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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.

Related medical policies are -

• Biofeedback
• OnabotulinumtoxinA (Botox®), AbobotulinumtoxinA (Dysport®), RimabotulinumtoxinB (Myobloc®), IncobotulinumtoxinA (Xeomin®)
• Occipital Nerve Stimulation

Migraine Without Aura:
Description:
Recurrent headache disorder manifesting in attacks lasting 4-72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia.

Diagnostic criteria:
A. At least 5 attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
C. Headache has at least two of the following characteristics:
1. unilateral location
2. pulsating quality
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)
D. During headache at least one of the following:
1. nausea and/or vomiting
2. photophobia and phonophobia
E. Not attributed to another disorder

Migraine with Aura:
Description:
Recurrent disorder manifesting in attacks of reversible focal neurological symptoms that usually develop gradually over 5-20 minutes and last for less than 60 minutes. Headache with the features of migraine without aura usually follows the aura symptoms. Less commonly, headache lacks migrainous features or is completely absent.

Diagnostic criteria:
A. At least 2 attacks fulfilling criterion B
B. Migraine aura fulfilling criteria B and C for one of the subforms 1.2.1-1.2.6
C. Not attributed to another disorder

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.

Non-Covered Codes

This is not an all-inclusive list of non-covered procedure codes.

All codes billed for this procedure are considered investigational and not eligible for coverage. 

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