|Subject:||Surgical and Ablative Treatments for Chronic Headaches|
|Policy #:||SURG.00096||Current Effective Date:||07/09/2013|
|Status:||Reviewed||Last Review Date:||05/09/2013|
This document addresses surgical and ablative treatments for chronic headache (e.g. migraine and tension type headaches) and occipital neuralgia. A variety of procedures are proposed for this purpose and include, for example, identification of nerve trigger points in the forehead and surgically removing muscle tissue from these areas, removing intranasal contact points between opposing nasal mucosal surfaces and closure of a patent foramen ovale. This document does not address sinus surgery for chronic sinus disease with associated headache when there is evidence the sinus disease is likely to be the cause of the headache.
Note: Please see the following related documents for additional information:
Investigational and Not Medically Necessary:
Surgical treatment for chronic headaches (including but not limited to chronic migraine headache and chronic tension type headache) is considered investigational and not medically necessary. This includes but is not limited to the following procedures:
Surgical and ablative treatments of occipital neuralgia are considered investigational and not medically necessary. This includes but is not limited to the following procedures, for treatment of occipital neuralgia:
It has been postulated that activation of peripheral sensory nerves, including the trigeminal nerve causes release of peptides, (e.g., substance P, calcitonin gene-related peptide, neurokinins), resulting in vasodilatation and migraine headache. Also, that trigger points can be identified, particularly in the region of the forehead, at which peripheral nerve activation occurs. Further, intranasal contact points between mucosal surfaces of the nasal septum and turbinates are suggested to act as triggers releasing pain mediators that are also present in the trigeminovascular system contributing to migraine headaches.
Resection, manipulation or repositioning of musculature surgery:
The available literature includes a preliminary study that considered the possibility of a relationship between the removal of the corrugator supercilii muscle and the elimination or significant improvement of migraine headaches. Guyuron and colleagues (2000) conducted a chart review and survey of those who had undergone corrugator supercilii muscle resection during forehead rejuvenation procedures and found that 39 had a history of migraine. Of this group, 31 noted an improvement or elimination of migraine headaches after surgery and the benefits lasted over a mean follow-up period of 47 months. Guyuron (2002) also conducted a prospective study to investigate the role of removal of corrugator supercilii muscles, transection of the zygomaticotemporal branch of the trigeminal nerve, and temple soft-tissue repositioning in the treatment of migraine headaches. The diagnosis of moderate to severe migraine headaches was confirmed in 29 participants. Botulinum toxin A (Botox) was then injected into each corrugator supercilii muscle and 24 participants experienced either an elimination or significant intensity reduction of migraines. Twenty-two participants went on to have the surgery and 21 participants post operatively had significant reductions in frequency and intensity of headaches. It was concluded that a diagnostic injection of Botox was a reliable predictor of surgical outcome.
Guyuron and colleagues (2005) conducted a randomized controlled study to investigate the efficacy of surgical deactivation of migraine headache trigger sites. Of 125 individuals diagnosed with migraine headaches, 100 were randomly assigned to the treatment group and 25 served as controls. The treatment group received sequential Botox injections for identification of triggers at the "four most common sites," beginning with the most common site and proceeding at monthly intervals according to an injection algorithm until all potential trigger points were found. Trigger points were found in 91 individuals, 65% of whom had 3 or 4 trigger sites identified. A positive response was defined as at least a 50% reduction in intensity and/or frequency of migraine headache lasting at least four consecutive weeks, and these individuals were considered surgical candidates. The 25 controls received 0.5 ml. of saline as a "placebo," however no information was provided regarding their response and it is unclear which of the four common trigger points were injected in this group. For the treatment group with frontal triggers identified, the glabellar muscle group-including the corrugator