lenses,” said Janis, an author of the 2024 study mentioned above. “I do know that some insurance companies deem this to be ‘experimental and investigational.’ That being said, there are 25 years of published evidence in peer-reviewed literature, which is the highest scrutiny one can face in science.”

Muhammad Arshad, MD, a board certified neurologist, said surgery is rarely needed because medications can usually help treat and prevent migraine.

“There’s also a subset of patients that are not even responsive to […] medications,” said Kaveh Alizadeh, MD, a plastic surgeon.

Janis agrees that these people might find relief from migraine surgery but that headache surgery is not a first-line treatment. Patients are usually referred by a neurologist after they haven’t found relief with medical and alternative treatments.

Should you try headache surgery?

Ultimately, the decision is one only you can make with a healthcare professional. Your neurologist will consider factors like medical history, severity of migraine, response to other treatments, and personal preferences.

If you proceed with the surgery, Alizadeh said it’s crucial to find a team of multiple specialists who you trust.

These include:

• a neurologist
• a pain specialist
• an internist who knows your medical history and story
• potentially a psychiatrist or psychologist for mental health support

Some questions to ask yourself and your healthcare team include:

• What are my treatment goals, and have I exhausted other options?
• What is the success rate of the surgery for patients with similar characteristics to mine?
• What are the long-term outcomes and potential complications of the surgery?
• Am I OK with the potential risks?
• What are the costs associated with the surgery, and will my insurance cover it?

Takeaway

Options for preventing and reducing migraine traditionally include medication and avoiding triggers like stress and certain foods. However, not everyone responds to these treatments.

Over the last 20+ years, migraine surgery has emerged as a potential option. The surgery involves freeing trigger points that can prompt migraine attacks.

Medical professionals and organizations have different positions on whether migraine surgery is a good idea. Ultimately, it’s a personal decision, and it’s important to work with a team you trust to weigh the pros and cons for you.