Photo by Dominic Burr
Dr. Thomas Mühlberger may be Berlin’s most controversial migraine specialist. The plastic surgeon has been treating migraine patients in Berlin for four years by popularizing a new surgical method developed in America: the removal of a muscle in the forehead that presses on the trigeminal nerve – a nerve believed to play a pivotal role in migraine attacks.
While Mühlberger claims a very high success rate for people who pass a Botox “test” that simulates the surgery, the German medical establishment continues to dismiss him and his work.
Neurologists are the migraine experts – you’re a plastic surgeon…
Well, nowadays everyone’s an expert. There are hardly any normal doctors any more. I don’t think that any speciality ‘owns’ a disease. If anything, the patient owns the disease, not the doctor. So the patient shouldn’t be bothered about who takes care of what, as long as they can help them. That’s the bottom line.
Why are neurologists so fiercely opposed to your treatment?
Because they think it’s their disease! And they don’t want anyone else to treat it. Never in the history of medicine has there been something fundamentally new that wasn’t met with fierce opposition. Whether it was the first heart transplant or the story about ulcers being caused by a certain personality type. It’s not true, bacteria causes stomach ulcers. The history of medicine is full of that sort of stuff. Most of the people performing medicine are not the most creative or innovative people.
At Charité, they’re skeptical about what you do because of the lack of convincing trials.
This claim is simply not true. There have been many clinical trials, including the epitome of surgical study, which is a “sham surgery study”. For this, you take two groups of patients and you make an incision, in this case in the eyelid. In one group, you take the muscle out, and in the other group you just pretend to do the proper operation, but you don’t. The trials all showed really significant results.
They talk about a high placebo response to Botox. It’s even higher with surgery: the higher the expectations, the better one feels.
Do you really think that the placebo effect would last for the three months the Botox lasts?
So, among the patients you have operated on, how many are still better, years down the road?
We have one long-term group of 167 patients who completed four years. Of those, about 60 percent had no symptoms at all anymore. The other ones had fewer symptoms, or else they know that today is a ‘migraine day’ and take a regular painkiller and just carry on with their lives.
Neurologists consider Botox to be a last resort, after the preventative drugs.
I do not understand how something that has almost no side-effects can be considered the last resort compared to their first and second choices, which come with a truckload of possible side-effects. I have yet to meet a patient who is taking an anti-epileptic prophylactic like Topamax and not thinking about an alternative.
The doctors tell us Topomax has limited side-effects.
Then talk to someone who has taken it! The majority of patients stop taking it because the sideeffects are so severe. Usually people who come to see us have tried everything. Conventional medicine, alternative medicine, all sorts of things. Ultimately, it’s not about whether treatment ‘A’ is better than treatment ‘B’. The fundamental problem is more of an intellectual one. We don’t understand how migraines work. If we did, there wouldn’t be a plethora of different treatments.
So what do you know about brains and migraines?
Migraines are a data-processing disorder. We still have no concise understanding of how the migraine works in your brain, but as far as we know now, it happens in the brain stem. This is where the most basic functions of your organism – the fact that you’re breathing, your breathing rate, your bloodpressure regulation and so on – are based. This is where current research suspects migraines take place.
What about triggers…
The way American neurologistssee it these days is – and this is my view – that yes, there are triggers, but this doesn’t mean that the migraine is in the trigger. The trigger consists of a signal, there are thousands of them: food, sleep, weather, hormones… but there is no causal relationship between your hormones and the migraine, or the way you lead your life and the migraine. The migraine is not in the chocolate. It just means you are misinterpreting these signals in your brain. We don’t know why and we don’t know how. But we know something in the data processing goes wrong.
How, as a plastic surgeon, did you end up treating migraines?
Towards the end of my 15 years in America, I ended up doing facial reconstructions almost exclusively. Over time, we noticed that whenever we removed certain muscles, once in a while a patient said, “My migraine is gone.” Several American plastic surgeons noticed this, but it was Bahman Guyuron, head of the Plastic Surgery department at Case Western Reserve University in Cleveland, who realised there was a clear-cut connection between migraines and specific operations.