supercilii, depressor supercilii and procerus muscles-was removed to relieve compression of the supraorbital and supratrochlear nerves traversing these muscles. Those with temporal migraine underwent endoscopic removal of 3 cm of the zygomaticotemporal branch of the trigeminal nerve to prevent its compression by the temporalis muscle. For those with occipital migraine, a portion of the semispinalis capitis muscle surrounding the greater occipital nerve was removed and the nerve shielded from the muscle with a subcutaneous flap. Participants with migraines triggered from the nasal septum and turbinates underwent septoplasty and inferior and/or middle turbinectomies based on the "intranasal abnormality." Of this group, 89 completed follow-up requirements, and 82 of the 89 noted at least a 50% reduction in migraine headache frequency and intensity. Post operatively, 31 reported elimination and 51 reported improvement over a follow-up period of 396 days. In comparison, three of the 19 in the control group who completed 1 year follow up recorded reduction in migraine headaches and no participant observed elimination. Adverse effects from the surgery were minor and transient, however 23% of those receiving Botox in the temporal area developed hollowing of the temples giving the face an "hour glass" appearance. It was concluded that surgical deactivation of migraine trigger sites can eliminate or significantly reduce migraine symptoms but that additional studies are necessary to clarify the mechanism of action and to determine the long-term results. Drawbacks of this study include lack of information regarding the response of the control group to placebo or sites of injection in this group, and no description of other migraine therapies or any changes in therapy received by either the control or treatment group during the study that might have influenced the outcomes.
In 2010, Guyuron and colleagues reported five year follow-up data on the prior study. Out of the 100 individuals originally enrolled in the treatment group, 89 underwent surgery and 79 have been followed for 5 years. Ten participants underwent deactivation of additional (different) trigger sites during the follow-up period and were not included in the five year analysis. The authors stated that with or without inclusion of these 10 participants did not affect statistical findings. At five years, 62 of the 69 participants (88%) had a positive response to the surgery. Twenty individuals (29%) reported complete elimination of migraine headaches, while 41 (59%) noticed a significant decrease and eight (11%) had no significant change. When compared to the baseline questionnaires of the SF-36 (short form 36 health survey), MSQ (Mental Status Questionnaire), and MIDAS (Migraine Disability Assessment) testing values, all measured variables at 60 months improved significantly (p less than 0.0001).
In another study, Guyuron and colleagues (2009) published results of single-center blinded randomized controlled trial for surgical treatment of frequent moderate to severe migraine headaches. In 76 eligible participants, headache trigger sites were identified by a positive response to botulinum toxin injections. The participants were randomly assigned to a treatment group (n = 49) or sham group (n = 26). The treatment group had muscle or nerve tissue removed from their trigger site. The sham surgery group had exposure but not resection of the muscles and nerves through a similar incision. At 12 months, the treatment group showed statistically superior outcomes compared to the sham group. While these results are promising, larger randomized studies are warranted to demonstrate clinical efficacy.
Nasal or sinus surgery:
Behin (2004), in a small retrospective review (n=21), found that for selected individuals with refractory headaches, demonstrable sinonasal contact points (seen on CT scan between the nasal septum and superior or middle turbinate and/or medial wall of the ethmoid sinus), and positive response after topical anesthesia, a surgical approach toward the triggering factor may be useful. Surgeries included septoplasty, middle turbinectomy, medial ethmoidectomy and, in some cases, removal or lateralization of the superior turbinate. Seventy-six percent of the participants reported at least a 50% reduction in headache frequency and severity at 6-12 months. The authors concluded that prospective studies are necessary to confirm these results. Drawbacks of this study include the unclear number of those with a true migraine diagnosis and the fact that a validated questionnaire was not used raising the issue of interpretation of the data.
