Coverage Policy Manual
Policy #: 2012051
Category: Surgery
Initiated: August 2012
Last Review: August 2018
  Surgical Deactivation of Headache Trigger Sites

Description:
Surgical deactivation of trigger sites is a proposed treatment of migraine headache. The procedure involves identifying a patient’s predominant migraine trigger site and transecting the branches of the trigeminal nerve supplying that area of head and neck. The treatment is based on the theory that migraine headaches arise due to inflammation of trigeminal nerve branches in the head and neck caused by irritation of the surrounding structures. This technique could potentially be used to treat other types of headache.
 
Background
Migraine is a recurrent headache disorder with a prevalence in the United States of approximately 18% in women and 6% in men (Bigal, 2009). According to the International Headache Society, migraine headache is a recurrent disorder with attacks lasting 4-72 hours. Typical features of migraine headaches include unilateral location, pulsating quality, moderate or severe intensity and associated symptoms such as nausea, photophobia, and/or phonophobia (ICHD-2).
 
A variety of medications are used to treat acute migraine episodes. These include medications that are taken at the outset of an attack to abort the attack (triptans, ergotamines), and medications to treat the pain and other symptoms of migraines once they are established (non-steroidal anti-inflammatory drugs (NSAIDS), narcotic analgesics, antiemetics). Prophylactic medication therapy may be appropriate for individuals with migraines that occur more than 2 days per week. In addition to medication, behavioral treatments such as relaxation and cognitive therapy are used in the management of migraine headache. Moreover, botulinum toxin A injections are a Food and Drug Administration (FDA)-approved treatment for chronic migraine (migraines occurring on at least 15 days per month for at least 3 months).
 
Another proposed treatment of migraine headaches is surgical deactivation of trigger sites. The procedure was developed by plastic surgeon Dr. Bahman Guyuron, following observations that some patients who had cosmetic forehead lifts often reported improvement or elimination of migraine symptoms post-surgery (Guyuron, 2009; Liu, 2012). The procedure is based on the theory that migraine headaches arise due to inflammation of trigeminal nerve branches in the head and neck caused by irritation of the surrounding musculature, bony foramen, and perhaps fascia bands. Accordingly, surgical treatment of migraines would involve removing the relevant nerve sections, muscles, fascia and/or vessels. The treatment is also based on the theory that there are specific migraine trigger sites and that these can be located in individual patients. In studies conducted by Dr. Guyuron’s research group, clinical evaluation and diagnostic injections of botulinum toxin have been used to locate trigger sites. The specific surgical procedure varies according to the individual’s migraine trigger site. The surgical procedures are performed under general anesthesia in an ambulatory care setting and take an average of 1 hour.
 
Surgical procedures have been developed at 4 trigger sites; frontal, temporal, rhinogenic, and occipital. Frontal headaches are believed to be activated by irritation of the supratrochlear and suborbital nerves by glabellar muscles or vessels. The surgical procedure involves removal of the glabellar muscles encasing these nerves. Fat from the upper eyelid is used to fill the defect in the muscles and shield the nerve. Temporal headaches may be activated by inflammation of the zygomatico-temporal branch of the trigeminal nerve by the temporalis muscles or vessels adjacent to the nerve. To treat migraines located at this trigger site, a segment (approximately 2.5 cm) of the zygomatico-temporal branch of the trigeminal nerve is removed endoscopically. Paranasal headaches may involve intranasal abnormalities, e.g., deviated septum, which may irritate the end branches of the trigeminal nerve. Surgical treatment includes septoplasty and turbinectomy. Finally, occipital headaches may be triggered by irritation of the occipital nerve by the semi-spinalis capitis muscle or the occipital artery. Surgery consists of removal of a segment of the semispinalis capitis muscle medial to the greater occipital nerve approximately 1 cm wide and 2.5 cm long, followed by insertion of a subcutaneous flap between the nerve and the muscle to avoid nerve impingement.
 
It has been proposed that other types of headaches, e.g., tension headaches, may also be triggered by irritation of the trigeminal nerve. Although this mechanism of action is less well-established for headaches other than migraine, it is possible that surgical treatment of trigger sites may also be beneficial for some non-migraine headaches.
 
Regulatory Status
Surgical deactivation of headache triggers is a surgical procedure and, as such, is not subject to regulation by FDA.
 