So what did plastic surgeons stumble on exactly?
When we thought there might be an association, we started to look into the literature. We found that there had been observations that the trigeminal nerve is affected in a big way by migraines. The amazing thing is that this was described in 1684 by a guy in Cambridge called Thomas Willis. He is considered the founding father of neurology. This nerve – and this closes the loop – originates in the brain stem from exactly the same area current research points to as where the migraine is going on. So we have an area in your brain stem and this is where the explosion starts, and out of this very same area the trigeminal nerve comes up, travels for a short distance inside your head, then exits and spreads out into your face. The upper part of this so-called “triplet nerve” is severely altered when you’re having a migraine attack. I can’t tell you why it is altered, but we do know two things for sure: it is altered and inflamed.
So migraine sufferers have a sensitive nerve going through their heads – and that causes migraines?
Here we touch on another huge problem with migraines: we cannot differentiate between what is the cause and what is the consequence. All we know is that if you irritate this trigeminal nerve, a migraine patient gets a migraine attack. It would hurt me, but I would not. We don’t know why.
Your treatment doesn’t work on everyone.
The Botox test works on about 50 percent of patients. Of the 50 percent who show a significant improvement, about 30 percent decide to go ahead with the surgery. The success rate of the surgery is not 100 percent, but it’s sky-high.
But you only operate on a pre-selected group…
Of course and that’s the beauty of this method - I can test it beforehand. The risk that the operation might not be successful is very, very small, because I get exactly what I had after the Botox test. It’s a one-to-one simulation. I can find out who’s eligible and who’s not. The 50 percent for whom it doesn’t work – they’re out. That’s not the right method. I’m not the right person.
Are there any side-effects to the Botox test?
Isn’t the botulinum toxin a poison? Botox is always described as a nerve poison. The terminology is wrong. It doesn’t do anything to your nerves. It paralyses your muscle. Poison is, by definition, a question of dosage. You can make a poison out of coffee or sugar just by overdosing. The Botox is diluted so significantly that it paralyses only the muscle that I inject into and not the rest of you.
Does the Botox used for migraines have cosmetic effects?
Yes. If you have impressive vertical lines between your eyebrows, you won’t have them after that. But most migraine patients are worrying about other things than a few wrinkles.
You’ve worked in many countries. Would you say there are cultural differences in the approach to migraine treatment?
There are huge cultural differences. The US and England have a much more pragmatic approach. They are just interested in how it works, whether it works and what the structure of the treatment is. The fact that you can test it; the fact that the surgery is not obligatory following the tests. There are some patients who don’t want the surgery for a variety of reasons, be it religious or whatever, and carry on with Botox. Americans are more open-minded about new things.
Are American neurologists more cooperative?
Everything I know about migraines, I know from American neurologists. New migraine surgery centres in the States are usually collaborations between neurologists and plastic surgeons. That would be the ideal solution, but it’s not possible here. We’re moving towards that in England, which is a very nice development. We’re working on setting up another trial with neurologists in London.
And why can’t you try that in Berlin?
I tried. I made an application with Charité’s Ethics Commission for a study design to do another sham surgery test here. It was denied. I applied for three other studies at the university; they were all denied. This is one of the surprising things about the neurologists in Germany: I never, ever heard a smart argument about why what we’re doing wouldn’t work. They just said “No, it’s nonsense”, but I never heard why. If there was a chance to discuss this with a neurologist at a conference or public discussion, it would be wonderful.
Dr. Thomas Mühlberger studied literature and medicine in Munich, Berlin and Boston. He was trained as a surgeon at Oxford, Cambridge and Johns Hopkins University and is a member of the Fellowship of the Royal College of Surgeons. Mühlberger was the first to bring “migraine surgery” to Europe, opening Berlin’s first Migraine Surgery Centre four years ago. His procedure costs €450 for the Botox “test” and €3462 for the operation. He has operated on about 700 migraine patients to date and has opened up clinics in Munich, Düsseldorf, London, Zurich, Bolzano, Rome and Milan.
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