Treatment of thoracic outlet syndrome to alleviate chronic migraine headache

BackgroundPrior case reports have indicated that treating thoracic outlet syndrome (TOS) may relieve intractable migraine headaches, but the reported experience has been limited. We report in a large case series how a strategy of treating concurrent TOS can help relieve intractable migraine headaches in patients with these dual diagnoses. MethodsRetrospective chart review for diagnostic and interventional data on patients with migraine and TOS followed by a questionnaire to investigate specific migraine features and changes in headache burden before and after treatment of TOS. Results50 patients (48 women, 2 men, age = 43.9+/12.7years) with dual diagnoses of chronic migraine and TOS were included (20 migraine with aura, 28 migraine without aura, two hemiplegic migraines). Based on review of available data, headaches had become chronic within one year of onset in 21 patients (42%) and included these characteristics: side-locked or greater severity ipsilateral to limb paresthesia (38/50 patients), presence of limb swelling (32/48 patients), and worsened by recumbency (32/38 patients). Interventions included physical therapy, percutaneous transluminal venoplasty, 1st rib removal, scalenectomy, pectoralis minor tenotomy, and vein patching. Thirty-two patients needed surgery. Mean patient-reported improvement of headaches on the treated side was 72+/-26.7%; 12 patients experienced complete resolution of headaches after surgical treatment of TOS (follow-up 7.2+/-5.2 months). Questionnaire responders reported significant reductions in headache days (18.3+/-8.6 to 11.1+/-10.8 days/month, p<0.0016), severity (7.8+/2.5 to 5.4+/-2.9, p<0.00079), and need for emergency care (3.6+/-4.0 to 0.71+/-1.3 visits/year, p<0.0029) after having had their TOS treated with surgery. Questionnaire responders and non-responders were not significantly different in underlying clinical features. ConclusionChronic migraines can be important manifestations of TOS. Early transition to a chronic state, headaches worsened by recumbency, and headaches with lateralized myofascial pain are clues to a contribution by TOS pathology. The TOS contribution to migraine has been under-recognized. Addressing it can significantly improve migraine headache burden.