Coding
There is no specific CPT code for this procedure but it might be reported using one of the following:
 
15824 Rhytidectomy; forehead
15826 ; 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
64716 Neuroplasty and/or transposition; cranial nerve (specify)
67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)
  

Policy/
Coverage:
Effective August 2013
Surgical deactivation of trigger sites for the treatment of migraine and non-migraine headaches does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
 
For members with contracts without primary coverage criteria, surgical deactivation of trigger sites is considered investigational for the treatment of migraine and non-migraine headaches. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Effective prior to August 2013
Surgical deactivation of trigger sites for the treatment of migraine headache does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
 
For members with contracts without primary coverage criteria, surgical deactivation of trigger sites is considered investigational for the treatment of migraine headache. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
 

Rationale:
Literature Review
The policy was created with a search of the MEDLINE database through June 2012. Outcomes in headache studies are subjective e.g. pain intensity, and thus blinded, sham-controlled randomized controlled trials (RCTs) are the ideal study design. To date, 2 RCTs, both from the same research group, and several observational studies have been published. A description of the RCTs is as follows:
 
Randomized controlled trials
An initial trial RCT evaluating surgical deactivation of migraine trigger sites was published by Guyuron and colleagues in 2005; this study was not blinded and did not include a sham control (Guyuron, 2005). Individuals diagnosed with migraine headache according to International Classification of Headache Disorders II (ICHD-II) criteria were eligible to participate. A total of 100 patients were assigned to the treatment group and 25 to the control group in a 4:1 allocation. They received up to 3 injections of botulinum toxin A (Botox), one at each of their most common trigger sites, to identify a predominant site of headache trigger and potential response to treatment. Individuals were considered candidates for surgery if they had at least a 50% reduction in symptoms for 4 weeks after a Botox injection. Patients in the control group received saline injections instead of Botox and were not eligible for surgery; for the remainder of the treatment period, they received usual care. For patients in the intervention group, surgery varied by trigger site. In patients with predominantly frontal trigger migraine headache, the glabellar muscle group was removed to relieve compression of the supraorbital and supratrochlear nerves. Patients with temporal migraine headache underwent removal of 3 cm of the zygomatico-temporal branch of the trigeminal nerve. Patients with both temporal and frontal migraine headaches underwent both procedures. Patients with occipital migraine headache underwent removal of a portion of the semispinalis capitis muscles surrounding the occipital nerve and a subcutaneous flap was used to shield the nerve from the muscle. Finally, patients with migraine headaches triggered from the septum and turbinates underwent septoplasty and inferior and/or middle turbinectomies.
 
Among patients assigned to the treatment group, 91 responded to Botox injection and underwent surgery and 89 of 100 (89%) completed the 12-month follow-up. Nineteen of 25 (76%) patients in the control group were evaluated at 12 months. A total of 17 of 125 (14%) randomized patients were excluded from the analysis. In a per protocol analysis at 12 months, 82 of 89 (92%) patients in the treatment group and 3 of 19 (16%) in the control group experienced significant improvement, defined as at least a 50% reduction in baseline migraine frequency, intensity, or duration. The difference between groups was statistically significant, p<0.001. Thirty-one (35%) of patients in the treatment group and none in the control group reported complete elimination of migraines. Most adverse events following surgery were minor and transient. The most commonly reported events were temporary nasal dryness (n=12) and rhinorrhea (n=11). Seven patients experienced intense scalp itching that lasted a mean of 6 months.
 
Five-year outcomes for individuals in the treatment group were reported by Guyuron and colleagues in 2011 (Guyuron, 2011). Follow-up data were available for 79 patients (87% of those who underwent surgery and 79% of those randomized to this group). Outcomes were reported for 69 patients. The other 10 had received additional migraine headache surgery and were excluded from the analysis. At 5 years, 20 of 69 (29%) reported complete elimination of migraine headache, 41 (59%) reported a significant decrease in symptoms, and 8 (12%) reported no significant change. All measured variables improved significantly at 5 years compared to baseline. For example, mean headache frequency per month decreased from 10.9 to 4.0 (p<0.0001). Long-term data were not reported for patients assigned to the control group.
Limitations of the 2005 RCT include lack of blinding, lack of a sham-control, and randomization prior to determining eligibility for surgery. In addition, findings were not reported separately by surgical procedure. In terms of long-term follow-up, 5-year data were reported only for the treatment group; long-term outcomes compared to the control group are not available.
 
