Latest Review Date:  February 2024

Category:  Surgery                                                                

POLICY:

Surgical deactivation of trigger sites is considered investigational for the treatment of migraine and non-migraine headache.

DESCRIPTION OF PROCEDURE OR SERVICE:

Migraine is a common headache disorder that is treated using various medications, which can be taken at the onset of an attack and/or for migraine prophylaxis. Other treatments include behavioral treatments and botulinum toxin injections. Surgical deactivation of trigger sites is another proposed treatment. Surgical deactivation is based on the theory that migraine headaches arise due to inflammation of the trigeminal nerve branches in the head and neck and that specific trigger sites can be identified in individual patients. Surgical deactivation has also been proposed for other types of headaches (e.g., tension headaches).

Migraine Headache

Migraine is a common headache disorder with prevalence in the United States of approximately 18% in women and 6% in men. According to the International Headache Society (2018), migraine headache is a recurrent disorder with attacks lasting 4 to 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. International Headache Society classification criteria (3rd edition, 2018) are listed in Table 1.

Table 1. International Headache Society Classification Criteria for Migraines

Adapted from Headache Classification Committee of the International Headache Society (2018; available at http://www.ihs-headache.org/ichd-guidelines). ICHD-3: International Classification of Headache Disorders, 3rd edition.

Treatment

A variety of medications are used to treat acute migraine episodes. These include medications taken at the onset of an attack to abort the attack (e.g., triptans, ergotamines, and certain calcitonin gene-related peptide [CGRP] receptor antagonists), and medications to treat the pain and other symptoms of migraines once they are established (e.g., non-opioid analgesics, antiemetics). Prophylactic medication therapy (e.g., certain antidepressants, beta-blockers, and anti-seizure medications) may be appropriate for people with migraines that occur more than 2 days per week. Onabotulinumtoxin A and several CGRP receptor antagonists have also been approved by the U.S. Food and Drug Administration (FDA) as prophylactic treatments for episodic and/or chronic migraines. In addition to medication, behavioral treatments such as relaxation and cognitive therapy are used to manage migraine headache.

Surgical Deactivation

Surgical deactivation of trigger sites is another proposed treatment of migraine headaches. The procedure was developed by plastic surgeon Bahman Guyuron, MD, following observations that some patients who had cosmetic forehead lifts often reported improvement or elimination of migraine symptoms post surgery. 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 involves 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 patient’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 the 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 (»2.5 cm) of the zygomatico-temporal branch of the trigeminal nerve is removed endoscopically. Rhinogenic 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 caused by the semispinalis 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.

Non-Migraine Headache

It has been proposed that other types of headaches, e.g., tension headaches, may also be triggered by irritation of the trigeminal nerve.

Treatment

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.

KEY POINTS:

The policy was created and updated regularly with searches of the PubMed database. The most recent literature update was performed through December 18, 2023.

Summary of Evidence

For individuals who have migraine headaches who receive surgical deactivation of headache trigger sites, the evidence includes randomized controlled trials (RCTs). Relevant outcomes are symptoms, change in disease status, quality of life (QOL), and treatment-related morbidity. Three RCTs have been published; only 1 used a sham control and blinded patients to the treatment group. All 3 reported statistically significantly better outcomes at 12 months in patients who received decompression surgery for migraine headache than the control intervention. However, the trials were subject to methodologic limitations (e.g., unclear and variable patient selection processes, variability in surgical procedures depending on trigger site). In addition, findings from 2 trials with no blinding or sham-controls were subject to the placebo effect. Additional sham-controlled randomized studies are needed. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have non-migraine headaches who receive surgical deactivation of headache trigger sites, the evidence includes no published studies. Relevant outcomes are symptoms, change in disease status, QOL morbid events, and treatment-related morbidity. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Practice Guidelines and Position Statements

American Headache Society

The American Headache Society (2013) approved a list of 5 items that provide low value in headache medicine. 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 2013 document stated that the value of this procedure is still a research question and that large, multicenter randomized controlled trials with long-term follow-up are needed to provide accurate information on its benefits and harms.

U.S. Preventive Services Task Force Recommendations

Not applicable.

KEY WORDS:

Migraine headache, trigger site deactivation, surgical deactivation of migraine headache trigger sites, surgical deactivation

APPROVED BY GOVERNING BODIES:

Surgical deactivation of headache triggers is a surgical procedure and, as such, is not subject to regulation by FDA.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply.

FEP:  Special benefit consideration may apply.  Refer to member’s benefit plan. 