Abu-Samra and colleagues (2011) conducted a prospective, controlled, single blinded study of 42 individuals with chronic daily headaches refractory to medical treatment and CT imaging showed nasal contact point between the septum and the lateral nasal wall as well as other nasal contact points such as between the septum and turbinates and or the medial wall of the ethmoid sinuses. A local anesthetic test was performed on each participant at the specified contact point, however the test results were not considered criteria for surgical decision. The surgical technique was either septoplasty or submucous resection with or without endoscopic assisted partial turbinectomy for both or either turbinates based upon areas of contact. In this cohort, 22 were classified as having chronic tension type headache (CTTH) and 20 were classified as chronic migraineurs (CM). Results from the group showed 8 were totally free from headache, 26 were satisfied with the procedure as their headache severity and frequency could be managed without medication. There was no improvement in seven and one participant had a 50% increase in headache severity. The local anesthetic test was positive in 12 individuals and six of this group were also part of the group being totally free from headaches. The authors acknowledged that the sample size was small with no control group. The authors also considered the contact point as a trigger rather than a cause of headache. The authors did not define how the intensity of headaches was measured nor the length of the post operative observation. Other small studies have evaluated the feasibility and effectiveness of nasal surgery for contact points to relieve chronic headaches (Kunachak, 2002; Mohebbi, 2010; Welge-Luessen, 2003).
In general, the literature addressing surgical treatment for migraine lacks large randomized controlled studies. Also, the postulated mechanisms constituting the rationale for the procedures require further clarification. Additionally, it is unclear, how other potential "trigger point" areas were evaluated or eliminated in some studies focusing only on identifying and treating triggers in either the intranasal region or forehead. Several investigators note their findings require additional prospective studies for confirmation of their observations and to further clarify the mechanisms by which the surgeries may produce any benefit.
Closure of patent foramen ovale:
An interesting observation has been the higher prevalence of patent foramen ovale (PFO) in migraine sufferers compared to the general population. Theories include elimination of prior paradoxical microemboli to the terminal branches of the basovertebral artery and closure of a shunt previously allowing vasoactive substances triggering migraine to bypass the pulmonary filter. Published studies have shown that PFO closure resulted in migraine cessation or improvement in migraine headaches (Dowson, 2009; Rigatelli, 2010; Trabattoni, 2011; Wahl, 2010). However, the body of evidence is limited and hindered by small participant numbers and non-uniform study methods. Currently, it is not clearly recommended that closure of a patent foramen ovale be performed for the indication of migraine alone (Beda, 2005; Cheng, 2006; Dowson, 2008). There are clinical trials recruiting participants to study PFO closure for the treatment of migraine headaches.
Surgical and ablative treatments of occipital neuralgia:
Various treatments and procedures have been proposed for treatment of occipital neuralgia, however, the published literature addressing these treatments consists of small, non randomized studies, case reports and case series as well as retrospective studies and reviews.
In a small study, Ducic and colleagues (2011) reported on 25 individuals with documented bilateral occipital neuralgia-related chronic headaches who underwent peripheral nerve surgery with decompression of the greater occipital nerve bilaterally, including the area of its intersection with the occipital artery. All individuals were evaluated intraoperatively for evidence of arterially mediated greater occipital nerve compression and the configuration of the nerve-vessel intersection. Pathologic evaluation of the occipital artery from 15 individuals showed vasculitis. The authors concluded that, based on these findings, mechanical (and not primary inflammatory) irritation of the nerve by the occipital artery remains an important theoretical cause for otherwise idiopathic cases. The authors proposed that physical separation of the nerve-artery intersection (in addition to musculofascial neurolysis) can be a therapeutic approach for treatment of occipital neuralgia.
Gille and colleagues (2004) examined surgical treatment of greater occipital neuralgia by neurolysis of the greater occipital nerve and sectioning of the inferior oblique muscle in a case series study of 10 individuals. Of this group, three individuals had anatomic anomalies. The mean follow-up of the series was 37 months. The results of the treatment were assessed according to three criteria: 1) degree of pain on a Visual Analogue Scale (VAS) before surgery, at three months, and at last follow-up; 2) consumption of analgesics before surgery and at follow-up; and 3) the degree of satisfaction at follow-up. The mean VAS score was 80/100 before surgery and 20/100 at last follow-up. Consumption of analgesics decreased in all individuals. Seven of the 10 individuals were very satisfied or satisfied with the operation. Although the authors concluded that the outcomes in these individuals shows that this surgical technique provides good results when performed on well chosen individuals, the small size, short follow-up and lack of a control group limits the validity of the results of this study when applied to a larger population.