In 2009, Guyuron and colleagues published a double-blind, sham-controlled trial evaluating surgical deactivation of migraine trigger sites in 76 patients (Guyuron, 2009). Eligibility criteria included a diagnosis of migraine headache according to ICHD-II criteria (ICHD-2). In addition, participants were required to have headaches triggered from a single or predominant site, as determined by a headache diary and physical examination. Individuals were then given an injection of botulinum toxin A (Botox) at the prominent site from which migraine pain started. Patients who had a positive response to Botox (i.e., at least a 50% decrease in headache symptoms) and in whom headaches recurred after the effect of the Botox disappeared were eligible for randomization. The methodology differed from that of the 2005 RCT, described above, which randomized patients prior to receiving diagnostic Botox injections. In addition, it is worth noting that in 2012, Liu and colleagues (Dr. Guyuron was a co-author of this study) published an analysis further investigating the method of botulinum toxin injections to select patients for deactivation surgery and found that outcomes were similar in migraine surgery patients who did and did not undergo diagnostic Botox injections (Liu, 2012). The Liu et al. analysis raises questions about the need for the complex patient selection process used in the published RCTs.
 
In the 2009 RCT, participants were stratified by the predominant site from which headaches were triggered; frontal (F), temporal (T), or occipital (O) and were then randomized on a 2:1 basis to receive active or sham surgery. A total of 317 individuals were screened for inclusion, 130 received Botox injections and, based on their response to Botox, 76 were considered eligible to participate and underwent randomization. In each of the 3 active treatment groups, surgery consisted of exposure and removal of nerves and/or muscles. For patients in the sham group, surgery was limited to exposing the nerves and/or muscles; the integrity of the structures was left intact. The procedures differed according to the predominant headache trigger site and were similar to procedures used in the Guyuron et al. 2005 trial. Briefly, patients in the F active surgery group underwent removal of the glabellar muscles encasing the supraorbital and supratrochlear nerves. Patients in the T active surgery group underwent removal of a segment of the zygomaticotemporal branch of the trigeminal nerve. In the O surgery group, a segment of the semispinalis capitis muscle medial to the greater occipital nerve was removed.
 
Patients kept headache diaries and were seen at 3, 6, 9, and 12 months after surgery. Seventy-five of 76 patients (49 in the active treatment group and 26 in the sham group) completed the 1-year follow-up. There were 29 patients in the F group (19 active treatment, 10 sham), 28 in the T group (19 active treatment, 9 sham), and 18 in the O group (11 active treatment, 7 sham). Patients remained blinded to their group assignment through 12 months, at which time individuals in the sham surgery group were offered the operation.
 
In the 2009 study, in addition to the between-group differences, there was statistically significant improvement in headache frequency, intensity, and duration from baseline to 12 months within the active surgery group and significant improvement in headache frequency and intensity within the sham surgery group. The improvement in outcomes within the sham group were greater than those seen after usual care in the 2005 RCT, suggesting that there may be a substantial placebo effect associated with the surgery to deactivate trigger sites.
 
No adverse events were reported in the sham surgery group. All patients in the active treatment group reported some degree of paresthesia immediately after the operation. One patient experienced numbness 12 months after the operation. The most common adverse event in the active treatment group was temporal hollowing in 10 of 19 (53%) patients in the T (temporal) group.
 
Advantages of the 2009 study included a sham control group and blinded comparison of outcomes in the 2 groups through 12 months after surgery. Limitations of the study include small numbers of patients in each sub-group and a lack of reporting of patients’ use of other migraine treatments e.g., Botox, medications, etc. during the 12-month follow-up period. In addition, patient selection involved a long multi-component selection process which might not be practical on a widespread basis.
 
