Migraine Surgery

For chronic migraine that no longer responds to medication, surgery can release the compressed nerves at the trigger points that set the attacks off. It is not brain surgery — and in carefully selected patients, published results are striking: most improve, and around half become free of migraine. Honest, careful patient selection is the heart of this operation, and Dr. Paulo Michels works alongside your neurologist throughout.

What is migraine surgery?

Migraine surgery — nerve decompression, or trigger-site deactivation — treats migraine at its peripheral trigger points. In many patients an attack is set off where a sensory nerve is compressed by a small muscle, blood vessel, band of fascia or a point of contact in the nose. Releasing that pressure removes the trigger.

It is not brain surgery: it addresses small sensory nerves just beneath the skin of the face, scalp and neck, and never touches the brain or the skull. It is usually a day case, through incisions hidden in the hairline, the upper-eyelid crease or inside the nose.

It is also not a first step and not for everyone — it is for people with chronic migraine that has not responded to medication, in whom a specific trigger site can be identified and confirmed.

How can surgery stop a migraine?

The peripheral trigger theory — developed and validated over two decades of plastic-surgery research — holds that in many sufferers a migraine begins where an irritated sensory nerve is squeezed at a specific point. That constant irritation is what fires the migraine, which is why the pain so often starts in the same spot every time.

Surgery decompresses the nerve — freeing it from the structure pressing on it. With the irritation gone, the trigger is switched off, so attacks become far less frequent, milder, or stop altogether. It treats the cause at that site, not just the symptom.

What are the migraine trigger sites?

Migraines have recognisable patterns depending on which nerve is involved — and identifying your pattern is the whole basis of the operation. A useful sign is pain that reliably starts at one spot you can point to. Many patients have more than one trigger site; where appropriate the dominant one is treated first, or several are released in the same operation.

Trigger site	Where the pain starts	What is released
Frontal	Around the eyebrows or between the eyes, spreading across the forehead	The supraorbital and supratrochlear nerves are freed from the corrugator muscle — through the upper-eyelid crease or endoscopically
Temporal	Sharp, throbbing pain in the temple	The zygomaticotemporal branch, through a small incision hidden in the hair
Occipital	Base of the skull, radiating up toward the crown — often shooting or electric	The greater occipital nerve is freed from the muscle and vessels compressing it; the zone with the most consistent reported results
Nasal (rhinogenic)	Pressure deep behind or between the eyes, mimicking sinus congestion	Contact points inside the nose, corrected internally by septoplasty and turbinate work — no external scar
Nummular	A small, coin-shaped tender spot on the top of the scalp	The nerve at that point is released like the others, when confirmed

How is the trigger site found — and who is a candidate?

The success of migraine surgery depends almost entirely on choosing the right patient and the right site. Dr. Paulo Michels never operates on a guess — a confirmatory test is central to deciding whether surgery is appropriate:

• A detailed headache diary and mapping of where each attack begins
• A diagnostic block — a temporary, reversible nerve-block injection (sometimes Botox) at the suspected site
• A clear, meaningful reduction in pain on testing — not a vague or partial one — is what supports proceeding
• Botox at a site relieving the migraines both confirms the trigger and predicts a good surgical result
• A CT scan when a nasal trigger is suspected, to map the contact points

Candidates typically have neurologist-confirmed chronic migraine (about 15+ days a month) that has not responded to medication — or medication they cannot tolerate — with pain that localises to a specific point, a positive response to the diagnostic block or Botox test, and fitness for a general anaesthetic.

When surgery is not the answer

Just as important is knowing when to say no. Migraine surgery is not appropriate for migraines that begin centrally (within the brain), hormone-driven or vestibular migraines, headaches from unrelated sinus disease, patients who have not yet tried standard treatment, those with no relief from the diagnostic block, unaddressed medication-overuse headache, or where anaesthetic risk is too high. In these cases medication and neurology care remain the right path — and Dr. Paulo Michels will tell you so.

Does migraine surgery actually work?

For carefully selected patients, the published results are consistent. Migraine surgery has been studied in peer-reviewed trials over more than twenty years:

• Roughly 9 in 10 suitable patients experience a meaningful reduction in the frequency, intensity or duration of their migraines
• Around half of well-selected patients report becoming completely free of migraine after decompression of the confirmed trigger sites
• Most who respond well reduce their migraine medication, and some stop daily preventives — which can also help medication-overuse headache

The occipital zone tends to give the most consistent results, and benefit has been maintained at five years. Results vary between individuals, are not guaranteed, and depend on correct trigger identification — all discussed honestly at your consultation, and medication changes are always made gradually with your neurologist.

Anaesthesia, comfort and the scars

The procedure is performed under general anaesthesia (total intravenous anaesthesia, TIVA), giving a safe, deeply comfortable procedure and a smooth, clear-headed wake-up with very little nausea. Most patients go home the same day or after one night at Elyzee Hospital in Abu Dhabi.

The incisions are designed to be invisible: the frontal site is reached through the upper-eyelid crease or endoscopically; the temporal, occipital and nummular sites through small incisions hidden in the hair; the nasal site entirely from inside the nose. Because the frontal release removes the frown (corrugator) muscle, it also softens the frown lines between the brows — a natural aesthetic benefit alongside the relief.

What is the recovery timeline?

• Days 1–3 — Mild, medication-controlled discomfort. Rest with the head elevated; some bruising around the eyes is expected after frontal work, and nasal work may feel congested
• Days 4–7 — Many return to light activity and desk work; any sutures are removed and early swelling settles
• Weeks 2–4 — Exercise resumes gradually; neck stiffness after occipital work eases, and some numbness or tightness at the treated site is normal while the nerve settles
• Weeks 4–6 — Most people reach essentially full recovery
• ~3 months — The effect on the migraines usually becomes clearer. It is not unusual to have a headache, or even a migraine, in the early days or weeks — this does not mean the surgery has failed. For those who respond, the relief is lasting

What are the honest risks?

• Temporary numbness, itching or tightness near the treated nerve
• Some temple hollowing (temporal), neck stiffness (occipital) or nasal dryness (nasal)
• Where a nerve is divided rather than released, a small area of numbness can be permanent, and rarely a tender scar (neuroma) forms
• Uncommonly, infection or bleeding; the usual anaesthetic risks apply
• The migraines may be reduced rather than eliminated, or a second hidden site may still need treating