Treatment of thoracic outlet syndrome to relieve chronic migraine

Abstract

Prior case reports have suggested that treating thoracic outlet syndrome (TOS) may relieve intractable migraine headaches, but there has been no case series large enough to show when underlying TOS should be suspected as a contributor to migraine burden. This observational followed by questionnaire study was performed in an outpatient neurology practice to identify clinical features of patients with migraine in which TOS contributed to migraine burden. We report the clinical features of 50 consecutive patients (48 women, 2 men, age = 43.9+/12.7 years) who were treated for chronic migraine and TOS (20 migraine with aura, 28 migraine without aura, two hemiplegic migraines). Headaches had become chronic within 1 year of onset in 21 patients (42%) with characteristics as follows (percentages are based on known data): greater severity ipsilateral to TOS limb pain (38/50=76%), presence of limb swelling (32/48=67%), and worsened by recumbency (32/38=84%). Thirty-two patients eventually needed surgery, which included percutaneous transluminal venoplasty, 1st rib removal, scalenectomy, pectoralis minor tenotomy, and/or vein patching. The mean improvement of headaches on the treated side was 72 ± 26.7%; 12 patients experienced complete resolution of headaches after 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). Chronic migraines can be important manifestations of TOS. Early transition to a chronic state, lateralized limb pain, and headaches worsened by recumbency are clues to the contribution of TOS pathology. Addressing the TOS contribution to migraine can significantly reduce migraine headache burden.

Keywords: brachial plexus; headache; migraine; subclavian vein; thoracic outlet syndrome.

FIGURE 1

Examples of clinical signs of venous obstruction. (A1) Left supraclavicular fossa, dashed arrow showing normal concavity. (A2) Right supraclavicular fossa, solid arrow showing loss of definition of the lower sternocleidomastoid posterior border due to swelling in a patient with right venous TOS (vTOS). (B1) Arms at the sides, dashed arrow showing flat external jugular vein. (B2) Arms abducted to 90 degrees, solid arrow showing dilated right external jugular vein in a patient vTOS. (C) Flushness and swelling of an arm in a patient with bilateral vTOS (only one arm shown), compared with the normal color of the leg. TOS = thoracic outlet syndrome.

FIGURE 2

Representative examples of imaging in this cohort of chronic migraine and TOS patients. Relevant abnormalities are marked by either open arrowheads or closed arrowheads. (A) Right subclavian vein narrowing between the clavicle and 1st rib (open arrowhead) with contrast reflux into the internal jugular vein and lack of flow into the brachiocephalic vein (closed arrowhead), (B) overdeveloped external vein (closed arrowheads) with extensive collaterals (open arrowheads) in the setting of a stenosed subclavian vein. (C) 3D reconstruction of venous system showing bilateral subclavian vein narrowing (open arrowheads) as well as a narrowed right‐sided internal jugular vein (closed arrowhead).

FIGURE 3

Change in patient participants' rating of statements related to their functional capabilities before and after treating underlying thoracic outlet syndrome (TOS). Scales go from strongly disagree (−2) to strongly agree (+2) for a maximum possible change of 4 points. Positive deflections represent improvement in clinical status after TOS treatment.