Plastic surgeons in the US are
using Botox to treat migraine headaches — a debilitating
neurological condition that, according to the Migraine
Association of Canada, affects over three million Canadians
and costs our economy around $500 million annually in
absenteeism and lost productivity.
By injecting the neurotoxin into
different muscles of the face and head, surgeons can
assess whether any are compressing or irritating the
surrounding nerves, thus causing migraine. If the paralysis
of one of the muscles prevents or improves migraine
symptoms, the targeted muscle is surgically removed.
"We're seeing improvement
in a substantial number of patients — about 80%
in those treated with Botox and 90% who receive surgery,"
says Dr Jeffrey E Janis, co-director of the plastic
surgery residency program at the University of Texas
Southwestern Medical Center, and one of the technique's
co-developers. "There's improvement across the board
in the frequency, duration and intensity of their headaches."
In some rare but encouraging cases, he adds, patients
are cured entirely.
TO
BE PRECISE
The idea of using Botox to treat migraines is not a
new one: many neurologists use it as an alternative
to traditional medications, injecting it in a headband-like
fashion around the skull. But with this method —
what Dr Janis refers to as a "shotgun" approach —
patients only get about three months of relief before
having to come back for a second round of shots. In
contrast, a pinpointed, diagnostic use of Botox followed
by surgery provides a longer-lasting, if not permanent
solution, he says.
Despite the deliberate precision
of the methodology, Dr Janis admits the basis for the
combined chemical and surgical technique was discovered
quite by accident by a colleague, eminent plastic surgeon
Dr Bahman Guyuron.
"Five years ago or so, [Dr Guyuron]
noticed that, after doing cosmetic brow lifts, a couple
of patients reported very excitedly that their migraines
were gone The only explanation seemed to be that, during
the procedure, he had removed the corrugator muscles,
which might have relieved compression or irritation
of the nerves around them," he explains.
He and Dr Guyuron began collaborating
on cadaver head studies, closely analysing nerve and
muscle anatomy to determine which would likely be involved
in migraines. "We couldn't go and operate on everybody,
but we could perform a sort of chemical surgery —
that is, use Botox to paralyze a given muscle so that
it can't contract against these nerves. It's like removing
it, but with a needle instead of a knife," he said.
After testing several injection points, they ended up
with a sort of roadmap, which could guide them towards
a focused surgical procedure.
MEETING
OF MINDS
Treating headaches is clearly outside the normal scope
of a plastic surgeon's practice, so Dr Janis requires
that all patients be referred from a neurologist with
an official diagnosis of migraine headache. Typically,
he sees those for whom traditional treatment hasn't
worked.
"I treat a lot of 'kitchen sink'
patients — people who have been to many neurologists,
tried an assortment of medications, modified their lifestyle
and diet. They live in the dark, don't go out of their
house, don't like strong smells. Basically, people who
no longer enjoy life because they're dominated by migraine
headaches," explains Dr Janis. "By the time I see them,
they're looking for anything that can help them, because
they've tried everything else medicine has to offer."
Such collaboration between plastic
surgeons and neurologists isn't obvious. But Dr Janis
insists the alternative he's offering should be seen
as an adjunct to traditional treatment. "We're working
with neurologists, not against them," he says.
Of course, his colleagues weren't
always so gung-ho. "At first, people thought what we
were doing was crazy. No neurologist wanted anything
to do with me," he recalls. It took a lot of personal
phone calls, but Dr Janis eventually forged an alliance.
"This really is a collaborative effort that demands
the expertise of both neurologists and plastic surgeons,"
he says, adding that the results, fortunately, speak
for themselves.
FRINGE
FACTOR
Dr Guyuron has published several studies over the course
of ongoing clinical trials, showing significant improvement
in a substantial number of patients. But despite its
promise, the technique remains on the medical fringe,
being practiced by only about 10 doctors in all of the
US.
Dr Donald Lalonde, president of
the Canadian Society of Plastic Surgeons, is unaware
of any Canadian physicians using the technique. "Some
plastic surgeons in Canada may have heard of it, but
99% probably haven't. Dr Guyuron is finishing his clinical
trials of the procedure, so hopefully, once his findings
are published, it will be more well known," he says.
To that end, Dr Guyuron has begun
organizing annual migraine headache symposia, the first
of which was held in October 2006 at Case Western Reserve
University, Cleveland, where he serves as chairman.
But Dr Lalonde suspects it'll take more than physician
awareness to gain the interest of Canadian migraine
sufferers. "I've discussed this treatment with some
patients, and though several expressed interest initially,
it ended once they found out that it wouldn't be covered
by Medicare. Canadians aren't used to having to pay
[out-of-pocket] for medical procedures," he says.
|
