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DESCRIPTIONSurgical deactivation of trigger sites is a proposed treatment of migraine headache. The procedure involves identifying a patient’s predominant migraine trigger site and transecting the branches of the trigeminal nerve supplying that area of head and neck. The treatment is based on the theory that migraine headaches arise due to inflammation of trigeminal nerve branches in the head and neck caused by irritation of the surrounding structures.
Migraine is a recurrent headache disorder with a prevalence in the United States of approximately 18% in women and 6% in men. According to the International Headache Society, migraine headache is a recurrent disorder with attacks lasting 4-72 hours. Typical features of migraine headaches include unilateral location, pulsating quality, moderate or severe intensity and associated symptoms such as nausea, photophobia, and/or phonophobia.
A variety of medications are used to treat acute migraine episodes. These include medications that are taken at the outset of an attack to abort the attack (triptans, ergotamines), and medications to treat the pain and other symptoms of migraines once they are established (non-steroidal anti-inflammatory drugs (NSAIDS), narcotic analgesics, antiemetics). Prophylactic medication therapy may be appropriate for individuals with migraines that occur more than 2 days per week. In addition to medication, behavioral treatments such as relaxation and cognitive therapy are used in the management of migraine headache. Moreover, botulinum toxin A injections are a Food and Drug Administration (FDA)-approved treatment for chronic migraine (migraines occurring on at least 15 days per month for at least 3 months).
Another proposed treatment of migraine headaches is surgical deactivation of trigger sites. The procedure was developed by plastic surgeon Dr. Bahman Guyuron, following observations that some patients who had cosmetic forehead lifts often reported improvement or elimination of migraine symptoms post-surgery. The procedure is based on the theory that migraine headaches arise due to inflammation of trigeminal nerve branches in the head and neck caused by irritation of the surrounding musculature, bony foramen, and perhaps fascia bands. Accordingly, surgical treatment of migraines would involve removing the relevant nerve sections, muscles, fascia and/or vessels. The treatment is also based on the theory that there are specific migraine trigger sites and that these can be located in individual patients. In studies conducted by Dr. Guyuron’s research group, clinical evaluation and diagnostic injections of botulinum toxin have been used to locate trigger sites. The specific surgical procedure varies according to the individual’s migraine trigger site. The surgical procedures are performed under general anesthesia in an ambulatory care setting and take an average of 1 hour.
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.
It has been proposed that other types of headaches, e.g., tension headaches, may also be triggered by irritation of the trigeminal nerve. Although this mechanism of action is less well-established for headaches other than migraine, it is possible that surgical treatment of trigger sites may also be beneficial for some non-migraine headaches.
Related medical policies are -
POLICYSurgical deactivation of trigger sites is considered investigational for the treatment of migraine and non-migraine headaches.
POLICY GUIDELINESInternational Headache Society (IHS) Classification II Criteria
Migraine Without Aura:
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY11/15/2012: Approved by Medical Policy Advisory Committee.
10/22/2013: Policy revised to include migraine and non-migraine headaches.
10/09/2014: Policy reviewed; no changes.
SOURCE(S)Blue Cross Blue Shield Association policy # 7.01.135
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.