In a retrospective chart review, Ducic and colleagues (2009) reported on 206 consecutive subjects undergoing neurolysis of the greater or, less commonly, excision of the greater and/or lesser occipital nerves. Preoperative and postoperative visual analogue pain scores and migraine headache indices were measured. Success was defined as a reduction in pain of 50 percent or greater. Of the 206 subjects, 190 underwent greater occipital nerve neurolysis (171 bilateral), 12 subjects underwent greater and lesser occipital nerve excision and four underwent lesser occipital nerve excision alone. The authors found that 80.5 percent of the subjects experienced at least 50 percent pain relief and 43.4 percent of the subjects experienced complete relief of headache. Mean preoperative pain score was 7.9 +/- 1.4. Mean postoperative pain was 1.9 +/- 1.8. Minimum duration of follow-up was 12 months. The authors concluded that neurolysis of the greater occipital nerve appears to provide safe, durable pain relief in the majority of selected subjects with chronic headaches caused by occipital neuralgia.
Vanelderen and colleagues (2010) conducted a prospective study on 19 participants receiving pulsed radiofrequency for the treatment of occipital neuralgia with a six month follow-up. Participants with clinical findings suggestive of occipital neuralgia and a positive test block of the occipital nerves with 2 ml of local anesthetic underwent a pulsed radiofrequency procedure of the culprit nerves. Mean scores for pain, quality of life, and medication intake were measured one, two, and six months after the procedure. Mean VAS and median Medication Quantification Scale scores declined by 3.6 units (P = 0.002) and 8 units (P = 0.006), respectively, during six months. Approximately 52.6% of the participants reported a score of six (pain improved substantially) or higher on the Likert scale after six months. No complications were reported. The authors noted that pulsed radiofrequency treatment of the greater and/or lesser occipital nerve is a promising treatment of occipital neuralgia and warrants further placebo-controlled trials.
In April of 2012, the American Headache Society released a statement urging caution when using surgical interventions for the treatment of headaches. They specifically state:
In our view, surgery for migraine is a last-resort option and is probably not appropriate for most sufferers. To date, there are no convincing or definitive data that show its long-term value. Besides replacing the use of more appropriate treatments, surgical intervention also may produce side effects that are not reversible and carry the risks associated with any surgery.
They conclude with, "Most importantly, it may not work for you at all."
Chronic headaches are those that occur daily or almost daily for more than 15 days a month. The International Classification of Headache Disorders (ICHD) lists migraine as a primary headache. A primary headache is one that is not associated with any demonstrable organic disease, structural or neurologic abnormality. Migraines may be unilateral or bilateral. They may occur with or without a preceding aura such as dizziness, tinnitus, photophobia, or visual scintillations (e.g., bright zigzag lines). Migraines manifest as a recurring attack usually lasting for 4–72 hours and involving pain of moderate to severe intensity, often with nausea, sometimes vomiting, sensitivity to light, sound and other sensory stimuli. Migraines are present in about 28 million people in the United States. They may occur at any age, but usually begin between the ages of 10 and 40 and diminish after age 50. Approximately 75% of migraine sufferers are women. The exact pathology is unknown, but it is felt that a family history of migraine headaches, medications (i.e., birth control pills, vasodilators), fatigue, emotional stress and specific foods or alcohol are probable triggers. Management of migraine headaches has consisted largely of pharmacologic treatment.
Migraines are generally treated by two approaches: abortive and preventive. The goal of abortive therapy is to prevent a migraine attack or to stop it once it starts. The prescribed medications stop a headache during its prodrome stage or once it has begun and may be taken as needed. Preventive treatment is considered if an individual has more than one migraine per week. The goal is to lessen the frequency and severity of the migraine attacks with daily medication.
The American Academy of Neurology (AAN) does not address surgical treatment of migraines. Currently their goals of long-term migraine treatment, both pharmacologic and nonpharmacologic are as follows: (AAN, 2004)
Occipital neuralgia is classified as a secondary headache by the ICHD. Secondary headaches are usually associated with any disease, structural or neurologic abnormality. In this case, accurate diagnosing is important because treatment of the underlying problem usually eliminates the headache.
