A plastic surgeon's passionate defense of his pioneering but controversial treatment for migraine failed to win many converts among headache specialists here.

A show of hands by some 500 attendees at the International Headache Congress, after an hour-long debate between surgeon Bahman Guyuron, MD, of University Hospitals and Case Medical Center in Cleveland, and a German neurologist who has been a vocal skeptic of Guyuron's procedure, suggested that fewer than 10 believed the evidence supports the intervention's clinical value.

Guyuron has performed more than 950 surgeries on migraine patients aimed at relieving peripheral nerve compression at various locations on the outside of the skull. Originally a cosmetic surgeon specializing in rhinoplasties and facelifts, he said he stumbled on the anti-migraine effect in 1999 after two female migraineurs reported that their headaches were abolished after browlifts.

Since then, he has devoted his practice to researching so-called trigger sites for migraine that can be relieved temporarily by botulinum toxin A (Botox) injections and permanently via relatively superficial surgery. Such procedures are now offered by dozens of surgical centers nationwide, including one in New York City offering procedures at any time of the day or night.

He has published some 30 papers describing his results, mostly open-label case series but also including a randomized, sham-controlled trial in 2009. But they have all been published in Plastic and Reconstructive Surgery, not in neurology journals. He told congress attendees that he had submitted manuscripts to the latter but they have always been rejected.

In the controlled trial, Guyuron and colleagues (including a neurologist) randomized 75 patients with a history of migraine 2:1 to receive the actual surgery or a sham procedure, in which only an incision was made and then sutured.

They reported that 57% of those in the active treatment group claimed complete eradication of headaches versus 4% (one patient) of the 26 controls.

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