Case series
Other research groups have published retrospective case series evaluating some type of surgical deactivation of trigger sites for individuals with migraine headache, but no controlled studies. Dirnberger and Becker in Austria reported on 60 patients with migraine headache diagnoses meeting International Headache Society criteria (Dimberger, 2004). Patients all underwent resection of the corrugator supercilii muscle by the same surgeon who used the technique recommended by Bahman Guyuron. At 6 months, 35 of 60 (58%) reported at least a 50% reduction in headache days and at least a 50% reduction in headache medication use. Twenty patients (33.3%) reported no reduction in headache days at 6 months. Poggi and colleagues reported on 18 patients who had undergone surgical decompression of various nerves by a single surgeon (Poggi, 2008). Mean follow-up was 16 months (range, 6 to 41 months). The mean number of headaches per month decreased from 11.9 (SD: 9.3) pre-operatively to 3.7 (SD: 4.4) post-operatively. Three patients (17%) reported complete relief of migraines. Behin and colleagues published outcomes in 21 patients who underwent endoscopic sinus surgery and septoplasty for refractory migraine headache and completed a 2-year follow-up questionnaire (Behin, 2005). Mean reported headache frequency was 17.7 (SD: 11.2) per month prior to surgery and 7.7 (SD: 7.6) at follow-up. Mean headache severity (10-point scale) decreased from 7.8 (SD: 1.5) to 3.6 (SD: 3.7).
 
Practice Guidelines and Position Statements
No relevant national guidelines or position statements were identified. The American Academy of Neurology (AAN) evidence-based guideline on migraine headache was last updated in 2000. As of July 2012, an update is in progress.
 
Summary
The evidence on the effectiveness of surgical deactivation of trigger sites to treat migraine headache consists of one double-blind sham-controlled RCT and an earlier non-blinded RCT without sham control by the same research group, which is also the research group that developed the procedure. In the 2 published RCTs, patients were selected for randomization based on clinical evaluation and their response to injections of botulinum toxin A. A 2012 analysis questions the necessity of using diagnostic botulinum toxin injections for patient selection; however, the efficacy of surgical deactivation of trigger sites following patient selection by clinical evaluation alone has not been evaluated in RCTs. Both trials reported statistically significantly better outcomes at 12 months in patients who received active surgery for migraine headache. In addition, several case series, but no controlled studies, have been published by other research groups.
 
This evidence is suggestive of a benefit from surgical deactivation, but is not sufficient to form definite conclusions. There is a need for additional sham-controlled studies by other research groups to confirm the results of the single published trial using sham surgery. In addition, there is a need for further refinement of patient selection criteria and evaluation of any altered selection process e.g., without the use of diagnostic Botox injections in controlled studies.
 
2013 Update
A literature search of the MEDLINE database was conducted through July 2013. There was no new literature identified that would prompt a change in the coverage statement for the treatment of migraine headaches.
 
In 2012 and 2013, the research group headed by Guyuron published several retrospective case series that included patients who underwent surgical deactivation of migraine headache trigger sites (Chmielewski, 2013; Lee, 2013; Liu, 2012). The case series evaluated various aspects of the intervention, such as whether removal of the third occipital nerve improves outcomes (Lee, 2013) and whether outcomes are better with endoscopic versus transpalpebral decompression (1Liu, 2012).
 
No studies were identified that evaluated surgical deactivation of trigger sites as a treatment of non-migraine headache. The coverage statement has been changed to address this indication.
 
2014 Update
A literature search conducted through July 2014 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
A 2014 review article critically evaluating the RCTs on surgical deactivation of migraine trigger sites included the following points (Matthew, 2014):
  • The authors of the sham-controlled trial did not mention patients’ use of other headache treatments. Post-operative use of medications could have resulted in a reduction in headache frequency; these cases would have been counted as a surgical success in the study.
  • In the sham-controlled trial, baseline headache frequency was 9.9 migraines per month in the intervention group and 9.5 migraines per month in the control group and therefore the reduction of a small number of migraine episodes per month (which may not be clinically significant) could be considered a surgical success based on the author’s criterion of a 50% decrease in frequency.
  • Use of the terminology “migraine headaches per month” does not provide information on the number of days per month with migraine headaches or the number of non-migraine headaches per month.
  • Patients in the sham group may have guessed their group assignment because of retained movement of the corrugator supercilii, depressor supercilii and procerus muscles. This could have biased their responses to subjective outcome questions.
  • Botox injections are a non-specific screening tool and can lead to false-positives when used to select patients for migraine surgery since Botox injections into the peripheral nerves may also modulate pain at central targets.
 
Another relatively large series, published in 2013 by Ducic and colleagues, reported on patients who had undergone surgical decompression of the greater, lesser and dorsal occipital nerves for chronic migraine following a positive response to Botox (Ducic, 2013). A total of 71 of 108 patients (66%) responded to a follow-up survey. The mean length of follow-up was 33 months. Clinical success, defined as at least a 50% reduction in the migraine headache index (MHI), was achieved in 50 of the 71 respondents (70.4%). Twenty-nine patients (41% of respondents) had a 90% or greater reduction in the MHI. In addition to a lack of a control group, the Ducic data are limited by a low response rate; clinical outcomes in over 30% of patients who underwent surgery are unknown.
 
