Plastic Surgeons Are Pushing Hard for Migraine Surgery Right Now. Read This Before Anyone Operates on You.

What's Happening

Back in 2023 I wrote a long breakdown of why migraine surgery doesn't make much biological sense and why the trial everyone cites has serious problems. The evidence has barely changed since then, but the number of articles promoting the surgery has gone up.

In the last seven weeks, Plastic and Reconstructive Surgery (PRS), the journal of the American Society of Plastic Surgeons, has published four pieces that push migraine surgery forward. The last two came out eight days apart. Neither has an abstract because both are opinion pieces rather than studies.

• On October 15, Ohio State's plastic surgery department published "The Evidence for Migraine Surgery Isn't in Doubt. Coverage Still Is."
• On October 20, a Cleveland Clinic plastic surgery group published a viewpoint titled "Surgical Treatment of Rhinogenic Migraines," subtitled "A Call to Action."

Those two follow a September 2 viewpoint on what to do when migraine attacks come back after surgery and a September 23 retrospective study arguing that surgery works better when it's done earlier.

I can't tell you whether this is coordinated. What I can tell you is that all four point in the same direction. Together, they argue that the surgery is legitimate, that insurers should pay for it, that it should happen earlier, and that it should reach more patients, now including people whose pain gets blamed on their nose. If you live with migraine, that message is going to reach you through surgeon websites, social media, and maybe a referral. Below is what each piece says and the evidence behind it.

"The Evidence Isn't in Doubt. Coverage Still Is."

This piece is by Sacha Hauc and Jeffrey Janis, both in Ohio State's Department of Plastic and Reconstructive Surgery. Janis is one of the best-known advocates for migraine surgery in the field. Their disclosure says Janis receives royalties from Thieme and Springer Publishing.

As the title makes clear, the goal is insurance coverage. The piece responds to a quality review. An independent team recently used AMSTAR 2, a standard tool for grading how trustworthy a systematic review is, to assess every systematic review on migraine surgery. All 20 were rated "Critically Low."

Their argument is that the low ratings came from paperwork problems, mainly reviews not registering a protocol in advance and not explaining what they excluded, rather than flawed methods. They also point out that every downgraded review still reported improvement.

That explanation leaves out why those steps matter. Registering a protocol ahead of time and reporting your exclusions aren't red tape. They stop a review from picking the outcomes and studies that tell the story you want once the data are in. A review that pools mostly uncontrolled surgical case series will always "report improvement," because uncontrolled case series nearly always report improvement. Quality tools are designed to catch that pattern, so pointing out that every review found benefit doesn't answer the criticism.

The authors then ask surgeons to "press that case directly with payers." They close by saying that patients "are not waiting on our methodology debates, and neither should we." That last line should worry anyone who has migraine.

The "Rhinogenic Migraine" Call to Action

The second piece, published October 20, comes from the Cleveland Clinic Department of Plastic Surgery. The senior author, Ali Totonchi, is a board-certified plastic surgeon at MetroHealth who lists migraine surgery among his clinical areas. He also lists a private practice, Zeeba Clinic, as an affiliation. The authors declare no financial interests.

"Rhinogenic" means "coming from the nose." The idea is that spots where the inside of the nose touches itself (a deviated septum or spur pressing on a turbinate, for example) set off headaches, and that operating on the nose fixes them. The highlighted lines on the second page show how the authors frame the research.

1. The authors decide the answer before the research

"It is imperative the migraine community strives to publish results in support of surgical treatment of rhinogenic migraine." Research is supposed to test whether a treatment works. Setting out to publish results in support of a treatment assumes the answer before the work is done.

2. The authors admit the anatomy doesn't match the symptoms

The authors write that there isn't a direct relationship between nasal anatomy and contact points, since "some patients with severe deformities have no pain, and vice versa." If the anatomy doesn't predict who has pain, it's hard to claim the anatomy is causing it.

3. Every study they found was positive

Their review found 14 studies with 591 patients, and "all included articles reported significantly reduced pain." Going by the titles and journals in their own reference list, most are single-center surgical series, largely from ear, nose, and throat departments, and only one is described as a randomized trial. Every study measured pain on a simple 0 to 10 scale, and only two used a migraine disability score. When 14 of 14 studies are positive and none has a sham control, placebo response, regression to the mean, and the tendency for negative surgical series to go unpublished can explain much of the result. To see how large placebo effects can be in migraine, look at what a 126-study analysis of placebo response in migraine trials found. Those trials used pills, and placebo effects from procedures tend to be even stronger.

