Surgery offers relief to chronic migraine patients

Mumbai: Smita Kulkarni has popped up to 15 ibuprofen painkiller tablets on some days, banged her head against the wall on other days and visited various doctors every year. For 16 years, the Pune resident waged a losing battleagainst migraine. On Thursday, 31-year-old Kulkarni took another, decisive step to drive away the pain along her left  temple: a five-hour brain procedure at Jaslok Hospital on Pedder Road. This is only the second time this procedure has been performed in India.      "Each of my migraine attacks would last at least five days. I would be too disoriented to do anything on such days," said the mother of a seven-year-old boy. Worse, she would have at least two such attacks every month.      "She had chronic migraine that hadn't eased with medication. She was an ideal candidate for the occipital nerve stimulator procedure,'' said neurosurgeon Paresh Doshi, who fixed an implantable device near Kulkarni's occipital nerve which will increase her pain threshold and jam the pain signals from the nerves. Implants break migraine patient's pain 'circuit'  Mumbai: Migraine is the most common of all the 150 different conditions that can produce a headache, and it can sometimes also be one of the most painful. "It is often a chronic disorder that won't go away just with a two-or-threemonth treatment. But there is no awareness in India about the need to handle it like other chronic conditions such as diabetes or asthma," said neurologist Dr K Ravishankar of Jaslok and Lilavati Hospital's headache clinic who directed Pune's Smita Kulkarni to surgery. It is only the second surgery to cure migraine in India.      Dr Ravishankar estimates that 20% of the women between 15 and 40, and 8% men suffer from the disorder. "It's one of the most researched headache disorders in the US, with the latest consensus being that it is a genetically inherited disorder of the brain." Most migraine patients get relief with modern medicine. "It's a small fraction like Kulkarni who need a surgical procedure," said neurosurgeon Paresh Doshi, who conducted the operation.      The occipital nerve stimulation procedure is not complex like other brain surgeries: the surgeon doesn't need to cut or go deep into the brain but only place two thin wires in the back of the skull. "Twelve nerves arise from the brain; migraine attacks are felt in distribution of the fifth nerve called the trigeminal nerve," said Dr Doshi. This nerve 'communicates' with the occipital nerve which lies in the spinal cord. "Any stimulation to the occipital nerve can be communicated to the fifth nerve through the pathways in the brainstem, changing the neuro-transmissions.''      The implants provide electrical impulses—through a power source implanted just below the collar bone—that stimulate the occipital nerve. The migraine patient's pain circuit is broken. "Doctors believe the procedure works in three ways. The implants increase the patient's pain threshold; they jam the pain signals and/or change the neuro-transmitter patterns,'' said Dr Doshi.      Dr Milind Sankhe, a neurosurgeon from Hinduja Hospital, said that surgery for migraine is rare in India, but is known to work. A doctor who didn't want to be identified said that long-term studies are needed to observe the efficacyof the procedure. A day after the surgery, Kulkarni is more concerned about her hair that was partially shaved off. "There is pain where the cuts were made, but my head doesn't ache,'' said Kulkarni, who was awake through the surgery. "Within a year, the brain will get used to the new circuitry and Smita may even be able to switch off the power source,'' said Dr Doshi.  NEUROVASCULAR DISORDER  Headaches account for 25% of a general neurologist's out-patient practice Of the various types of headaches, migraine is the most common and also the most burdensome It has mainly genetic causes, with three genes recently identified as being responsible Migraine is now labelled a Corbis 'Neurovascular disorder' and is thought to arise from a primary dysfunction of the brain and the brain stem Migraine are, in most cases, easy to diagnose and treat, but in a small number, it can be complex and debilitating The WHO has identified migraines as among the world's top 20 leading causes of disability. It is more common among women than men SYMPTOMS | Moderate/severe throbbing head pain | Sensitivity to sound and light | Nausea | Vomiting  OCCIPITAL NERVE STIMULATION PROCEDURE      In 50 references available on PUBMED, doctors from across the world have used the greater occipital nerve stimulation procedure to treat chronic migraine      The occipital nerve is a spinal nerve, arising between the first and second cervical vertebrae. It spreads right up to the scalp at the top of the head, over the ear, etc      Its stimulation using an implantable device, say neurosurgeons, increases the patient's pain threshold, thereby reducing the intensity of migraines      A small device is implanted near the occipital nerve. The device is then connected to a power source that sends electrical impulses to the occipital nerve. The power source is also implanted, often under the collarbone      The procedure was first used for migraines in 1977, but is still considered a treatment in development      There have been complaints of a need for surgical revision of wire placement. Infection also is a risk  PROGNOSIS  The intensity and frequency of the migraine attacks are greatly reduced after the surgery. Doctors say that after a year, the brain circuitry is so changed that the patient can even keep his/ her power source off Source: JAPI medical journal PAIN RELIEF: Doctors perform the procedure on Smita who suffers from chronic migraine