Most recently, in 2014 Kurlander and colleagues conducted a chart review of 246 patients who had received migraine surgery by a single surgeon (Dr Guyuron) and had been followed for at least 1 year after surgery (Kurlander, 2014).  Mean follow-up was 3.2 years (range 1 to 10 years). Eighty-five percent of the patients experienced at least a 50% reduction in the temporal migraine index and 55% reported complete elimination of temporal migraines.
 
In 2013, the American Headache Society Board of Directors approved a list of 5 items that provide low value in headache medicine (Loder, 2013). This list was produced as part of the American Board of Internal Medicine Foundations Choosing Wisely Initiative. One of the 5 recommendations was, “don’t recommend surgical deactivation of migraine trigger points outside of a clinical trial.” The published document states that the value of this procedure is still a research question and that large, multicenter RCTs with long-term followup are needed to provide accurate information on its benefits and harms.
 
2015 Update
A literature search conducted through May 2015 did not reveal any new information that would prompt a change in the coverage statement.  The key identified literature is summarized below.
 
An additional small RCT was published by Guyuron  and colleagues in 2015 (Guyuron, 2015).  This study did not compare migraine surgery with a different intervention and, therefore cannot evaluate the efficacy of the procedure compared with a comparison intervention. Instead, it compared 2 methods of trigger site deactivation, avulsion versus decompression of the zygomaticotemporal branch of the trigeminal nerve.
 
A summary of evidence indicates for use of surgical deactivation of headache trigger sites for treatment of patients with migraine headache, the evidence consists of 2 randomized controlled trials (RCTs) by the same research group comparing the treatment to a different intervention. One RCT was double-blind and sham-controlled and the other was nonblinded with a usual care control group. Both trials reported statistically significantly better outcomes at 12 months in patients who received decompression surgery for migraine headache than the control intervention. However, both trials were subject to methodologic limitations and issues related to use of botulinum toxin injections for patient selection. Additional sham-controlled randomized studies by other research groups are needed to confirm the results of the 2 published RCTs. There is insufficient published evidence to determine that use of surgical deactivation of headache trigger sites for treatment of patients with migraine headache improves health outcomes.
 
For use of surgical deactivation of headache trigger sites for treatment of patients with non-migraine headache, there are no published studies. There is insufficient published evidence to determine that use of surgical deactivation of headache trigger sites for treatment of patients with non-migraine headache improves health outcomes.
   
2016 Update
A literature search conducted through April 2016 did not reveal any new information that would prompt a change in the coverage statement.
 
2017 Update
A literature search conducted through July 2017 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
Omranifard and colleagues published an RCT comparing surgical deactivation of migraine trigger sites to medical treatment in 50 patients from a single center in Iran (Omranifard, 2016). The trial did not include a sham control and patients were not blinded to treatment group. Patients met IHD diagnostic criteria for migraine headache and were asked about their most common migraine trigger sites. All patients received injections of botulinum toxin into the frontal, temporal, and occipital trigger sites in a stepwise manner, with the most common site injected first. Investigators did not state how they evaluated patients’ responses to botulinum toxin or how their responses to botulinum toxin affected their eligibility to participate in the trial. Patients in the medical treatment group (n=25) were prescribed propranolol (80 mg daily) and amitriptyline (100 mg daily). Patients assigned to the surgery group (n=25) underwent decompression surgery in 1 or any combination of 4 trigger sites (frontal, temporal, septum, and/or occipital) they identified as relevant to their pattern of headaches. Surgical procedures were similar to those used in the Guyuron and colleagues (Guyuron, 2005) RCTs except that a septal surgery option was added. For patients with frontal headaches, the glabellar muscles were removed. For patients with temporal headaches, a segment of the zygomaticotemporal branch of the trigeminal nerve was removed. For patients with occipital headaches, a segment of the semispinalis capitis muscle was removed, and the occipital artery was removed if it was entangled with the nerve. For patients with migraines originating at the septum, septoplasty and/or turbinectomy procedures were performed.
 
2018 Update
A literature search was conducted through July 2018.  There was no new information identified that would prompt a change in the coverage statement.  