4. The authors want a new name for the condition

The authors want everyone to call this "rhinogenic migraine" so the field can "bolster the validity of the disease entity." A new name doesn't make a diagnosis valid. In the International Classification of Headache Disorders (ICHD-3), headache attributed to disorders of the nasal mucosa, turbinates, or septum appears only in the appendix, which is where research criteria go when they haven't been validated well enough for the main classification. It's also listed as a secondary headache, meaning a headache caused by another condition, not a type of migraine.

They base the name on a 2002 paper showing that most people with "sinus headache" meet criteria for migraine. That finding means people with "sinus headache" usually have migraine and should be treated for migraine. It doesn't support treating migraine with nasal surgery, and merging the two labels makes an already common misdiagnosis harder to sort out.

Where the Evidence Stands

These are the studies the editorials rely on.

The 2009 trial by Guyuron and colleagues is still the centerpiece. As I explained in my original migraine surgery breakdown, it picked patients based on how they responded to botulinum toxin injections at trigger sites, which likely selected for strong placebo responders. Frontal surgery also changes how your forehead looks, which makes real blinding very hard. The sham group was also followed for only one year, so the longer-term results have no comparison group.

The September 23 PRS study from Taiwan argues that people who get surgery sooner after their migraine starts do better. It's a retrospective review of 54 patients with no control group. It can't separate the effect of surgery from placebo, from natural improvement over time, or from the fact that people with a longer disease history are a different group to begin with. Using it to recommend surgery earlier would turn a last-resort procedure into an early option.

The four PRS pieces at a glance

Every piece published in PRS since September 2 that pushes migraine surgery forward.

What Headache Experts and Insurers Say

Headache medicine groups and insurers have held a consistent position for over a decade.

• The American Headache Society advises in its Choosing Wisely list that clinicians should not recommend surgical deactivation of migraine trigger points outside of a clinical trial.
• Among insurers, Anthem's medical policy classifies surgical treatment of chronic headache, including chronic migraine, as investigational and not medically necessary. The Hauc and Janis piece itself confirms that UnitedHealthcare reaches the same conclusion.
• The American Society of Plastic Surgeons called the surgery safe and effective in its 2018 policy statement. This is the same society that publishes PRS.

When an editorial says the evidence "isn't in doubt," it means the evidence isn't in doubt among the surgeons who perform the procedure. Headache specialists and insurers still have serious doubts.

If a Surgeon Offers You This

This decision is yours to make. These are the things I would want to know first.

Make sure you've tried the medical options first

Many people are labeled "refractory" before they've had a fair trial of modern treatments. Compare your treatment history with the new AAN and AHS prevention guideline and the definitions of resistant and refractory migraine. Have you tried a CGRP monoclonal antibody like erenumab (Aimovig), fremanezumab (Ajovy), galcanezumab (Emgality), or eptinezumab (Vyepti)? Have you tried a gepant like atogepant (Qulipta) or rimegepant (Nurtec ODT)? What about onabotulinumtoxinA (Botox) if you have chronic migraine? Have you had peripheral nerve blocks? If the answer to most of those is no, surgery shouldn't be on the table yet.

Two free tools can help with that conversation. The preventive response calculator shows whether your current treatment is failing, and the medication overuse headache checker helps rule out rebound headache, which is one of the most common reasons treatment seems to stop working.

Questions to ask the surgeon

• Has a neurologist or headache specialist confirmed my diagnosis and reviewed my treatment history?
• Which sham-controlled trials support the specific procedure you're recommending for me?
• Would you do this within a registered clinical trial?
• What happens if my migraine attacks move to a new site afterward? Will you recommend another operation?
• What's your rate of numbness, scarring, and chronic nerve pain, including anesthesia dolorosa (painful numbness)?
• What will this cost me if my insurer denies it?

Key Takeaways

Migraine is a disease of the brain, and our understanding of its pathophysiology hasn't changed because of these editorials. If someone tells you the evidence for migraine surgery is settled, ask which sham-controlled trials support it.