Migrating Migraines: Risk factors for residual symptoms and unmasking of secondary trigger sites after headache surgery
Banafsheh Sharif-Askary, MD1, Salma A. Abdou, MD2, Karina Charipova, BS3, Idanis Perez-Alvarez, BS3 and Grant M. Kleiber, MD1, (1)Medstar Georgetown University Hospital, Washington, DC, (2)MedStar Georgetown University Hospital, Washington, DC, (3)Georgetown University School of Medicine, Washington, DC
Background: Headaches pose a considerable financial and emotional burden, with many patients choosing to undergo surgical management. There is limited evidence regarding the risk of residual symptoms and unmasking of new trigger sites after surgery. These adverse events can threaten patient satisfaction and quality-of-life. This study identifies the patient, procedure, and headache-related characteristics that predispose to residual symptoms and unmasking of secondary trigger sites.
Methods: Records from a single institution were reviewed for patients who underwent primary headache surgery. Trigger sites were classified as frontal, rhinogenic, temporal, and occipital based on origin. Operative interventions were categorized as nerve decompression or neurectomy. Residual symptoms were defined as a persistence or re-emergence of the original headache. Unmasked secondary trigger sites were defined as new headache origins that emerged after the initial surgery. Demographic, clinical, and surgical characteristics were compared.
Results: A total of 79 patients between 2013-2020 were identified. Following exclusion of patients with incomplete records and less than 30-day follow up, 49 patients (33 female, 16 male) with a mean age of 40.7±17.8 years were included. The most common trigger sites were occipital (77.6%) and frontal (18.4%). Most patients underwent nerve decompression (53.1%). Thirty-two patients (65.3%) experienced unmasking of a secondary trigger site following surgery. The most commonly unmasked sites were frontal (56.3%) and temporal (34.4%). Female patients were significantly more likely to experience unmasking as compared to male patients (81.3% vs. 18.8%), p=0.004). History of prior brain/spinal surgery was associated with higher rates of unmasking (53.1% vs. 11.8%, p=0.006). Most patients underwent block and surgical release (82.1%) for their unmasked sites. There was no association between unmasking sites and chronic pain disorders, original trigger site, or surgery type (all p>0.05). Twenty-three patients (46.9%) had residual symptoms at the original site with younger age being a risk factor (p=0.047). Among patients who had residual symptoms, the majority underwent block and surgical release (70.0%). Mean follow-up was 21.0±26.4 months.
Conclusions: There are high rates of residual symptoms and unmasking of secondary trigger sites after primary headache surgery. Female gender and previous brain/spinal surgery are risk factors for unmasking, while younger age is associated with residual symptoms. Our findings can be used to obtain data-driven informed consent to set patient expectations and improve postoperative satisfaction.
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