CPT/HCPCS:
15824Rhytidectomy; forehead
15826Rhytidectomy; glabellar frown lines
30130Excision inferior turbinate, partial or complete, any method
30140Submucous resection inferior turbinate, partial or complete, any method
30520Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft
64716Neuroplasty and/or transposition; cranial nerve (specify)
67900Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)

References: Poggi JT, Grizzell BE, Helmer SD.(2008) Confirmation of surgical decompression to relieve migraine headaches. Plast Reconstr Surg 2008; 122(1):115-22; discussion 23-4.

2nd Edition of the International Headache Classification (ICHD-2)2nd Edition of the International Headache Classification (ICHD-2). Available online at: http://ihs-classification.org/en/. Last accessed July, 2012.

Behin F, Behin B, Bigal ME et al.(2005) Surgical treatment of patients with refractory migraine headaches and intranasal contact points. Cephalalgia 2005; 25(6):439-43.

Bigal ME, Lipton RB.(2009) The epidemiology, burden, and comorbidities of migraine. Neurol Clin 2009; 27(2):321-34.

Chmielewski L, Liu MT, Guyuron B.(2013) The role of occipital artery resection in the surgical treatment of occipital migraine headaches. Plast Reconstr Surg 2013; 131(3):351e-6e.

Dirnberger F, Becker K.(2004) Surgical treatment of migraine headaches by corrugator muscle resection. Plast Reconstr Surg 2004; 114(3):652-7; discussion 58-9.

Ducic I, Felder JM, 3rd, Khan N, et al.(2014) Greater occipital nerve excision for occipital neuralgia refractory to nerve decompression. Ann Plast Surg. Feb 2014;72(2):184-187. PMID 24322636

Guyuron B, Harvey D, Reed D.(2015) A Prospective Randomized Outcomes Comparison of Two Temple Migraine Trigger Site Deactivation Techniques. Plast Reconstr Surg. Mar 17 2015. PMID 25829156

Guyuron B, Kriegler JS, Davis J et al.(2005) Comprehensive surgical treatment of migraine headaches. Plast Reconstr Surg 2005; 115(1):1-9.

Guyuron B, Kriegler JS, Davis J et al.(2011) Five-year outcome of surgical treatment of migraine headaches. Plast Reconstr Surg 2011; 127(2):603-8.

Guyuron B, Lineberry K, Nahabet EH.(2015) A retrospective review of the outcomes of migraine surgery in the adolescent population. Plast Reconstr Surg. Jun 2015;135(6):1700-1705. PMID 26017602

Guyuron B, Reed D, Kriegler JS et al.(2009) A placebo-controlled surgical trial of the treatment of migraine headaches. Plast Reconstr Surg 2009; 124(2):461-8.

Headache Classification Committee of the International Headache Society.(2013) The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. Jul 2013;33(9):629-808. PMID 23771276

Kurlander DE, Punjabi A, Liu MT, et al.(2014) In-depth review of symptoms, triggers, and treatment of temporal migraine headaches (Site II). Plast Reconstr Surg. Apr 2014;133(4):897-903. PMID 24675192

Lee M, Lineberry K, Reed D et al.(2013) The role of the third occipital nerve in surgical treatment of occipital migraine headaches. J Plast Reconstr Aesthet Surg 2013

Liu MT, Armijo BS, Guyuron B.(2012) A comparison of outcome of surgical treatment of migraine headaches using a constellation of symptoms versus botulinum toxin type A to identify the trigger sites. Plast Reconstr Surg 2012; 129(2):413-9.

Liu MT, Chim H, Guyuron B.(2012) Outcome comparison of endoscopic and transpalpebral decompression for treatment of frontal migraine headaches. Plast Reconstr Surg 2012; 129(5):1113-9.

Loder E, Weizenbaum E, Frishberg B, et al.(2013) Choosing wisely in headache medicine: the American Headache Society's list of five things physicians and patients should question. Headache. Nov-Dec 2013;53(10):1651-1659. PMID 24266337

Mathew PG.(2014) A critical evaluation of migraine trigger site deactivation surgery. Headache. Jan 2014;54(1):142-152. PMID 24116941

Omranifard M, Abdali H, Ardakani MR, et al.(2016) A comparison of outcome of medical and surgical treatment of migraine headache: In 1 year follow-up. Adv Biomed Res. 2016;5:121. PMID 27563631


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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