BlueCross BlueShield of Tennessee Medical Policy Manual

Surgical Deactivation of Headache Trigger Sites

DESCRIPTION

Surgical deactivation of trigger sites is a proposed treatment of migraine headache.  The procedure involves identifying an individual’s predominant migraine trigger site and transecting the branches of the trigeminal nerve supplying that area of the head and neck.  The treatment is based on the theory that migraine headaches arise from inflammation of trigeminal nerve branches in the head and neck caused by irritation of the surrounding structures.

The specific surgical procedure varies according to the individual’s headache trigger site.  Surgical procedures have been developed at 4 trigger sites: frontal, temporal, rhinogenic, and occipital.  Frontal headaches are believed to be activated by irritation of the supratrochlear and suborbital nerves by glabellar muscles or vessels. The surgical procedure involves removal of the glabellar muscles encasing these nerves.  Fat from the upper eyelid is used to fill the defect in the muscles and shield the nerve.  Temporal headaches may be activated by inflammation of the zygomatico-temporal branch of the trigeminal nerve by the temporalis muscles or vessels adjacent to the nerve.  To treat migraines located at this trigger site, a segment (approximately 2.5 cm) of the zygomatico-temporal branch of the trigeminal nerve is removed endoscopically.  Paranasal headaches may involve intranasal abnormalities, e.g., deviated septum, which may irritate the end branches of the trigeminal nerve. Surgical treatment includes septoplasty and turbinectomy.  Finally, occipital headaches may be triggered by irritation of the occipital nerve by the semi-spinalis capitis muscle or the occipital artery.  Surgery consists of removal of a segment of the semispinalis capitis muscle medial to the greater occipital nerve approximately 1 cm wide and 2.5 cm long, followed by insertion of a subcutaneous flap between the nerve and the muscle to avoid nerve impingement.  The surgical procedure is performed under general anesthesia in an ambulatory care setting and takes an average of one hour.

It has been proposed that other types of headaches, e.g., tension headaches, may also be triggered by irritation of the trigeminal nerve. Surgical treatment of trigger sites is also proposed for some non-migraine headaches.

POLICY

IMPORTANT REMINDERS

ADDITIONAL INFORMATION 

Well-designed, sham-controlled, randomized studies are lacking.  There is insufficient data to determine the effects of this technology on health outcomes.

SOURCES

BlueCross BlueShield Association. Medical Policy Reference Manual. (2:2018). Surgical deactivation of headache trigger sites (7.01.135). Retrieved February 28, 2018 from  BlueWeb. (9 articles and/or guidelines reviewed)

Gfrerer, L., Maman, D. Y., Tessler, O., Austen, W. G, Jr. (2014). Nonendoscopic deactivation of nerve triggers in migraine headache patients: surgical technique and outcomes. Plastic and Reconstructive Surgery, 134 (4), 771-778. Abstract retrieved July 17, 2015 from PubMed database.

Guyuron, B., Lineberry, K., & Nahabet, E.H. (2015). A retrospective review of the outcomes of migraine surgery in the adolescent population. Plastic and Reconstructive Surgery, 135 (6), 1700-1705. Abstract retrieved February 28, 2018 from PubMed database.

Kurlander, D.E., Sattar, A., & Guyuron, B. (2016). In-depth review of symptoms, triggers, and surgical deactivation of frontal migraine headaches (site I). Plastic and Reconstructive Surgery, 138 (3), 681-688. Abstract retrieved March 15, 2017 from PubMed database.

Omranifard, M., Abdali, H., Ardakani, M., & Talebianfar, M. (2016). A comparison of outcome of medical and surgical treatment of migraine headache: In 1 year follow-up. Advanced Biomedical Research, 2016, 5, 121.  (Level 2 evidence)

ORIGINAL EFFECTIVE DATE:  2/10/2013

MOST RECENT REVIEW DATE:  4/12/2018

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Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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