RIO — Classified by the World Health Organization as one of the most disabling diseases on the planet, migraine afflicts 30 million Brazilians. Women are the main victims, due to the natural oscillation of hormones in the female body. No wonder the problem is one of the main targets of the drug industry. One of the most interesting procedures, however, with no connection to medications, has been gaining ground in Brazil and worldwide in recent times: migraine surgery.
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The procedure consists of decompressing two types of nerves associated with sensitivity: the trigeminal (which passes through the nose, jaw, cheeks, forehead and lateral regions) and the occipital (branching through the back of the head and the back of the head). Both are pointed out as one of the causes of intense headaches.
There are seven types of surgeries already practiced, one for each area where pain usually starts or becomes stronger. With a price that can vary from R$ 5 thousand to R$ 50 thousand, depending on the complexity, they are made in hospitals, under general or local anesthesia, and last from 20 minutes to five hours. The most common is the removal of a small piece of muscle or vessel to decompress the sensitive nerves.
The operation is indicated for patients diagnosed with migraine by neurologists and who do not respond well to conventional treatment or who suffer many side effects caused by drugs against the disease. About 80% to 90% of people undergoing migraine surgery show at least 50% improvement in the intensity, duration and frequency of attacks, with 30% to 40% of them claiming they no longer feel the pain.
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In the United States, where it is most popular, it is performed at universities such as Harvard, and has recently been recognized by the American Society for Plastic Surgery. In Brazil, the procedure is considered experimental by the Brazilian Academy of Neurology and the Brazilian Society of Headache, and, therefore, neurologists cannot perform it. The Federal Council of Medicine (CFM) does not bar the practice, however.
— This is a procedure that has been in existence for over a decade and has greatly evolved. This is superficial surgery, and therefore it doesn’t come close to the brain. The side effects are related to the sensitivity of the operated region, there is no risk of neurological sequelae – highlights Paolo Rubez, plastic surgeon and specialist in migraine surgery at the Case Western University, USA, one of the doctors who most perform the operation in Brazil.
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The technique was born in the 2000s in the United States, by chance. At that time, plastic surgeon Bahman Guyuron noticed that after cosmetic surgical procedures on the face, some patients reported a decrease in migraines.
Not every headache can be classified as a migraine. It is defined as pain that can last from four to 72 hours, with moderate to severe intensity, and that makes it difficult to carry out daily activities, such as working, reading, eating. The sensation is usually pulsatile, that is, like a throbbing artery. It is usually accompanied by other symptoms, such as irritability with light (photophobia), with sounds and smells.
The types of treatment for migraine are varied: they range from the use of analgesics to monoclonal antibodies and the application of botulinum toxin. They will depend on whether the migraine is acute — a specific episode — or chronic — recurrent.
– In cases of chronic migraine, the treatments aim to reduce the frequency and intensity of pain throughout the month. It’s not a cure, it’s putting the patient in the group where the pain is episodic — explains Gabriel Batistella, neurologist and Clinical Neuro-Oncology assistant at Unifesp’s Escola Paulista de Medicina.
It is in cases of chronic migraine that monoclonal antibodies and botulinum toxin also enter. In 2019, Anvisa approved the use of erenumab, which belongs to the first group. It blocks the receptors for the calcitonin-related peptide genes (CGRP), responsible for triggering migraine attacks. Botulinum toxin, on the other hand, promotes muscle relaxation in the region where it is applied, preventing contractions, and inhibits painful signs, thus relieving crises. These two techniques are helpful in preventing frequent episodes of pain.
When the migraine is acute, explains the doctor, the treatment is aimed at suspending the pain of that moment. The most common medications are dipyrone, paracetamol, anti-inflammatory and triptans.
– I do not usually recommend drugs that have a combination of many substances, such as dipyrone, caffeine and muscle relaxant. This type of medication can induce resistance to itself or generate an addiction in the patient. The body likes the medicine so much that it will generate a headache just for the patient to use it again – says Batistella.