Aura: Symptoms such as disturbances in vision, smell or perception that occur prior to a migraine that serve as a warning that the headache may follow.
Etiology:The cause or origin of disease.
Neuroplasty: Surgery to repair or restore nerve tissue.
Neurolysis: The release of a nerve sheath by cutting it longitudinally; operative breaking up of neural adhesions.
Neuralgia: an intense burning or stabbing pain caused by irritation or nerve damage from systemic disease, inflammation, infection, and compression or physical irritation of a nerve.
Nociceptive: Refers to specialized nerve endings that respond to pain or other unpleasant sensations and transmits information about those sensations to the central nervous system.
Occipital: Relating to the back of the head or skull.
Prodrome: The period of time preceding a migraine headache during which a person may feel irritable, out of sorts, moody, unusually sensitive to light or noise, and may notice some fluid retention; this may go on for one or two days or just a few hours before the actual headache begins.
Trigger point: Hyperirritable spots in skeletal muscle that are associated with palpable nodules in taut bands of muscle fibers; the palpable nodules are said to be small contraction knots and a common cause of pain. Compression of a trigger point may elicit local tenderness, referred pain, or motor dysfunction.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
When services are Investigational and Not Medically Necessary:
For the following procedure codes for a diagnosis of chronic headaches, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.
|15826||Rhytidectomy; glabellar frown lines|
|30130||Excision inferior turbinate, partial or complete, any method|
|30140||Submucous resection inferior turbinate, partial or complete, any method|
|30520||Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft|
|31200||Ethmoidectomy; intranasal, anterior|
|31201||Ethmoidectomy; intranasal, total|
|31205||Ethmoidectomy, extranasal, total|
|31254||Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior)|
|31255||Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior)|
|64732||Transection or avulsion of; supraorbital nerve|
|64734||Transection or avulsion of; infraorbital nerve|
|67900||Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)|
|93580||Percutaneous transcatheter closure of congenital interatrial communication (ie, Fontan fenestration, atrial septal defect) with implant|
|04.02||Division of trigeminal nerve|
|21.5||Submucous resection of nasal septum|
|35.52||Repair of atrial septal defect with prosthesis, closed technique|
|35.71||Other and unspecified repair of atrial septal defect|
|339.00-339.09||Cluster headaches and other trigeminal autonomic cephalgias|
|339.10-339.12||Tension type headache|
|ICD-10 Procedure||ICD-10-PCS draft codes; effective 10/01/2014:|
|00BK0ZZ-00BK4ZZ||Excision of trigeminal nerve [by approach; includes codes 00BK0ZZ, 00BK3ZZ, 00BK4ZZ]|
|02U53JZ-02U54JZ||Supplement atrial septum with synthetic substitute [by approach; includes codes 02U53JZ, 02U54JZ]|
|095U0ZZ-095V4ZZ||Destruction of ethmoid sinus [right or left, by approach; includes codes 095U0ZZ, 095U3ZZ, 095U4ZZ, 095V0ZZ, 095V3ZZ, 095V4ZZ]|
|09BL0ZZ-09BL8ZZ||Excision of nasal turbinate [by approach; includes codes 09BL0ZZ, 09BL3ZZ, 09BL4ZZ, 09BL7ZZ, 09BL8ZZ]|
|09BM0ZZ-09BM4ZZ||Excision of nasal septum [by approach; includes codes 09BM0ZZ, 09BM3ZZ, 09BM4ZZ]|
|09BU0ZZ-09BV4ZZ||Excision of ethmoid sinus [right or left, by approach; includes codes 09BU0ZZ, 09BU3ZZ, 09BU4ZZ, 09BV0ZZ, 09BV3ZZ, 09BV4ZZ]|