CURRENT CODING: 

CPT Codes:

REFERENCES:

1. Bigal ME, Lipton RB. The epidemiology, burden, and comorbidities of migraine. Neurol Clin 2009; 27(2):321-34.
2. Ducic I, Felder JM, 3rd, Khan N, et al. Greater occipital nerve excision for occipital neuralgia refractory to nerve decompression. Ann Plast Surg. Feb 2014; 72(2):184-187.
3. Guyuron B, Kriegler JS, Davis J et al. Comprehensive surgical treatment of migraine headaches. Plast Reconstr Surg 2005; 115(1):1-9.
4. Guyuron B, Kriegler JS, Davis J et al. Five-year outcome of surgical treatment of migraine headaches. Plast Reconstr Surg 2011; 127(2):603-8.
5. Guyuron B, Reed D, Kriegler JS et al. A placebo-controlled surgical trial of the treatment of migraine headaches. Plast Reconstr Surg 2009; 124(2):461-8.
6. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. Jan 2018; 38(1): 1-211.
7. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. Jul 2013; 33(9): 629-808.
8. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
9. Kurlander DE, Punjabi A, Liu MT, et al. In-depth review of symptoms, triggers, and treatment of temporal migraine headaches (Site II). Plast Reconstr Surg. Apr 2014; 133(4):897-903.
10. Liu MT, Armijo BS, Guyuron B. 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.
11. Loder E, Weizenbaum E, Frishberg B, et al. 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.
12. Martin BC, Pathak DS, Sharfman MI, et al. Validity and reliability of the migraine-specific quality of life questionnaire (MSQ Version 2.1). Headache. Mar 2000; 40(3): 204-15. 
13. Mathew PG. A critical evaluation of migraine trigger site deactivation surgery. Headache. Jan 2014; 54(1):142-152.
14. Omranifard M, Abdali H, Ardakani MR, et al. A comparison of outcome of medical and surgical treatment of migraine headache: In 1 year follow-up. Adv Biomed Res. 2016; 5:121.
15. Stewart WF, Lipton RB, Kolodner KB, et al. Validity of the Migraine Disability Assessment (MIDAS) score in comparison to a diary-based measure in a population sample of migraine sufferers. Pain. Oct 2000; 88(1): 41-52.
16. Yang M, Rendas-Baum R, Varon SF, et al. Validation of the Headache Impact Test (HIT-6™) across episodic and chronic migraine. Cephalalgia. Feb 2011; 31(3): 357-67.

POLICY HISTORY:

Medical Policy Panel, August 2012

Medical Policy Group, August 2012 (2): New Policy. Policy created with literature search through July 2012.  Surgical deactivation of trigger sites considered investigational for the treatment of migraine headache

Medical Policy Administration Committee, September 2012

Available for comment September 18 through November 1, 2012

Medical Policy Panel, August 2013

Medical Policy Group, September 2013 (2): Policy statement added to include non-migraine headache as investigational.   Key Points and References updated to support policy statement.

Medical Policy Administration, September 2013

Available for comment September 19 through November 2, 2013

Medical Policy Panel, August 2014

Medical Policy Group, August 2014 (1): Update to Key Points and References; no change to policy statement

Medical Policy Panel, August 2015

Medical Policy Group, August 2015 (6):  Updates to Description, Key Points and References; no change to policy statement

Medical Policy Panel, February 2016

Medical Policy Group, February 2016 (6):  Updates to Key Points; no change in policy statement.

Medical Policy Panel, February 2017

Medical Policy Group, February 2017 (6): Updates to Key Points & References; No change to policy statement.

Medical Policy Panel, February 2018

Medical Policy group, February 2018 (6): Updates to Description, Key Points and Coding.

Medical Policy Panel, February 2019

Medical Policy Group, March 2019 (3): 2019 Updates to Key Points. No changes to policy statement or intent.

Medical Policy Panel, February 2020

Medical Policy group, March 2020 (3): 2020 Updates on Key Points. No changes to policy statement or intent.

Medical Policy Panel, February 2021

Medical Policy Group, March 2021 (3): 2021 Updates to Key Points. Policy statement updated to remove “not medically necessary”, no other changes to policy statement or intent.

Medical Policy Panel, February 2022

Medical Policy Group, February 2022 (3): 2022 Updates to Description, and Key Points. No changes to policy statement or intent.

Medical Policy Panel, February 2023

Medical Policy Group, March 2023 (3): 2023 Updates to Key Points, Benefit Applications, and References. No changes to policy statement or intent.

Medical Policy Panel, February 2024

Medical Policy Group, February 2024 (3): Updates to Description, Key Points, Practice Guidelines, Current Coding and References.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.