Surgical Deactivation of Headache Trigger Sites

POLICY NUMBER

A.7.01.135

DESCRIPTION

Migraine is a common headache disorder that is treated using various medications, which can be taken at the onset of an attack and/or for migraine prophylaxis. Other treatments include behavioral treatments and botulinum toxin injections. Surgical deactivation of trigger sites is another proposed treatment. Surgical deactivation is based on the theory that migraine headaches arise due to inflammation of the trigeminal nerve branches in the head and neck and that specific trigger sites can be identified in individual patients. Surgical deactivation has also been proposed for other types of headaches (eg, tension headaches).

Migraine Headache

Migraine is a common 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 to 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.

Treatment

A variety of medications are used to treat acute migraine episodes. These include medications taken at the onset of an attack to abort the attack (eg, triptans, ergotamines, and certain calcitonin gene-related peptide [CGRP] receptor antagonists), and medications to treat the pain and other symptoms of migraines once they are established (eg, non-opioid analgesics, antiemetics). Prophylactic medication therapy (eg, certain antidepressants, beta-blockers, and anti-seizure medications) may be appropriate for people with migraines that occur more than 2 days per week. Onabotulinumtoxin A and several CGRP receptor antagonists have also been approved by the U.S. Food and Drug Administration (FDA) as prophylactic treatments for episodic and/or chronic migraines. In addition to medication, behavioral treatments such as relaxation and cognitive therapy are used to manage migraine headache.

Surgical Deactivation

Surgical deactivation of trigger sites is another proposed treatment of migraine headache. The procedure was developed by a plastic surgeon (Bahman Guyuron, MD), following observations that some patients who had cosmetic forehead lifts 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 involves 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 sites can be located in individual patients. In studies conducted by 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 patient's migraine trigger site. The surgical procedures are performed under general anesthesia in an ambulatory care setting and take an average of one hour.

Surgical procedures have been developed at four 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 the 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. Rhinogenic 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 caused by the semispinalis 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.

Non-Migraine Headache

It has been proposed that other types of headaches (e.g., tension headaches) may also be triggered by irritation of the trigeminal nerve.

Treatment

Although the 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.Surgical deactivation of headache triggers is a surgical procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration.

Related medical policies are -

• Biofeedback

• Botulinum Toxin

• Occipital Nerve Stimulation

POLICY

Surgical deactivation of trigger sites is considered investigational for the treatment of migraine and non-migraine headaches.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

International Headache Society Classification Criteria for Migraines

Migraine Without Aura:Description:Recurrent headache disorder characterized by attacks lasting 4 to 72 hours.

Diagnostic criteria:

1. At least 5 attacks fulfilling criteria B through D

2. Headache attacks lasting 4 to 72 hours (untreated or successfully treated)

3. At least two of the following four 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);

4. During headache, at least one of the following:

   1. nausea and/or vomiting;

   2. photophobia and phonophobia;

5. Not better accounted for by another ICHD-3 diagnosis

Migraine with Aura:Description:Recurrent attacks, lasting minutes, of unilateral fully reversible visual, sensory or other central nervous system symptoms that usually develop gradually and are usually followed by headache and associated migraine symptoms.

Diagnostic criteria:

1. At least 2 attacks fulfilling criteria B and C

2. One or more of the following fully reversible aura symptoms:

   1. visual;

   2. sensory;

   3. speech and/or language;

   4. motor;

   5. brainstem;

   6. retinal;

3. At least three of the following six characteristics:

   1. at least one aura symptom spreads gradually over ≥5 minutes;

   2. two or more aura symptoms occur in succession;

   3. each individual aura symptom lasts 5 to 60 minutes;

   4. at least one aura symptom is unilateral;

   5. at least one aura symptom is positive;

   6. the aura is accompanied, or followed within 60 minutes, by headache;

4. Not better accounted for by another ICHD-3 diagnosis, and transient ischemic attack has been excluded.

Adapted from Headache Classification Committee of the International Headache Society (2018; available at http://www.ihs-headache.org/ichd-guidelines ).*ICHD-3: International Classification of Headache Disorders, 3rd edition.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

11/15/2012: 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.

07/23/2015: Code Reference section updated for ICD-10.

11/05/2015: Policy description updated. Policy statement unchanged. Investigative definition updated in policy guidelines section.

04/01/2016: Policy reviewed; no changes.

05/31/2016: Policy number A.7.01.135 added.

03/01/2017: Policy description updated regarding treatments. Policy statement unchanged. Policy guidelines updated regarding classification criteria for migraines.

03/07/2018: Policy description updated. Policy statement unchanged.

03/20/2019: Policy reviewed; no changes.

03/11/2020: Policy reviewed; no changes.

05/20/2021: Policy reviewed. Policy statement unchanged. Policy Guidelines updated regarding diagnostic criteria for migraines.

04/21/2022: Policy reviewed; no changes.

03/20/2023: Policy reviewed; no changes.

03/20/2024: Policy description updated regarding treatment. Policy statement unchanged.

04/10/2025: Policy reviewed; no changes.

SOURCE(S)

Blue Cross Blue Shield Association policy # 7.01.135

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

Investigational Codes

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