|09DL0ZZ-09DL8ZZ||Extraction of nasal turbinate[ by approach; includes codes 09DL0ZZ, 09DL3ZZ, 09DL4ZZ, 09DL7ZZ, 09DL8ZZ]|
|09DU0ZZ-09DV4ZZ||Extraction of ethmoid sinus [right or left, by approach; includes codes 09DU0ZZ, 09DU3ZZ, 09DU4ZZ, 09DV0ZZ, 09DV3ZZ, 09DV4ZZ]|
|09TL0ZZ-09TL8ZZ||Resection of nasal turbinate [by approach; includes codes 09TL0ZZ, 09TL4ZZ, 09TL7ZZ, 09TL8ZZ]|
|09TU0ZZ-09TV4ZZ||Resection of ethmoid sinus [right or left, by approach; includes codes 09TU0ZZ, 09TU4ZZ, 09TV0ZZ, 09TV4ZZ]|
|0J010ZZ-0J013ZZ||Alteration of face subcutaneous tissue and fascia [by approach; includes codes 0J010ZZ, 0J013ZZ]|
|0KB00ZZ-0KB04ZZ||Excision of head muscle [by approach; includes codes 0KB00ZZ, 0KB03ZZ, 0KB04ZZ]|
|0KB10ZZ-0KB14ZZ||Excision of facial muscle [by approach; includes codes 0KB10ZZ, 0KB13ZZ, 0KB14ZZ]|
|ICD-10 Diagnosis||ICD-10-CM draft codes; effective 10/01/2014:|
|G44.001-G44.099||Cluster headaches and other trigeminal autonomic cephalgias(TAC)|
When services are also Investigational and Not Medically Necessary:
For the following procedure codes for a diagnosis of occipital neuralgia, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.
|64640||Destruction by neurolytic agent; other peripheral nerve or branch [when specified as thermal or cryodenervation of occipital nerve]|
|64722||Decompression; unspecified nerve(s) [when specified as decompression of occipital nerve]|
|64744||Transection or avulsion of; greater occipital nerve|
|04.2||Destruction of cranial and peripheral nerves [when specified as thermal or cryodenervation of occipital nerve]|
|04.49||Other peripheral nerve or ganglion decompression or lysis of adhesions [when specified as decompression of occipital nerve]|
|723.8||Other syndromes affecting cervical region (occipital neuralgia)|
|ICD-10 Procedure||ICD-10-PCS draft codes; effective 10/01/2014:|
|For the following procedures when specified as occipital nerve:|
|01510ZZ-01514ZZ||Destruction of cervical nerve [by approach; includes codes 01510ZZ, 01513ZZ, 01514ZZ]|
|01810ZZ-01814ZZ||Division of cervical nerve [by approach; includes codes 01810ZZ, 01813ZZ, 01814ZZ]|
|01N10ZZ-01N14ZZ||Release cervical nerve [by approach; includes codes 01N10ZZ, 01N13ZZ, 01N14ZZ]|
|ICD-10 Diagnosis||ICD-10-CM draft codes; effective 10/01/2014:|
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Web Sites for Additional Information|
The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.
|Reviewed||05/09/2013||Medical Policy & Technology Assessment Committee (MPTAC) review. Rationale, Reference and Index sections updated.|
|Reviewed||05/10/2012||MPTAC review. No change to position statement. Rationale updated to address nasal contact point.|
|Revised||02/16/2012||MPTAC review. Title changed. Position statement revised to clarify nasal surgery criteria and the inclusion of surgical/ablative treatments of occipital neuralgia as investigational and not medically necessary. Description, Rationale, Background, Definitions, Coding and References updated.|
|Reviewed||02/17/2011||MPTAC review. Rationale and References updated.|
|Reviewed||02/25/2010||MPTAC review. Rationale and references updated.|
|Reviewed||02/26/2009||MPTAC review. References updated.|
|10/01/2008||Updated Coding section with 10/01/2008 ICD-9 changes.|
|Reviewed||02/21/2008||MPTAC review. References updated. The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.|
|New||03/08/2007||MPTAC review. Initial document development.|